An obese 40-year-old man (centre) works out at a Kuala Lumpur fitness centre. With just over half of Malaysian adults either overweight or obese, this sight is more the norm than the exception. — AFP
By the second day, there was a clear sense of frustration among some of the participants of the Addressing the Global Health Challenge of Obesity in Malaysia and Beyond workshop, which was organised by Academy of Sciences Malaysia (ASM) and The Academy of Medical Sciences, Britain.
Not surprising as the main solution they had come up with to tackle the problem of obesity in Malaysia turned out to have already been implemented.
This was a national-level taskforce to tackle this growing issue – a taskforce that already exists within the Government, chaired by the Health deputy director-general for public health.
According to the ministry’s former Nutrition Division director Rokiah Don, the multisectoral taskforce took one-and-a-half years to come up with various strategies to tackle obesity.
“We had, at that point of time, identified 40 strategies that have been prioritised (in terms of acceptability, finances and human resources) and presented to the Minister of Health late last year, and that have been taken up in the planning of the Eleventh Malaysia Plan that is to happen from 2016 to 2020,” she said.
“The taskforce is still there, making sure that these strategies get through the next five years.”
Rokiah proposed the radical idea of making it more difficult for Malaysians to access healthcare, so that they will take more ownership of their own health, instead of just leaving it to the doctor. — Photos: ASM
Currently an associate professor in nutrition and dietetics at the International Medical University, Rokiah added: “The system is already there. The political
commitment is already there.
“It’s just that we need to push it from various stakeholders.”
She emphasised that many voices need to be vocal in order to really push for change.
“Having experienced 35 years in the Ministry of Health, there is a lot more that can be done, within and outside.
“But you must understand the system to make things work more effectively.
“And the system’s not just within the Ministry of Health, it is the systems surrounding the Ministry of Health – having to work with other agencies in order to get things done,” she said.
And this problem is not isolated to Malaysia.
Dr Sania Nishtar, one of the three recent finalists for the World Health Organisation (WHO) director-generalship, said in her presentation at the workshop: “During my interactions with 191 countries, I found ministers of health more than willing to tackle NCDs (non-communicable diseases), but they shared that they are up against their parliaments and their finance and trade ministers, and the international communities in their countries, because NCDs do not feature on their list of priorities.
“They feel powerless because there are no multistakeholder mechanisms and platforms for private-public convening to tackle the challenges.”
The problem with obesity research
While the current obesity taskforce does include input from various stakeholders, Health Ministry Disease Control Division (NCDs Unit) senior principal assistant director Dr Feisul Idzwan Mustapha thinks that a more formal partnership between the ministry, industry and academia needs to be established.
“The thing I would like to highlight is the discrepancy between what research is being done and what the ministry’s programme needs.
“One of the key issues is relating the research to the work that is being done in the field in Malaysia, relating it to the public health aspects and the implications as well.
“We do not want the perception that research is being done, a lot of effort is being made, but no one is using it,” he said.
Prof Looi opened the workshop by saying: There is a prize we are winning year after year – the prize for obesity.
Scientists and ministry officials need to engage with one another early on in order to ensure that everyone is on the same page and meet each other’s expectations, he said.
In addition, scientists need to be involved in the creation of short policy briefs, such as what the National Institutes of Health is currently doing.
“You have to realise, the policymakers are no longer just the Ministry of Health when it comes to public health interventions for NCDs in general – it’s other ministries as well.
“And if you expect other ministries’ policymakers to read (scientific) papers without your interpretation in terms of policy briefs… we are going to have that gap between knowledge and usefulness,” said Dr Feisul.
The conclusion from one of the workshop’s breakout sessions was also that while there is some research done locally on obesity interventions, they are small in nature and insufficient to inform policy.
This is mainly due to lack of funding and awareness among the various stakeholders.
This results in researchers tending to use data from other countries to justify their findings.
“I think, in the future, we need to focus more on the local dataset to understand the local setting,” said Universiti Malaya (UM) senior lecturer Dr Phan Chia Wei, representing his group.
“The information collected most of the time is locked in the safe or on the shelves of the individual researcher, (and) never shared with other researchers.
“I think we need to publicise the findings.”
Another problem highlighted was the lack of evaluation on the public health interventions on obesity done to date.
“We know that in Malaysia, we have a lot of public health programmes, but the effectiveness of the programmes is unknown.
“We know what are the strengths and weaknesses, but we don’t know whether they are effective or not, whether they work or not,” said Universiti Sultan Zainal Abidin nutrition lecturer Dr Mohd Razif Shahril, representing his group from another of the breakout sessions.
Universiti Putra Malaysia (UPM) Emeritus Prof Dr Khor Geok Lin agreed.
“For some of us who have been involved in the last 20-30 years, we’ve seen a lot of these efforts – very well-intended, well-planned, well-executed, but unfortunately, the gap is in feedback – whether it has been effective in reaching the target groups, in reaching whatever the goals were.
“There is some feedback here and there, but not in a systematic way,” she said.
However, Rokiah had a different point of view.
“In most of the programmes we have done, at least with nutrition, we have done evaluations, except that it doesn’t get disseminated the way it should be – that’s where one of the major gaps is.
“And many other agencies may not even know the research priorities because it may not have been disseminated well,” she said.
Changing the focus
Dr Feisul (standing) leading one of the breakout sessions during the workshop. He believes that understanding the emotional drivers of obesity, as well as how to obtain political and public support for obesity interventions is key to having an effective programme.
Another issue however, is the need to shift the focus in current obesity interventions.
“I think we’ve been approaching it always the same way – just sort of repackaging it in a way,” said Dr Feisul.
“When I propose something in my work, then my boss will say, ‘Yeah, I’ve done it 15 years ago’, somebody else will say, ‘Yup, I’ve done it before.’
“The main basis (of interventions) has always been to increase knowledge and awareness, there will be a bit about changing motivation, but it’s not a strong component.”
He added: “I think one of the key things is that we don’t really understand what are the key barriers.
“Without understanding the key barriers, for our community to change and for our policymakers to change, it would be very hard to design an intervention.”
As Monash University Jeffrey Cheah School of Medicine and Health Sciences internal medicine professor Datuk Dr Anuar Zaini Md Zain said at the opening of the workshop, “The point of this workshop is not to look at what we have been doing because what we have been doing has only gotten us more obesity.”
In fact, the current situation of around half of Malaysian adults being either obese or overweight is probably being underestimated.
According to National University of Singapore Yong Loo Lin School of Medicine vice dean Prof Dr Lawrence Ho Khek-Yu, the bad news is that Asians have higher body fat compared to Caucasians of the same weight.
And this discrepancy is not accounted for with body mass index (BMI), which is the current standard measurement of obesity and overweight.
“So this is where our heart failure rate is 10 years younger than the Caucasians.
“And bad news also for diabetes: if you load them with sugar, Asians have a higher level (remaining in them, compared to Caucasians) after that,” he explained.
The problem with public obesity interventions, he later said, was inertia. “You have to change the public’s mindset from ‘don’t bother’ to ‘bother’.”
In addition, Dr Feisul said: “Even if you provide them with choices or they have the realisation to change, if the environment doesn’t support that change, it is very difficult for Malaysians to make that change.”
The emotional and social factors affecting obesity need to be better understood, according to him.
In terms of research, this means involving experts from sociology, anthropology and behavioural science to help design studies and interventions revolving obesity – not just medical doctors – as “I really need to understand why Malaysians do the things that Malaysians do”, added Dr Feisul.
He also said: “Change is not just about evidence, but also the political will and public support.
“So, your interventions must take into account: how do I change public perception, how do I get support for this intervention, and how do I get the key political person responsible within that particular area of intervention to believe in its importance?”
He gave the example of schools that come under the Education Ministry, where it is essential to get ministry officials to buy into the importance of helping overweight school students lose weight, rather than just focusing on getting all A’s, which is their main concern.
In fact, a group from one of the breakout sessions proposed refocusing obesity intervention outcomes by linking obesity with academic performance.
“We know that the interest of parents and schools is more towards academic performance, rather than BMI.
“So we want to look at which important obesity indicator is linked with academic performance,” said the group’s representative, adding that a British study found that physical activity has a positive impact on academic performance.
Another controversial point that came up during the workshop was that perhaps the obesity epidemic in Malaysia is partially fuelled by our excellent universal healthcare system.
UPM Faculty of Medicine and Health Sciences senior lecturer Dr Chau De Ming said: “Perhaps we are making healthcare too easily accessible to everyone, so people don’t necessarily want to care so much about their health, just leaving it in the hands of the doctor.
“So someone mentioned that perhaps we could make it a bit more less accessible, maybe make it a bit more difficult to get to doctors, so that people will take more ownership of their own healthcare.”
He was reporting on his group’s conclusions from one of the workshop’s breakout sessions.
This was also the finding of an Economist Intelligence Unit report on Tackling Obesity in Asean, commissioned by the Asia Roundtable on Food Innovation for Improved Nutrition (Arofiin). (See High costs of obesity)
Of the six Asean populations involved, Malaysians emerged as a particular example of considering the treatment of obesity to be the responsibility of the healthcare community, rather than something they could affect themselves via lifestyle choices.
Nutrition Society of Malaysia president Dr Tee E Siong, who was both interviewed for the report and a participant at the workshop, noted that not only do many Malaysians view obesity as more of a cosmetic problem, but that “Many people think it is cheap to get treated (at public hospitals), so why bother (with preventive measures)?”.
Will it make a difference?
The frustration from some of the workshop’s participants also stemmed from the fact that they have been involved in creating reports about the policies and actions necessary to tackle obesity before.
“That’s the reason why I said I’m frustrated. We did all this and there’s a lot of time involved, and where did it go after that?” said UM Assoc Prof Dr Muhammad Yazid Jalaludin.
In fact, the ASM Task Force on Obesity produced an advisory report on Reprioritising Food Policy Options to Reduce Obesity in Malaysia in 2013, which Assoc Prof Muhammad Yazid and Dr Feisul were a part of.
The unasked question was whether this workshop would be yet another one in the list of well-meant and well-thought out, but ultimately ineffective events of its kind.
However, as UM Distinguished Prof Datuk Dr Looi Lai Meng said at the end of the workshop: “Don’t be disappointed. I think hope is something we all must have.”
In the meantime, our obesity and overweight rates are only likely to increase further if current trends continue, leading to a domino effect of increasing numbers of sick people, increasing healthcare expenditure and increasing loss of productivity.
See How the UK came up with a plan to tackle obesity.