Obesity : Issues and Challenges(with particular reference to Adult Malaysian)Mohd Ismail Noor FASc, FIUNS Department of Nutrition and Dietetics Faculty of Allied Health Sciences Universiti Kebangsaan Malaysia Kuala Lumpur

Kursus Pengurusan Berat Badan- KKM 18 September 2006

Outline Global and regional scenario BMI Classification issues Prevalence of Obesity Etiology of Obesity Health Implication and cost Combating Obesity Take home message

We are unanimous in our belief that OBESITY is a hazard to health and a detriment to well-being. It is common enough to constitute one of the most important MEDICAL & PUBLIC HEALTH problem of our time, whether we judge importance by a shorter expectation of life, increased morbidity, or cost to the community in terms of both MONEY and ANXIETY. Professor Waterloo MRC Report 1976

Disease of the New MillenniumIOTF, 1998

Obesity: a time bomb to be defusedBray, 2000

Treatment of obesity: Mission ImpossibleGolay, 2000

Overweight and Obesity: A new nutrition Emergency?SCN, WHO 2005

Global epidemic of obesity2000 15001.1 billion

1.7 billionBMI>30 BMI>25 BMI>23

1000 500 0>300 million

BMI>23 BMI>25 BMI>30 Million

IOTF (2005)

Obesity Rates Could Double In 30 Years50 n USA n

% of population BMI >30

40 30 20 10 0 n

l

England Australia l t n n u u l 1980 n u

o Mauritius u Brazil n

l l l l l u o o 1990 2000 Year 2010 2020 2030

1960

1970

IOTF, 1998

BMI Distribution of Adult Population WorldwideUruguay Peru Tunisia Brazil Colombia Venezuela Argentina Costa Rica Cuba Chile Mexico Morocco Togo (urban) El Salvador MALAYSIA China Rwanda Zimbabwe Nicaragua Haiti Senegal Ethiopia India80 60

B.M.I. = >25 = 17-18.4 = 16-16.9 = 30.0)80 70 Obesity % (BMI >30) 60 50 40 30 20 10 0Ch in a Ja pa n K or ea Ph ili pp in es Th ai la nd M al ay Ne sia w Ze al an d Au st ra Sa lia m oa (r ur Sa al m ) oa (u rb an )1.6 1.2 13 2.7 1.7 1.9 1.4 3.4 1.7 5.6 1.7 7.9 4.7 10 13.2 11.5 59.2 76.8 58.4

41.5

Men Women

Ismail, 1998

Overweight and Obesity prevalence among adults in AsiaCountry Iran Malaysia Korea Japan China Thailand Philippines Hong Kong India Year 1999 1996 1998 1995 1997 1996 1993 1997 1998 Sex M F M F M F M F M F M F M F M F M F OWT (%) 44.1 51.0 15.1 17.9 24.3 23.5 22.3 18.3 12.0 13.8 13.2 25.0 11.0 11.8 33.0 (M&F) 4.0 4.0 Obese (%) 10.2 26.4 2.9 5.7 1.7 3.0 2.2 3.1 2.5 2.4 ? ? 1.7 3.4 5.4 7.0 0.5 0.5 Source Ghassemi* 2002 Lim et al* 2000 Lee et al* 2002 Popkin et al*, 2002 Du et al* 2002 Kosulwat* 2002 Solon* 2002 Janus 1997 Shetty* 2002

*Obesity Review, August 2002

Prevalence of overweight and obesity in selected Asian countries ( Urban vs Rural )Country Year Area OWT (%) 28.0 19.9 17.4 15.5 10.9 7.3 OBESE (%) 12.4 6.8 4.5 4.3 1.1 0.8 Source

Iran

1999

U R U R U R

Ghassemi* 2002 Ismail et al,* 2002 Shetty* 2002

Malaysia

1996

India

1998

*Obesity Review, August 2002

Classification of Body Weight in Adults According to Body Mass Index, BMIClassification Underweight Normal range Overweight Pre-Obese Obese Class I Obese Class II Obese Class IIIWHO, 1998

BMI, kg/m2 < 18.5 18.5 24.9 > 25.0 25.0 29.9 30.0 34.9 35.0 39.9 > 40.0

Risk of co-morbidities Low (but risk of other clinical problems increased) Average

Increased Moderate Severe Very severe

The Asia-Pacific

perspective:Redefining

obesityand its

treatment

February 2000

World Health Organization Western Pacific RegionIASO INTERNATIONAL ASSOCIATION FOR THE STUDY OF OBESITY

International Obesity TaskForce

IOTF (2000)

Proposed Classification of Weight by Body Mass Index in Adult AsiansClassification Underweight Normal range Overweight At Risk Obese Class I Obese Class IIIOTF, 2000

BMI, kg/m2 < 18.5 18.5 22.9 > 23.0 23.0 24.9 25.0 29.9 > 30.0

Risk of co-morbidities Low (but risk of other clinical problems increased) Average

Increased Moderate Severe

IssuesAre population specific BMI cut-off points for overweight and obesity necessary? Recent studies in Hong Kong, Singapore, Indonesia and Japan suggested that these populations have a relatively high body fat % at low BMI Meta-analysis in Asian populations revealed: - Caucasian prediction equation cannot be applied to all Asian populations. - In general, both male and female Asians have more body fat then their European counterparts of the same age and BMI. - Calculated BMI cut-off points vary considerably from (21.6 25.9) for overweight and from (26.3- 30.8) for obesityWHO Consultation, July 2002.

Asian BMI action point - BMI>23

Source: THE LANCET Vol 363 January 10, 2004 www.thelancet.com

Ranges for determining public health and clinical action levels based on BMI16

High to Very High Risk Moderate to High Risk Low to Moderate Risk

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

WHO classification

underweight

overweight

Obese I

Obese II

Obese III

1998

= Suggested cutpoints for reporting population BMI distribution and specific action levels for populations and individuals

Lancet, 2004

Waist Circumference Correlates abdominal fat distribution and associated ill health. Increased risk: Men > 94 cm (37 in.) Women > 80 cm (32 in.)

Lower values have been proposed for Asian man ( 90cm for men and 80cm for women)

V ital S tatistic:ist Circ um feren ce Wa

The Obesity Epidemic

Malaysian scene

NATIONAL HEALTH AND MORBIDITY SURVEY (1996-97) AdultsOverweight(BMI 25-29.9 kg/m2) (%)

Obese(BMI > 30 kg/m2) (%)

Male Female Urban Rural Malay Chinese IndianLim et al, 2000

15.1 17.9 17.4 15.5 17.3 16.0 20.6

2.9 5.7 4.5 4.3 5.1 3.5 5.0

Prevalence of Obesity in Malaysia16.0 14.0

Obesity % (BMI > 30)

12.0 10.0 8.0 6.0 4.0 2.0 0.0 NHMS 1996 MANS 2002/2003

Men

Women

NHMS National Health & Morbidity Survey 1996 MANS Malaysian Adults Nutrition Survey, 2002-2003

Influences on Energy Balance and Weight GainENVIRONMENTAL & SOCIETAL INFLUENCES Individual / Biological Susceptibility

Dietary & Physical Activity Patterns ENERGY REGULATION EXPENDITURE ACTIVITY GAIN STABLE WEIGHT LOSS TEF BMR

INTAKE FAT CHO PROTEIN

BODY FAT STORES WHO, 1998

ENVIRONMENTAL MODIFIERS IN WEIGHTREGULATION POTENTIAL THAT INFLUENCE1. CHOICE & AMOUNT OF FOOD CONSUMED availability cost energy density fat sugar palatability variety portion size 2. CHOICE & AMOUNT OF PHYSICAL ACTIVITY access to recreational sports nonmotorized form of transportation television labour-saving devices

The Global ParadoxWhile wealthy industrialized nations spend significant amount of money to convince their populations to replace dietary fats with a simpler diet based on grains, vegetables and fruits, the developing nations use their growing incomes to replace their traditional diets, rich in fibers and grains, with diets that include a greater proportion of fats and sugars.Drewnowski & Popkin, 1997

3100 3000 2900 2800 2700 2600 2500 2400 2300 2200

100

Calories Protein Fat

90 80 70 60 50 40

Changes in availability of calories, protein and fat in Malaysia, 1961-1997 Source: Food Balance Sheet of Malaysia (FAO)

19 -63 64 19 -66 67 19 -69 70 19 -72 73 19 -75 76 19 -78 79 19 -81 82 19 -84 85 19 -87 88 19 -90 91 19 -93 94 -9 6 19 97

19

61

100% 90% 80% 70%

% of Calories

60% 50% 40% 30% 20% 10% 0% 1961-63 1970-72 Starchy roots Meat, fish, egg Oils & fats 1979-81 1988-90 Vegetables & fruits Milk-excl butter Miscellaneous 1997

Cereals Pulses Sweeteners

Changes in sources of calories in Malaysia, 1961-1997Food Balance Sheet FAO (1961-1997)

280 260 240 220 200 180 No. of outlets 160 140 120 100 80 60 40 20 01993 1994 1995 1996 1997 1998 1999 2000

1000K FC o u t l e t P i z z a h u t o u tl e t

900 800 700 600 Turnover (RM million) 500 400 300 200 100 0

K FC

1 9 9 31 9 9 41 9 9 51 9 9 61 9 9 71 9 9 81 9 9 92 0 0 0

Number of KFC and Pizza hut outlets from year 1993 to 2000

Turnover for KFC from year 1993 to 2000

Fast food industries in Malaysia a selected list (2000)Brand (origin) KFC (USA) Mc Donalds (USA) Pizza Huts (USA) A & W (USA) Marrybrown (Local) Sugar Bun (Local) Kenny Roger (USA) Dominos Pizza (USA) *Others combined 9% Source: The EDGE (2001) Year (Est) 1973 1982 1984 1961 1981 1981 1994 1997 No. of Outlets 294 141 85 44 88 45 25 17 Market Share (%) 45 30 8 4 4 * * * Sales (RM million) 578.7 349.6 120.0 47.8 NA 36.1 (1999) 36.1 NA

Know your Fast FoodsA quarter-pound cheeseburger, large fries, and a 16 oz. soda provides

1,166 calories51 g fat 95 mg cholesterol 1,450 mg sodium

Dietary fat and energy intake according to BMI classification in men.3000 2500 Energy intake (kcal) 2000

2752 220 6 30 2353 24 98

1500 1000 500 0 30.0

E nergy Intake (kcal)D ietary Fat (% )

Dietary fat (%)

Dietary fat and energy intake according to BMI classification in women.2500

21172000 Energy intake (kcal)

2153

2093

1794 31 28 30 30

1500

1000

500

0 30.0

35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20

E nergy Intake (kcal) D ietary Fat (% )

Dietary fat (%)

Energy and Fat intake in Men2500

2275 2025

35 33 31 29

Energy intake (kcal)

2000

1500

29

27 25

1000

23 21

500

19

190 RURAL URBAN

17 15

EI (kcal)

% Fat

Dietary fat (% )

Energy and Fat Intake in Women2500 40 38 36

Energy intake (kcal)

2000

1720

1710

34 32 30 Dietary fat (% )

1500

301000

28 26 24

500

22

0

21RURAL URBAN

20 18

EI (kcal)

% Fat

Physical ActivityPast Present

DAILY ACTIVITY PATTERNS OF OBESE SUBJECTS (min/day)minute700 600 500 400

Adolescents (13-17 yrs) Adults (20-24 yrs)

300 200 100 0

Lying/Sleep

Ismail, 1998

Personal necessities

Moderate exercise

Standing

Walking

Sitting

DAILY ACTIVITY PATTERN OF MALAYSIANS ACCORDING TO AGE-GROUPS90 80 70 60

LightAdolescents Adults 2 Elderly3 1

% of day

50 40 30 20 10 0male male female male1 2 3

Moderate Activefemale female

Poh et al (1996), Ismail et al (1993) Razali & Ismail (1996)

Basal metabolic rate (MJ/day), total daily energy expenditure (MJ/day) and physical activity level (PAL)Subjects Adolescent25 Adolescent26 Young Adults27 Adults27 Elderly28 Armed Forces29 Elite Athlete302 5

Age (yr) 12-14 16-18 18-30 30-60 >60 20-30 20-30

Male BMR TDEE PAL 5.08 5.76 5.85 5.66 4.92 5.74 6.84 7.89 8.64 9.40 9.53 7.35 12.08 14.91 1.55 1.50 1.61 1.68 1.50 2.10 2.18

Female BMR TDEE PAL 4.80 5.02 4.77 4.79 4.37 NA 5.39 7.09 7.64 7.58 8.17 6.74 NA 10.67 1.48 1.52 1.59 1.70 1.54 NA 1.98

Yap (2001), 26 Victor (1999), 27 Ismail et al. (1994), 28 Razali (1996), 2 9 Ismail et al. (1996), 30 Ismail et al. (1997)

Adapting exercise guidelines for energy balance Adapting exercise guidelines for energy balanceEnergy BalancePAL 1.8 PAL 1.60 606 1.50 PAL

CVD Guideline

1.6

0 1.75PAL 1.0

Sedentary

BMR

Erlichman, Kerbey & James, 2002. Obesity Reviews, 3: 257-271 and 273-287.

IssuesHow much physical activity is enough to prevent unhealthy weight gain? Current guidelines of 30 minutes of moderate activity daily is important for limiting health risks to chronic diseases For preventing weight gain or regain, compelling evidence suggest a 60-90 minutes of moderate activity To prevent a transition to overweight and obesity, a PAL of 1.7 or approximately 45-60 minutes per day of moderate activity is needed. For children even more activity time is recommended Stock Conference, Bangkok, March 2002

Summary of Local Research Findings Malaysians in general have a sedentary lifestyle Energy cost of habitual activities are lower as compared to Caucasians Predictive Equations (FAO/WHO/UNU1985) overestimates BMR of adults and adolescents between 9-13% and 1-10%, respectively In most studies, TDEE were found to be lower than the current RDA for energy. With food available around the clock (in some urban areas) ALL factors above adds up to be a recipe for disaster for Malaysians

Relative risk of health problems associated with obesity in developed countries .Greatly increased (relative risk >>3)Diabetes Gall bladder disease Hypertension Dyslipidaemia Insulin resistance Breathlessness Sleep apnoea

Moderately increased (relative risk ca 2-3)Coronary heart disease Osteoarthritis (knees) Hyperuricaemia and gout

Slightly increased (relative risk ca 1-2)Cancer (breast cancer in postmenopausal women, endometrial cancer, colon cancer Reproductive hormone abnormalities Polycystic ovary syndrome Impaired fertility Low back pain Increased anaesthetic risk Foetal defects arising from maternal obesity

WHO, 1997

Prevalence of risk factors (Hypertension (HT), Abnormal glucose tolerance (AGT) & Hypercholesterolaemia (CHO)) in normal and overweight men (n=8164) and women (n=9228)16 14 Prevalence (%) 12 10 8 6 4 2 0 2.1 Normal men Overweight men 2 Normal women Overweight women 6.7 5.7 8.4 6.6 6.1 13.3 14.5 11.4 8.9 HT AGT CHO 15.6

Source: Lim et al. (2000), Med. J. Mal., 55: 196-208

Social Consequences Community Loss of productivity Sick days

Individual Employment prospects Marriage/Divorce Stress/Self esteem Quality of Life

Annual direct costs of disease in relation to BMI

Annual cost (US$ billions)Wolf and Colditz, 1996

Published Costs of ObesityDirect USA 1998 $51.6 billion (5.7%) NZ 1996 $135 million (2.5%) France 1995 FF 12 billion (2%) Netherlands 1995 DG 1 billion (4%)*Caterson & Broom (2001)

Indirect$47.6 billion

FF0.57 billion* 3% from BMI 25-30

Published Costs of ObesityDirect Canada 1999 (2.4%) $1.8 billion* UK 1994 (15%) GBP30 million England 1999 (1.1%) GBP130 million GBP15 millionCaterson & Broom (2001)

Indirect* BMI > 27

GBP165 millionOverweight Obese

A Vicious Circle

Disrespect of obesity as Professional a serious condition

Media

Advocating absurd body weight ideals

PublicOveremphasis on cosmetic weight loss

Rossner, 1997

CAUSAL WEB OF SOCIETAL INFLUENCES ON OBESITY PREVALENCEINTERNATIONAL FACTORS NATIONAL/ STATE COMMUNITIES WORK/ SCHOOL/ HOMELeisure Activity/ Facilities

INDIVIDUAL

Education Policy Globalization of Markets Transport Policy

Public Transport

Public Safety

School Activity

Energy Expenditure

O B E S I T Y P R E V A L E N C E

Worksite Exercise Sanitation Development Urbanization Health Care System Health Policy Manufactured/ Imported Food Food Policy Agriculture/ Gardens/ Local Markets Infections

Labor

Food Intake: Nutrient Density

Worksite Food

School Food

Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999: http://www.iotf.org

General Objective

NPANM II ( 2006-2015 )TO ACHIEVE AND MAINTAIN THE NUTRITIONAL WELLBEING OF MALAYSIANSTo prevent and control diet-related non-communicable diseases

Specific objectives

To improve nutritional status of all

Improving household food security especially among the low income

Enabling strategies

Promoting optimal infant & young children feeding practices Preventing and controlling nutritional deficiencies Promoting healthy eating and active living Supporting efforts to protect consumers in food quality & safetyEnsuring all have Continuous assessment and monitoring of the nutrition SituationPromoting continuous research and development Ensuring nutrition and dietetics are practised by trained professionals Strengthenin g institutional capacity in nutritional activities

Facilitating strategies

access to nutrition information

Foundation strategy

Incorporating nutrition objectives and strategies into policies and programmes of relevant agencies

Specific objective 1

To Improve nutritional statusThe nutritional status of all Malaysians can be further enhanced through: Improving breastfeeding and complementary feeding

practices

Improving food intake and dietary practices Reducing protein-energy malnutrition Reducing micronutrient deficiency Reducing overweight and obesity

The current nutrition and health scenario suggests that Malaysia have not benefited from the western experience We need to intervene strategically before the typical dietary pattern associated with western affluence become widespread and established within our population The problem is real and need urgent attention for it may be just the tip of the ice-berg. There is a need to carry out National Nutrition Survey periodically There is a need for Health Economic Analysis

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