Prioritizing Food Security Options to Reduce Obesity in Malaysia


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ASM Advisory Report 4/2013 Prioritizing Food Policy Options to Reduce Obesity in Malaysia Academy of Sciences Malaysia 2013 master.indd 1 11/11/2013 2:57:12 PM


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©Akademi Sains Malaysia 2013 All rights reserved. No part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the Copyright owner. The views and opinions expressed or implied in this publication are those of the author and do not necessarily reflect the views of the Academy of Sciences Malaysia. Perpustakaan Negara Malaysia Cataloguing in Publication Data Prioritizing Food Policy Options to Reduce Obesity in Malaysia: ASM Obesity Task Force Advisory Report (ASM Advisory Report 4/2013) ISBN 978-983-2915-04-1 1. Obesity—Prevention—Law and Legislation—Malaysia. 2. Obesity—Social Aspects—Malaysia. 3. Obesity—Malaysia—Psychological Aspects. 4. Chronic Diseases—Malaysia. 5. Nutrition Policy—Malaysia. 6. Food Supply—Malaysia. I. Series. 362.196398 master.indd 2 11/11/2013 2:57:12 PM


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ASM Task Force on Obesity Chairman Prof Dr Mohd Ismail Noor, FASc., FIUNS Faculty of Health Sciences, MARA University of Technology (Previously at UniSZA) Members Prof Dr Poh Bee Koon Faculty of Health Sciences, Universiti Kebangsaan Malaysia Assoc. Prof Mohd Rizal Abd. Manaf Faculty of Medicine, Universiti Kebangsaan Malaysia Dr Muhammad Yazid Jalaludin Faculty of Medicine, University Malaya Dr Feisul Idzwan Mustapha Disease Control Division, Ministry of Health Malaysia Ms Rasyedah Ahmad Raqi Faculty of Health Sciences, Universiti Kebangsaan Malaysia (Post-graduate student, Deakin University, Australia) Secretariat Mr P. Loganathan and Ms Nurul Hidayah A. Razak (Academy of Sciences Malaysia) Acknowledgement Prof Boyd Swinburn, international collaborator from Deakin University, Australia, for his sharing of expertise and knowledgeable insight in the field of obesity prevention policies. iii master.indd 3 11/11/2013 2:57:12 PM


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Foreword I would like to convey my congratulations to the ASM Task Force on Obesity for its Advisory Report in addressing Prioritizing Food Policy Options to Reduce Obesity in Malaysia. This effort would not have been possible without the strong support and cooperation from various parties, including Government agencies, research institutes and the civil society, in providing the necessary input to undertake this effort. It has been reported that one out of four children in the country is either overweight or obese. One out of three teenagers is overweight, while one out of six is obese. Childhood obesity levels in Malaysia are higher than in most Asian countries as well as in developed nations such as the Netherlands, the United Kingdom and Germany. This statistic has earned Malaysia an unenviable spot in the “World Map of Obesity”. This Advisory Report is, I feel, timely in trying to resolve this national problem. It has identified six policy options for the consideration and, if feasible, eventual implementation by the Government. The policy options are proposed in the following areas: • Fiscal • Primary • Food processing • Food marketing and information • Food distribution and retail; and • Food services. The production of this Advisory Report is in fulfilment of the Academy’s many functions, among which are to provide independent advice to the Government through dissemination of ideas and suggestions amongst decision- and policy-makers, scientists, engineers and technologists through identifying where the innovative use of science, engineering and technology can provide solutions to particular national problems towards sustained national development. I am glad that this Advisory Report will be disseminated and made available to the various relevant Ministries, universities, and research institutes for wider public consumption. Tan Sri Dr Ahmad Tajuddin Ali, FASc President Academy of Sciences Malaysia master.indd 5 11/11/2013 2:57:12 PM


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Preface The epidemic of obesity that has developed over the past 30 years, is one of the largest epidemic in the history of mankind posing a unprecedented challenge for healthcare systems around the globe. Obesity is a complex disorder with both genetic and environmental causes. The predominant driver is environmental and changes to the environment will be essential if we are to tackle the current epidemic. While personal responsibility to prevent obesity is important, unless government instigates policies to encourage people to make healthier choices, the chances of reversing the obesity epidemic look bleak. The aim of this report is to trigger the development of potential ‘hard’ policy options for tackling obesity, and thus prevent the escalating prevalence of chronic diseases in Malaysia. We are grateful to the eight speakers for providing the background papers and the contribution of 28 stakeholders comprising seven related Ministries, five Professional institutions, three Academia and one from the Industry. A special thanks to Ms Rasyedah (Post-graduate Student from the School of Health and Social Development, Deakin University, Australia) whose tireless efforts have given substance to the report presented here and the Academy of Sciences Malaysia for the funding and secretarial support. Having identified and prioritized the list of food policy options, the next crucial step is to propose them to the relevant government sectors. Further refinement of selected policy food options will focus on cost-effectiveness and impact towards population’s health using best available evidence. We are hopeful that we will continue to receive full co-operation from the stakeholders to contribute complimentary actions in a coherent manner to help keep Malaysians healthy. Prof Dr Mohd Ismail Noor, FASc., FIUNS Chairman ASM Task Force on Obesity master.indd 7 11/11/2013 2:57:12 PM


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Contents Foreword Preface Contents Executive Summary Introduction and Background Workshop Overview The Participants of the Workshop Workshop process Obesity in Malaysia and Current Policies/Plans Affecting the Food Environment Paper 1: Obesity in Malaysia: Why the Concern? Paper 2: Efforts to Curb Obesity in Malaysia Paper 3: Sugar Supply in Malaysia: Current Scenario Paper 4: Cooking Oil Subsidy Paper 5: Regulations Pertaining Food and Beverages Advertising in the Media Paper 6: Healthy Eating in School Implementation Guidelines Paper 7: Operationalising Strategy 7 of the National Strategic Plan for Non communicable Diseases — Policy and Regulatory Interventions Paper 8: National Agrofood Policy, 2011–2020 Workshop Findings: Prioritizing Food Policy Options to Reduce Obesity in Malaysia Identifying and Refining Policy Options to Reduce Obesity in Malaysia Assessing the Feasibility, Impact and Side Effects of Potential Policy Options to Reduce Obesity in Malaysia ix v vii ix 1 3 5 5 5 6 6 9 10 11 13 14 17 23 25 25 28 master.indd 9 11/11/2013 2:57:12 PM


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Results and Discussions on the Assessment of Policy Options Ranking of Policy Options in the Fiscal Area Ranking of Policy Options in the Primary Production and Import Area Ranking of Policy Options in the Food Processing Area Ranking of Policy Options in the Food Marketing and Information Area Ranking of Policy Options in the Food Distribution and Retail Area Ranking of Policy Options in the Food Service Area Political Feasibility and Rankings of Policy Options Workshop Evaluation Recommendation: Pushing for Political Intervention to Curb Obesity in Malaysia Summary Special Acknowledgement Appendix 1. Workshop Participants/Stakeholders Appendix 2. Tools Used in the Workshop to Identify and Assess Obesity Prevention Policies References 29 29 30 30 31 32 33 41 44 45 47 48 49 50 52 x master.indd 10 11/11/2013 2:57:12 PM


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EXECUTIVE SUMMARY In Malaysia, the government have introduced ‘soft policies’ approach such as Healthy life style programmes and campaigns as means to curb obesity. Judging from the escalation in prevalence of overweight and obesity over the last few decades, it’s impact is questionable. ‘Hard policies’, such as regulations or fiscal policies (e.g. imposing a tax, removal of subsidies), may be used as an intervention to combat obesity in Malaysia. It is largely known that many of the areas of concern, fall outside the Ministry of Health’s jurisdiction but are within other Ministries such as Trade, Agriculture, Education and Consumerism. Various tools were employed to identify and assess food policy options to reduce obesity in Malaysia. Existing tools, such as policy mapping grids and scoring tools were utilised to identify potential policy options from a review of current plans and strategies, as well as to assess the policy options in terms of feasibility, potential impact and side effects. The participatory process adopted was successful in eliciting responses from the stakeholders on the potential food policy options. The key highlights derived were: • Rapid escalation of obesity and diabetes, which will blow out Malaysia’s health budget. • It shows no sign of abating despite the awareness programmes, self-regulation by industry and other soft policy approaches. • We need to consider stepping up to ‘harder’ and more effective policies. • Enormous opportunity costs from subsidising the food which are contributing to obesity (sugar and palm oil) creating a triple cost for the government — paying for diabetes ‘causes’, lost productivity and treatments. • Many policies to choose from, the aim of this Workshop was to undertake a prioritysetting process to identify the more promising ones to recommend. • Top ranked interventions included the following: Healthy food service policies in public institutions, especially schools; standards to limit fat and/or sugar content of processed foods and serving sizes for fast food meals; clearer front-of-pack labelling like traffic lights, and banning unhealthy food advertising to children on television. master2.indd 1 12/11/2013 7:55:27 PM


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ASM Advisory Report 4/2013 • The immediate cost-saving policy options of removing subsidies on palm oil and sugar did not score highly because they were presumed to be politically unfeasible (their rankings improved when analysed without the ‘political feasibility’ domain). • Subsidies and greater access for fruit and vegetables was also favoured, especially when analyses excluded the ‘political feasibility’ domain. RECOMMENDATIONS 1. The government should recognise the seriousness of obesity and related health threat of being overweight to the well-being of Malaysians and its impact on the economy and nation budgets and make the decision to take strong action using multiple policy tools (including the ‘hard’ tools of regulation and fiscal policies) across the several relevant ministries. 2. The Ministry of Health’s efforts in implementing healthy food policies throughout all public institutions including schools, government ministries and agencies should be fully supported by all relevant partners. 3. The Ministry of Health should strive towards setting up nutrient targets and standards for food composition and work with the food industry to reformulate processed foods to become healthier. 4. The Ministry of Health should develop an evidence-informed, clear, interpretive, easily understood, front-of-pack nutrition labels (such as the traffic light system being implemented in the UK). 5. The Ministry of Health should continue to work with other relevant ministries to develop statutory regulations to restrict the marketing of unhealthy foods to children, predominantly on television, but also through other media. 6. The Treasury should revise food fiscal policies so that they promote, not undermine health, and consider the removal of subsides on palm oil and sugar and use the savings to support strategies to increase fruit and vegetable consumption. The Taskforce hopes that this report, the first of it’s kind in looking at food policy options and will spur government into action, in order to reduce the prevalence of obesity in the country. 2 master2.indd 2 12/11/2013 7:55:27 PM


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Prioritizing Food Policy Options to Reduce Obesity in Malaysia INTRODUCTION AND BACKGROUND Obesity has doubled over the past decade in adult Malaysian from 21% to 43% (1996–2006) (Lim et al. 2000; Ministry of Health Malaysia, 2008), high in adolescent (19%) (Poh et al. 2003) and children (16.4%) (Ismail et al. 2009). The escalation of obesity, once thought to be an urban phenomenon, has now spread to rural population at an alarming rate. As Malaysia proceeds rapidly towards a developed economy status, the health of its population will probably continue to deteriorate (Ismail et al. 2002). Obesity is closely related to the major causes of death in Malaysia, including type 2 diabetes mellitus, cardiovascular diseases and certain types of cancers. It is largely known that obesity substantially increase healthcare cost as well as reducing life expectancies. The government, in particular Ministry of Health Malaysia and related professional bodies are fully aware of this problem. In 2005, the Malaysian Association for the study of obesity published a document on the strategy for the prevention of obesity (MASO 2005). However, efforts to address the situation thus far have failed to meet the desired effect judging from the rising trend of obesity in the country over the last few decades. In view of the above, the Academy of Sciences Malaysia (ASM) had set up an Obesity Task Force to look at potential policy options to combat obesity in Malaysia. The objectives of the task force are: 1. To create and maintain an effective knowledge exchange system between individuals and organizations working in obesity prevention; 2. To articulate the policy directions needed for obesity prevention and inspire their translation into policy, research and practice; 3. To organize workshops to identify and assess obesity prevention policy options; 4. To model potential policy interventions to reduce obesity in Malaysia in terms of costeffectiveness and health benefits; and 5. To advocate for effective, evidence-informed policy actions for obesity prevention at national level. The focus is to look at ‘hard policies’ such as regulations or fiscal policies (e.g. tax on unhealthy foods, removal of subsidies) which can be used as an intervention tool to reduce obesity. 3 master2.indd 3 12/11/2013 7:55:27 PM


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ASM Advisory Report 4/2013 It is important to note that for obesity prevention, many of the policy areas concerned fall outside the Health Ministry’s jurisdiction, but are also within other Ministries such as Trade, Agriculture and Consumerism, to name a few. Therefore, a comprehensive and coherent approach involving multi-sectoral stakeholders is urgently needed to identify and prioritize policy options that can be recommended to the government in an effort to combat obesity in Malaysia (Figure 1). Realizing this dire need, the ASM task force organized a two-day stakeholder workshop on Prioritizing Policy Options To Prevent Obesity held on 9 – 10 February 2012. The aim of the workshop’s was to specifically focus on assessing policy options that may help improve dietary habits of Malaysian population. This Report presents the findings from the two-day stakeholder Workshop. Summaries of presentations from key stakeholders are given and a prioritized list of obesity prevention policy options is laid out for further discussion. Reversing the epidemic should be the main agenda for decision-makers while research is urgently needed to identify and analyse potential policy solutions. Hence, it is of utmost importance that the initial findings of this Workshop be shared with the government in an effort to help reduce the prevalence of obesity in Malaysia. Figure 1. Systematic approach to setting priorities for obesity prevention policies in Malaysia (Adapted from Rasyedah et al. 2010). 4 master2.indd 4 12/11/2013 7:55:27 PM



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