Country profiles of the prevalence, impact, and interventions on obesity in six ASEAN countries.
Obesity is a growing public health burden, not just in affluent countries but also in many developing nations at all income levels. Increases in obesity prevalence are driven by a range of interlinked factors, including rising incomes, urbanisation, shifting lifestyles and genetic factors that may trigger obesity among individuals in once food-scarce environments. Obesity incidence is also rising steadily, bringing with it new challenges. The Association of South-East Asian Nations (ASEAN) is no exception to these trends.
If action is not taken, countries could find themselves fighting a range of related non-communicable diseases (NCDs), including type 2 diabetes, cancer, cardiovascular disease and stroke, as well as a range of chronic diseases including musculoskeletal disorders. For some countries, this challenge will emerge as they continue to battle a range of communicable and infectious diseases, as well as under-nutrition in some portions of the population, placing a great strain on public health systems.
Trends in Asia
Over the last three decades, the global prevalence of obesity has more than doubled. Between 1980 and 2013, the proportion of adults with a BMI at or above 25 kg/m2 (i.e., adults who are overweight) grew from 28.8% to 36.9% in men, and from 29.8% to 38% in women. Obesity rates have stabilised in some developed countries (such as Canada, Italy and South Korea), but in others they have increased (such as Australia, France and Switzerland).
Historically, the prevalence of obese and overweight people has been low in ASEAN countries, compared to other regions. In 1980, obesity rates in the region ranged from 1.1% to 1.9%, based on the World Health Organisation’s (WHO) definition of obesity. Countries in Central and Eastern Europe had the highest rates of obesity, ranging from 16.3% to 18.2%.
By 2013, however, obesity rates in South-East Asia had risen to an average of 4.8% among adult males and 7.6% among adult females. Although these rates are still low compared to global averages (13% of the world is obese), the prevalence of obesity is increasing rapidly. Indonesia and Vietnam experienced a 30% increase in the number of obese individuals between 2010 and 2014 alone. During the same period, the number of obese individuals in the United Kingdom and the United States increased by only 10% and 8%, respectively.
The implications of this trend are severe. Obesity is often linked to colorectal cancer, type 2 diabetes, hypertension, coronary heart disease, stroke, as well as reduced life expectancy. These have serious consequences for household income, economic growth and productivity.
Globalisation and increased urbanisation also play a role, as it is linked to more sedentary lifestyles and occupations. Ever-more available food products and the rise of “24-hour” consumer stores increase the ease and convenience of food consumption and may also stimulate over-eating.
In South-East Asia, urban living has been consistently associated with obesity in all age groups and both genders, and the association is even stronger in countries with lower gross national income. For instance, those living in an urban environment in the Philippines are 1.29 times more likely to suffer from obesity, relative to someone living in a rural environment. Similarly, people living in an urban environment in Vietnam or Laos were 3.36 times more likely to be obese, relative to those living in rural areas. Obesity is also the result of increased incomes, which naturally lead to increased food intake and consumption of “convenience” foods.
Certain characteristics of low- and middle-income countries (LMIC) also mean that their obesity pathways are different from—and more worrying than—those experienced by rich countries. For example, the “thrifty gene” hypothesis. Thrifty genes are believed to enable individuals to efficiently deposit fat during times of food abundance in preparation for times of food shortage. But can cause obesity when nutritional shocks are no longer present, as may be the case in countries that have quickly upgraded from food insecure to food stable or food abundant. These genes can also be passed on to children born to mothers who faced malnutrition—a genetic inheritance that increases their likelihood of becoming obese. Although, the evidence on the validity of this hypothesis is not conclusive.
- According to the WHO, Singapore has the second highest overweight prevalence in ASEAN at 32.8%—a reflection of its significantly higher income level.
- The 2010 Singapore National Health Survey put this figure at 40.1%.
- Malays had the highest prevalence of obese people at 24% in 2010, compared to 7.9% among Chinese; and Indians suffered from a higher obesity prevalence than Chinese.
- Several approaches were taken by the Singapore government to respond to these challenges.
- Healthier Choice Symbol - a positive food labelling programme, indicates when a packaged food product or beverage is healthier (e.g. lower in fat, sodium, and/or sugar) relative to comparable products.
- Trim and Fit Programme - aimed to improve physical fitness and reduce the prevalence of overweight students. The percentage of overweight students decreased from 11.7% in 1993 to 9.5% in 2006.
- National Steps Challenge - nation-wide intervention that encourages the use of a step tracker and offers incentives to motivate users to clock the recommended 10,000 steps a day.
- Healthier Dining Programme - encourage food vendors to use healthier ingredients. Modify dishes to contain less oil, salt and sugar and include more fruit and vegetables, and to introduce healthier new dishes.
- Adult overweight prevalence rose from 26% in 1995 to 34.7% in 2009.
- Thailand is experiencing increased urbanisation, longer life expectancy and reduced malnutrition, leading to the increased prevalence of obesity and overweight.
- Several drivers include the increased availability of calorie-dense, nutrient-poor foods. Also contributing is Thailand’s family planning programme that has resulted in fewer children per family, leading to a tendency to overfeed.
- After focusing on under-nutrition for many years, the government is beginning to prioritise efforts to tackle obesity. Obesity was included in the National Economic and Social Development Plan of 2009, and in 2012, the Ministry of Public Health developed the Thailand Healthy Lifestyle Strategic Plan, which emphasised the risks of unhealthy eating habits. Several public awareness campaigns were also implemented, involving the government, academics and non-governmental organisations (NGOs), although they lack scientific evaluations of their effectiveness.
- According to WHO estimates for 2014, 23.6% of Filipino adults above the age of 18 are overweight. Women (26.3%) were more affected than men (21%).
- With greater access to and availability of food, urban Filipinos are also opting for energy-dense foods and foods high in saturated fats, and they are consuming fewer fruits and vegetables.
- Physical inactivity is also a significant problem. Many adults are not physically active, and children lack places to play. Wealthier children are spending more time on computers, video games and electronic gadgets, and are assailed by food advertisements on television, computers and billboards.
- Habits in the home is also a contributing factor. Parents who do not eat well set the wrong example for their children.
- The Philippines continues to battle under-nutrition and this has been the focus of the government in recent years. The 2011–16 Philippine Plan of Action for Nutrition focuses on hunger, child under-nutrition, maternal under-nutrition, and deficiencies in iron, iodine and vitamin A. Obesity and overweight has since been added as a fifth pillar, but they are still not a high priority.
- The Philippines ranks ninth highest in the world in terms of the number of children facing stunted growth, affecting 30% of children under five years.
- Malaysia has the highest obesity (13.3%) and overweight (38.5%) prevalence in ASEAN, according to WHO.
- Dietary quality is low, with the Malaysian National Health and Morbidity Survey finding that 92.5% of adults aged 18 and above consume less than five portions of fruit or vegetables per day.
- Fat and sugar intake increased by 80% and 33%, respectively, between the early 1960s and 2005, and the Malaysian Adult Nutrition Study reported that only 14% of adults performed adequate levels of exercise.
- There is not a significant difference between urban and rural obesity.
- One of Malaysia’s obesity drivers is its rapid economic change. Its GDP per capita increased from US$7,101 in 1980 to US$23,267 in 2015, and this has had a knock-on effect on obesity and overweight, with rising incomes fueling increased food consumption (particularly of processed foods).
- Cultural factors are also pertinent. For instance, popular Malaysian foods include deep fried snacks, dishes heavy in coconut oil and fatty foods. There is also a strong culture of entertaining guests with food.
- Most people also think of obesity as a cosmetic issue, and are not aware of their associated dangers. Malaysia has in place a universal national healthcare system, providing access to affordable healthcare, which makes people think that it is easier to get treated than do preventative measures.
- Indonesia’s economic growth over the past three decades has produced a burgeoning middle class that is increasingly urbanised and sedentary. There is an overweight prevalence of 24.5% (28.4% among females compared to 20.6% among males).
- Regional overweight prevalence variation is significant, ranging from 15.2% in East Nusa Tenggara (the poorest province) to 39.2% in Jakarta (the richest province — indication of the correlation between income levels and obesity prevalence).
- 37.2% of children under the age of five are stunted (public awareness of this issue is low), which increases the risks of developing noncommunicable diseases when older—the double burden of malnutrition.
- Food availability and changing diets have played an important role in increasing the prevalence of overweight. For example, food availability per capita has grown by 40%, with 20% coming from fat sources, and 93.5% of the population consume less than five portions of fruits and vegetables a day.
- A larger working population also means that people spend more time commuting and less time on food preparation, leading to a preference for processed or pre-prepared food that but tends to be high in carbohydrates and fats.
- Indonesia’s physical environment is not particularly conducive to physical activity. There are few bike lanes, sidewalks or pedestrian precincts, and parks are rare.
- Vietnam has undergone rapid economic growth over the past two decades, spurred by the lifting of the US trade embargo, reforms in socioeconomic policy and urbanisation.
- A National Nutritional Survey conducted in 2005 found that one-sixth of the population was obese - 14.6% of men and 18.1% of women. Almost 6% of children under five were overweight.
- The country still faces what the WHO describes as a “double burden of over and under-nutrition”. City-dwellers are three times more likely than their rural peers to be obese, and children based in cities are much more likely to be overweight (32.5%, compared to 13.5% in rural areas). Boys were also more likely to be overweight or obese than girls, reflecting cultural norms which favours overfeeding sons. Household diets have also changed, with meals now including much more salt, fat, and animal-based protein than in the past. The amount of energy from fats consumed has also doubled.
- One-quarter of the adult population did not engage in enough physical activity in 2009–10. Motorcycles and cars are also replacing bicycles as a favoured mode of transport.
- General awareness about the problems of obesity is low. Excess weight is still viewed as a sign of prosperity and wealth.
- The government published its National Nutrition Strategy for 2011–2020, to recognise this gap. Interventional possibilities included a proposed tax on carbonated drinks and creating more green spaces in cities to facilitate exercise in public.