By Jason Loh & Anis Salwana Abdul Malik

The Ministry of Health (MOH) and the World Health Organisation (WHO) recently co-published a report titled The Direct Health-Care Cost of Noncommunicable Diseases in Malaysia on August 9, 2022.

The report, using data from 2019, shows what could well be deemed as a “depressing” amount of government spending on only three noncommunicable disease (NCD) categories estimated to be at RM9.65 billion.

The data shows that the three selected NCDs were as follows:

• Diabetes – which incurred the highest cost at RM4.38 billion (45.38% of the total); followed by
• Cardiovascular disease (CVD) – at RM3.93 billion (40.73%); and finally
• Cancer – at RM1.34 billion (13.8%).

The findings are already worrying even with the exclusion of the other NCDs (that are deemed relatively not as common) such as chronic respiratory diseases, mental health and osteoarthritis which were not included in the RM9.65 billion figure.

MOH has estimated that for 2017, these three NCDs cost Malaysia up to RM12.88 billion in productivity losses due to absenteeism, presenteeism and premature deaths (see “The Impact of Noncommunicable Diseases and Their Risk Factors on Malaysia’s Gross Domestic Product”, MOH, 2020).

This makes the combined cost of the three NCD categories in 2017 to be RM22.53 billion to the Malaysian economy.

We must look at the NCDs’ risk factors to understand why this is happening.

According to WHO, the risk of dying from an NCD can increase due to tobacco use, lack of physical activity, excessive use of alcohol, and unhealthy diets. Moreover, 77% of all NCD fatalities come from low- and middle-income countries.

The MOH 2020 report alluded to also revealed that the “burden of disease” (i.e., highly possible causes) of the three selected NCDs are according to four attributable risk factors: unhealthy diets, tobacco use, low physical activity, and alcohol use.

For CVD, unhealthy diets accounted for 62.1% of the burden of disease, whereas tobacco use accounted for 24.8%.

The same goes for diabetes – as unhealthy diets and tobacco use accounted for the most burden of disease at 39.7% and 18.5%, respectively.

As for cancer, tobacco consumption accounted for the highest burden of disease at 18% while unhealthy diets accounted for 8.33%.

However, because the combined effects of the risk factors have not been considered as such, percentages by disease are not to be regarded as cumulative.

Low physical activity was not a prominent risk factor whilst alcohol use was only a relatively minor contributor among the three NCD categories.

Unhealthy diets, the most prominent risk factor for CVD and diabetes, could be caused by the high cost of eating healthy food which makes it unaffordable for the low-income group.

According to a survey done by Food Industry Asia (FIA) and research firm IGD, despite 99% of Malaysian respondents indicating interest in trying to improve their eating habits, 71% identified cost as a key barrier (see Majority of Malaysian consumers want healthy foods but cost is a deterrent, IGD, May 16, 2019).

Moreover, Deputy Health Minister Datuk Dr Noor Azmi Ghazali said that according to the National Health and Morbidity Survey (NHMS) 2019, 95% of Malaysians do not consume enough vegetables as recommended by MOH.

Most only eat one type of vegetable and do not eat fruit and vegetables according to the “quarter (grains), quarter (proteins), half (fruits and vegetables) portion” (“Noor Azmi: 95pc of Malaysians don’t eat enough veggies” New Straits Times, July 19, 2022).

He said that eating only one type of vegetable per meal is not sufficient as it can result in “under-nutrition” and that excessive consumption of sugar and simple carbohydrates causes organic compounds to be stored as fat in the body leading to NCDs, especially the three major ones (of diabetes, CVD and cancer).

“Fattest” nation

Moreover, Malaysia is known to be the “fattest” nation in Southeast Asia, with one in two Malaysian adults being overweight or obese (“Fat, fatter and fattest”, New Straits Times, May 10, 2022).

In addition, according to the NHMS 2019, children from B40 households had obesity and overweight prevalence rates of 15.6% and 15.4%, respectively.

Prof Dr Ruzita Abd Talib, Professor of Nutrition in the Nutritional Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia (UKM), said that in addition to increasing the risk of obesity in children, poor eating choices could also increase their risk of developing diabetes and other NCDs (“Experts see higher risk of obesity among B40 children due to spike in food prices”, Malay Mail, July 14, 2022).

She further stated that obesity could also be induced by food insecurity (due to finances which then influences the dietary choices) when lower-income groups choose to eat energy-dense food with high fat and sugar contents since these are easier to obtain, cheaper, and satiates hunger quicker.

Furthermore, according to the “Health Literacy in Malaysia: A Population Based Study” (2021), which is based on a cross-sectional population-based survey conducted as part of the NHMS 2019, 37.7% of the B40 group had limited health illiteracy – the highest among the income groups.

Besides that, limited health literacy was more prominent among respondents in the older age group and lower education level.

Additionally, individuals with lower levels of education and older age groups were also more likely to have limited health literacy.

To reduce the impact of NCDs on our economy, MOH has sought to address the problem from the root cause.

One of the critical ways is to improve on Malaysians’ dietary habits and lifestyles.

The MOH introduced the Healthier Choices Logo (HCL) in April 2017. It is a criteria-based front-of-pack scheme that aims to give point-of-sales (POS) information so that it is easier for consumers to make an informed decision.

But we can do more.

MOH should also introduce front-of-pack warning labels as suggested by the article entitled, “‘Warning: ultra-processed’ – A call for warnings on foods that aren’t really foods”, published by BMJ Global Health (2021).

Several countries have implemented or plan to implement front-of-package warning labels on unhealthy food to lessen the unsustainable burden that bad diets place on society.

This measure builds on the front-of-package nutrition labelling already in use in the UK (see Figure 1):

Figure 1: Colour-coded system also known as the traffic-light labelling system
Source: British Nutrition Foundation – as cited in “Front of pack labelling around the world”, IGD (January 16, 2020)

The labels provide information on the specific compositions and structures of the foods concerned – e.g., whether these are high or low in saturated fat, salt and sugar.

The article suggests that, in addition, front-of-package labelling should incorporate an “ultra-processed” warning label such as, “Warning: this product is ultra-processed AND it is high in (saturated fat/salt/sugar)” as shown in Figure 2.

The additional label or extra wording would “signal an independent, additional measure of unhealthiness [sic]”. Such labelling serves to enhance the health literacy of consumers based on the level of food processing.

Figure 2: Proposed warning label for ultra-processed food (Vital Strategies)
Source: 'Warning: ultra-processed - a call for warnings on foods that aren't really foods”, BMJ Global Health, December 6, 2021

However, as highlighted before, the affordability of unhealthy food makes it a readily and easily accessible alternative and source of diet for the B40 group (as the lowest income group with limited health illiteracy).

Therefore, instead of only promoting healthier dietary choices and habits, MOH should go a step further as part of what should be a full-spectrum policy effort by a lateral focus on introducing front-of-package warning labels with respect to unhealthy and ultra-processed foods.

In the final analysis, since unhealthy diets can be said to be the primary risk factor for the major NCDs, it is vital that we seriously tackle the root cause by adopting a strategy that is similar to combatting smoking (which is also a major cause, including Type 2 Diabetes, no less).

Labelling which informs and warns is equally necessary if we want to carry the war beyond healthcare and towards preventative measures – after all “prevention is better than cure”.

-- BERNAMA

Jason Loh and Anis Salwana Abdul Malik are part of the research team of EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.