MALAYS & OBESITY (Big trouble)

The following is a report by Chang Ai-Lien, Senior Correspondent in the Saturday Special report of the Straits Times dated 13th March 2010.

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Fatty foods and a couch potato lifestyle have long been the Malay way but alarming rates of chronic disease and obesity are spurring policymakers, medics and community leaders into action, with programmes of diet and exercise. Success is simply a matter of life and death.
By Chang Ai-Lien, Senior Correspondent
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THE treats just roll off the tongue: nasi lemak with its glistening coconut-saturated rice, mutton rendang, that tender meat blanketed in rich, spicy gravy; delightfully rich, sinfully sweet melt-in-the-mouth kueh.

All part of Singapore's celebrated food heritage - but for the Malays, overindulging in these dishes so central to their cultural identity could become a meal ticket to an early grave.
To put it bluntly, Malays are too fat, getting fatter too fast and succumbing to chronic diseases in the process.

Dr Sum Chee Fang, director of Alexandra Hospital's diabetes centre, sums it up: 'First they get big, then they get diabetes, complications from diabetes such as eye damage and kidney disease, then it leads to heart trouble and stroke.'

Almost seven in 10 Malays here are considered at risk of health problems such as diabetes or heart disease because of their weight.

Over one in two Malays is too heavy, with a body mass index (BMI) of 25 or more. One in five has a BMI of 30 and above, and is obese. BMI is an international classification of weight status in adults, based on a person's weight and height.

Asians, who have relatively higher body fat than Caucasians, have an increased risk of health problems at lower BMI. Those with a BMI of 23 and above are considered at risk - that includes 66.2 per cent of the Malay community.

The numbers only hint at the dimension of a problem that involves huge health costs, family trauma, as well as underperformance at school and work.

The issue is so worrying that the Government is working with key community representatives to try a new tack to help Malays get active, eat better and take charge of their health.
Trained health ambassadors will go door to door to cajole families to buy into a healthier lifestyle later this year.

Several mosques are also leading the charge with exercise regimes, health checks and cooking sessions in a pilot project that will eventually be rolled out to every mosque.

The obesity issue has Minister-in-charge of Muslim Affairs Yaacob Ibrahim concerned.
'Making inroads into exercise and diet is a challenge,' he tells The Straits Times. 'In particular, the message to eat healthily has to seep in. It's an input, output thing; we have to start cutting back to what we actually need.'

Doctors and community leaders are equally concerned.

Madam Halimah Yacob, deputy secretary-general of the National Trades Union Congress (NTUC) and former chairman of the Government Parliamentary Committee for Health, is very worried because obesity is associated with diseases such as diabetes and high blood pressure, which could lead to heart attack and kidney failure.

'I think we should continue to engage the Malay-Muslim organisations and the mosques as these are effective vehicles to reach out to the community,' says Madam Halimah, who rides a stationary bicycle or does brisk-walking for 45 minutes several times a week to keep fit.
'In addition, we should focus a lot more on the women as they are the ones that plan and cook for the family.'

The incidence of chronic illnesses like kidney failure is already much higher among Malays, and, notes cardiologist Mak Koon Hou, they are more likely than other races to die from a heart attack. 'With increasing prevalence of diabetes and obesity, the occurrence of these chronic diseases will likely increase further. Health programmes targeted at Malays are needed to improve their outcomes,' he says.

FAT-SATURATED DIET

DOCTORS can point to the main culprits: a fat-saturated diet consisting of rich gravies, sweet dessert and fast food, on top of a sedentary lifestyle.

Endocrinologist Lee Chung Horn says: 'Most of us believe Malays are the heaviest ethnic group because of their diet which often includes high-calorie food like fried noodles, lontong lemak, nasi lemak, sayur lodeh, curry lemak, mutton rendang, beef rendang and Malay kueh.'

According to the 2004 National Nutrition Survey, one in two Malays has deep-fried food more than twice a week. One in five has at least seven sweetened drinks weekly.

Malays have also overtaken Indians when it comes to the amount of fat in their diet. They consumed 85.7g of fat each day, the survey found, up from 68.9g in 1998. In comparison, Indians had 83.3g, while the figure for Chinese was 77g.

What does not help is that social functions centre on eating. 'Malays are also very gregarious people, and arguably the most family-oriented of our country's major races,' says Dr Lee, who is president of the Singapore Association for the Study of Obesity, which comes under the International Obesity Task Force, a body that works with the World Health Organisation and other stakeholders to fight obesity.

'Traditional Malay culture is characterised by social assemblies, and at these assemblies - weddings, birthdays, parties - extended families and friends come together to meet and eat.'
Researchers have uncovered variants of genes that seem to be associated with obesity, but there is no evidence yet that ethnic differences in obesity have a genetic basis, says clinician-scientist Tai E Shyong, a consultant at the National University Hospital's (NUH) endocrinology department.

'What has been found so far is that these genetic variants explain only a small proportion of the risk of obesity,' he says.

But while genetic factors may predispose some people to being fat, the main causes are clearly a high-calorie diet combined with a sedentary lifestyle, notes Professor Chia Kee Seng, head of the epidemiology and public health department at the National University of Singapore's Yong Loo Lin School of Medicine. 'We should also look at the other end of the spectrum and study behaviour modification, and what is needed to encourage people to lose weight.

'Physical activity in Singapore is promoted as a leisure activity. We could look at what structural changes are needed for people to make it part and parcel of life, to get them to walk from point A to B rather than drive.'

Dr Yaacob notes that most Malays eat out, eat late and indulge frequently in rich foods such as nasi beriani, which in the past were a rare treat.

He laments that the expanding halal food industry has also embraced unhealthy options such as fast food. And he urges Malays just to change one thing, for starters: 'We should have dinner earlier, so as not to sleep on a full stomach.'

EVERY LITTLE BIT COUNTS

DOCTORS say the benefits of losing weight - no matter how little - are tremendous.
Dropping as little as 2 per cent of one's weight can improve diabetes control and often results in a reduction in medications, says Dr Tham Kwang Wei, director of the obesity and metabolic unit at the Singapore General Hospital Life (Lifestyle Improvement and Fitness Enhancement) Centre.
'The more weight one loses, the greater benefit one will see,' she adds, pointing to a recent study conducted by the United States National Institutes of Health, which showed that participants who lost 8.6 per cent of their weight over a year through diet and exercise improved their diabetes condition.

They reduced not only their diabetes medications, but those for blood pressure and cholesterol as well.

While Dr Yaacob is heartened to see more women taking to regular exercise, he notes men do not seem to be doing their bit. 'I see them jogging in their tudung and brisk-walking. For their husbands to join them, that's a lifestyle change I'd like to see.'

The percentage of obese Malay women dipped slightly from a high of 23.7 per cent in 1998 to 21.4 per cent in the 2004 National Health Survey, but the figure for Malay men almost doubled to 16.9 per cent from 8.8 per cent over the same period.

Doctors want to see the results of this year's National Health Survey before judging if the weighty issue of Malay women is indeed on a downward trend. But anecdotally, this group - traditionally the most sedentary - seems to be exercising more.

One customised programme that has taken off among women is 'kebayarobics' - an amalgam of aerobics with traditional Malay joget dance movements introduced by the Health Promotion Board (HPB). About 100 groups now do it regularly in places like mosques and community clubs since it started catching on here in 2004.

The need to get men on an exercise regime has prompted the board to set up a pilot programme with three mosques and the Football Association of Singapore to hold weekly soccer sessions. It has 80 sign-ups so far.

Over the next few months, the HPB will work with Malay caterers to customise healthier menu options, such as curries made with low-fat milk and vegetable dishes.
Nurses have also been selected to conduct workshops at community clubs and mosques for people who are overweight and at risk of developing chronic conditions, while mosque staff and cooks are being trained to whip up healthier food.

Dr Annie Ling, director of HPB's Adult Health Division, says the board was looking at customising programmes for other races, or specific groups such as women, but decided to start with Malays because 'this is where the need is greatest'.

The Committee for Community Health, set up in 2008 to work with the HPB on tailoring programmes for Malays, believes Malays will take to exercise if the initiative starts from the ground up and is rolled out with 'a human touch'.

'We are bringing the mountain to Muhammad,' says its chairman, cardiologist Abdul Razakjr Omar.

Dr Abdul, who is a consultant at the National University Heart Centre's cardiac department, adds that the problem among Malays - the race with the lowest median income here - is also a social issue.

Studies in developed countries such as the US have shown that obesity is more prevalent among the poorer and less educated. 'I believe that the more educated in our community should come forward to help,' he says.

His committee now comprises 10 Malay/Muslim representatives including doctors, grassroots mosque and media representatives. It means business, he says, adding that 'this is not just going to be a public relations exercise'.

One initiative is Sihat 360º, or Health 360º, a pilot programme involving four mosques in the south-west: Darussalam, Ar-Raudhah, Hasanah and Al-Khair.
A full-time Malay health promotion coordinator stationed at one of the mosques organises health screenings, exercise sessions, healthy cooking classes, weight and disease management workshops and so on.

Dr Abdul devised the idea after noting how the NUH heart failure programme had achieved sterling results by employing a Malay case manager to ensure Malay patients were taking their medication, eating properly and getting exercise. 'A lot of the time, people need motivation, someone to befriend them and to win their trust when they visit their homes, or at mosques where many Malays congregate,' he explains. 'It helps to have someone to call if you have a problem.'

If Sihat 360º takes off, similar projects will be rolled out in the 69 mosques islandwide, he adds.

In another initiative, 15 Malay grassroots leaders at Jurong Green are being trained by medics on chronic disease management and monitoring blood pressure and glucose levels, and even negotiation skills, says committee vice-chairman Zuraimi Mohamed Dahlan, a general practitioner who is volunteering time to conduct the weekly training.

They will visit people in their homes to check for obesity, high blood pressure, diabetes and high cholesterol, and encourage them to adopt a healthy lifestyle.

As well, 80 grassroots volunteers from Sembawang and Nee Soon East and Central constituencies are being trained as 'health champions' to work with residents under a similar scheme.

REACHING OUT

ALEXANDRA Hospital staff have come up with a similar concept.

Dr Michael Wong, head of the family and community medicine department and director of the Health for Life Centre, says it is planning to work with six mosques in the north, to hold health talks for worshippers.

Doctors, nurses, physiotherapists, dietitians and psychologists will hold sessions at the mosques, when staff move to the new Khoo Teck Puat Hospital in Yishun this year.

Darul Makmur Mosque manager Suzana Bakar says that such talks had been done on an ad hoc basis before, and that a more structured programme would hopefully yield better attendance and results. She adds that physical and spiritual food do go together.

'There is a commandment for Muslims to ensure that the food we eat is permissible in source and substance, and also good and nutritious for the body,' she says. 'It's our responsibility to not only make sure our food is halal, but to also look out for healthy ingredients.'

Driver Mohammed Yussof, 45, for one, says he would be keen to attend such sessions. 'I don't have much free time, so if I can get some tips when I go for prayers, it will be very useful.'