Recommended Prevention Strategies

Greater attention should be given to strategies aimed at preventing weight gain and obesity. These are likely to be more cost effective and have a greater positive impact on the long- term control of body weight than strategies designed to deal with obesity once it has fully developed. 

The Committee adapted relevant strategies recommended by WHO (1998) and the Surgeon General’s Report (US DHHS 2001) for this section.

Shared Responsibility

Control and prevention of obesity focus on the promotion of healthy diets or increasing levels of physical activity, or both, and should be a shared responsibility (Figure 10). They cannot be seen as the sole responsibility of any one sector. To be effective, strategies should be multisectoral, with the coordinated participation of the health, educational and agricultural sectors. Active participation should be sought from governments, the food industry, the media and the individual consumers. The support of professional bodies, non-governmental organizations and international agencies dealing with obesity and related non-communicable diseases (NCD) is essential. The prevention and management of overweight, obesity and associated co-morbidities require the synergism of national health policies on nutrition and NCD control as well as in relation to sports, housing environment, urban planning as well as transportation.

We must collectively build on existing programs in both the public and private sectors, identify current gaps in action, and develop and initiate actions to fill those gaps. Publicprivate working groups should be formed around key themes or around the major settings in which obesity prevention and treatment efforts need to take place. The design of successful interventions and actions for prevention and management of overweight and obesity will require the careful attention of many individuals and organizations working together through multiple spheres of influence.

Government

Government should play a leading role in the prevention of obesity by creating and implementing policies that promote an environment in which healthy dietary and physical activity options are readily accessible. Government can provide support for public education, and public awareness campaigns. It should be willing to work together in partnership with the key players involved in the prevention and control of obesity identified in this section. Governments should provide funding for research on the effects of interventions on overweight and obesity prevalence, prevention, and treatment, and on trends in diet and exercise among at-risk populations.

State governments can form task forces, steering committees, or advisory committees and can also develop State strategic plans for the prevention of obesity. Local authorities should work together with organisations and communities to facilitate goals for reducing overweight and obesity. This includes providing facilities to increase physical activity and promote healthy food choices.

Industry

The industries have a vital role in the prevention of overweight and obesity. They should continue to support government policies in relation to promotion of healthy lifestyle. They should also allocate resources to carry out action plans as part of their social responsibility. The food industry should pay greater attention to the nutritional value of products and should be encouraged to produce and market nutritious food products and healthier alternatives at an affordable price. Other industries (for example health, fitness and housing developers) may influence the extent of physical activity in which we engage. 

The industry, therefore, has the potential and responsibility to create and sustain an environment that encourages individuals to achieve and maintain a healthy or healthier body weight. The industry should adhere to regulations governing the marketing, advertising and labelling of their products and services.

Professional bodies 

These organizations can play vital and effective roles in reinforcing and enhancing programmes and activities of the government departments and the industry. The relevant professional bodies can provide the expertise required and often serve as the link between the government or industry and the community. Such organizations may have an advantage in implementing various intervention programmes for the communities. They must, nevertheless, have the necessary checks and balances within the organisations and play an unbiased role in the programme.

Non-governmental organizations

Organisations can initiate discussions on obesity and overweight within their membership and can establish weight and lifestyle goals. Programs can be developed to educate members on healthy food choices and appropriate levels of physical activity and to put these healthy habits into practice. Through networking, organisations can influence the wider community to conduct similar programs and thus serve as a useful public resource.

Communities

A forum should be provided in which all community members can discuss the scope of the problem of overweight and obesity within the community. The nature and adequacy of available resources for public education and treatment must be addressed. Policies and programs to reduce the burden of overweight and obesity within the community should

be strengthened.

Individuals

Individuals lie at the foundation of the solution to the problems of overweight and obesity. Individuals can share their own knowledge and habits regarding a healthy diet and physical activity with their children, other family members, friends, and co-workers. Through open discussions regarding the methods, challenges, and benefits of adopting a healthy lifestyle, individuals can be empowered to take responsibility in the prevention of obesity.

National Plan of Action

The prevention of obesity requires a range of long-term strategies. They should be part of an integrated, multi-sectoral, population-based approach, which includes environmental support for promoting a healthy life style, particularly healthy diets and regular physical activity. A national action plan for the control and prevention of obesity is thus proposed to effectively combat the problem. This Plan should complement and support National Plan of Action of Nutrition that is already established in the country and is in line with the Food and Nutrition Policy of Malaysia.  As emphasized above, in order to establish a sustainable action plan and for that plan to be effectively implemented, there must be committed government support, and smart partnerships between the public and private sectors and productive collaborations between organizations, industries, communities, schools, families and individuals.

National Steering Committee for the Prevention of Obesity 

It is proposed that a National Steering Committee for the Prevention of Obesity be established. The key functions of this Committee would include: planning and developing action plans and programmes for the control and prevention of obesity 

monitoring and implementation of these plans and evaluating the outcomes. The Committee should be led by the Ministry of Health and should involve the key players in the smart partnership mentioned above, namely the Ministry of Education, other relevant government agencies, industries, professional bodies, and NGO’s. This partnership will provide a strong central leadership with a multi-disciplinary approach. The multi-sectoral component of the National Steering Committee will foster learning, sharing of resources, division of labour, and consistency in the message to the public. Additionally they lend credibility to policies, and programmes in addressing the problem of obesity.

Formation of Working Groups

It is recommended that Working Groups should be formed around settings, such as in communities, schools, health care facilities and workplaces. These working groups will be charged with the responsibility of implementing the recommended programmes and activities identified by the Steering Committee. The formation of Working Groups would optimise the talents and resources available at the local level, and dedicated to operationalise the plan of action for obesity prevention. Each Working Group should preferably involve the media to facilitate communication and promotion in the various settings. It is important that there should be regular interactions among the various Working Groups to establish networking, share resources, as well as exchange ideas and experiences in the implementation of the action plan. Successful intervention programmes can be identified through this system and used as a model for other similar settings. The National Steering Committee should play the role of facilitating and ensuring that such interactions take place. 

Monitoring and evaluation

Systematic assessment and evaluation should be a routine part of all interventions aimed at preventing and managing overweight and obesity. The effectiveness of policies, programmes and activities in the prevention and management of obesity must be evaluated at regular intervals. Sound experimental design and statistical principles should be used to critically evaluate the impact of each proposed intervention programme. Monitoring should include gathering new information on obesity as well as reporting on the status of current programmes and activities. Monitoring will allow the national steering committee to gauge the success or failure of any action plans. 

A surveillance system should be established to track the problem of obesity. Monitoring and surveillance will form part of an evaluation system to monitor outcomes of action plans. This type of information is important for revision and expansion of these action plans. The nutrition surveillance system conducted by the MOH among infant and toddlers in government health centres should be continued and extended to kindergartens.

The current weight and height measurements of school children needs to be improved and data collected should be analysed. This activity should be extended to secondary schools. It is proposed that a periodic national nutrition survey to be conducted to monitor trends in body weight and lifestyle habits such as food habits and physical activity pattern.

Strategies for Prevention of Obesity

The development of effective strategies for the prevention of overweight and obesity

requires action at three levels (Figure 11):

• Public health prevention (directed at everyone in the population)

• Selective prevention (directed at subgroups of the population with an above average risk of developing obesity).

• Targeted prevention (directed at high-risk individuals with existing weight problems but who are not yet obese).

The key components of the strategies are education and action. Education involves providing information and tools to motivate and empower decision makers at the governmental, organisational, community, family, and individual levels who will create change toward the prevention and decrease of overweight and obesity. Action refers to interventions and activities that assist decision makers in preventing and decreasing overweight and obesity, individually or collectively.

The strategies are centred on activities and interventions in five key settings: families and communities, schools, health care, media and communications, and workplace. The key actions discussed are presented for each of these settings. Many of these actions can be applied in several or all settings.

Within each key settings, the Committee has recommended specific guidelines for the prevention of overweight and obesity. Please refer to Appendix A (dietary practice), Appendix B (physical activity), and Appendix C (psycho-behavioural aspects). 

Setting 1: Individuals, families and communities 

Individual behavioural change lies at the core of all strategies to reduce overweight and obesity. Successful efforts, however, must focus not only on individual behavioural change, but also on group influences and supportive environment with accessible and affordable healthy food choices and opportunities for regular physical activity. Other lifestyle habits such as getting enough rest, avoidance of unhealthy habits, including smoking and alcohol consumption, should also be given attention. Family members can share their own knowledge and habits regarding a healthy diet and physical activity with their children, friends, and other community members. Emphasis should be placed on family and community opportunities for communication, education, and peer support surrounding the maintenance of healthy dietary choices, physical activity patterns and behavioural changes.

Education

a. Educate policy makers of the need to develop social and environmental policy that would help communities and families consume a healthier diet and be more physically active.

b. Inform community leaders (for example Jawatankuasa Keselamatan Kampung (JKKK), Penghulu, political leaders) about the importance of developing healthy communities and highlight programs that support healthy lifestyle.

c. Educate individuals, families, and communities about healthy lifestyle based on the guidelines given in Appendix A and B. They should be educated and encouraged to demand food product of high nutritional quality and safe clean food. 

d. Educate parents about the need to serve as good role models by practising healthy eating habits and engaging in regular physical activity in order to inculcate lifelong healthy behaviours in their children. 

e. Educate expectant parents and other community members about the potentially protective effect of breastfeeding against the development of obesity.

Obesity prevention and management interventions should be carefully designed so that they do not cause undue fear of fatness and precipitate eating disorders especially in adolescent girls. Interventions should also discourage other unhealthy behaviours, for example cigarette smoking, that may be adopted in the belief that this habit will

prevent weight gain. 

Action

a. Resident associations should support the development of increased facilities for leisure time physical activity and to encourage local food outlets to increase availability of healthier food choices in their vicinities. 

b. Encourage the food industry to provide reasonable food and beverage portion sizes. c. Increase availability of nutrition information for food products and foods served in eating establishments. 

d. Create more community-based obesity prevention and treatment programs for children and adults. 

e. Empower families to manage weight and health through skill building in parenting, meal planning, and behavioural management (Appendix C). 

f. Expand efforts to encourage healthy eating patterns, consistent with the guidelines provided in Appendix A.

g. Place more nutritionists at community level to conduct nutrition education programs.

h. Create community supports and provide facilities that promote and support breastfeeding. 

i. Encourage outdoor activities among families and minimise time spent watching television and in similar sedentary behaviours. 

j. Provide and maintain more safe and accessible recreational facilities such as playgrounds and parks for the public.

k. Create and implement public policy related to the provision of safe and accessible sidewalks, walking and bicycle paths so as to encourage and facilitate more frequent daily outdoor activities. 

Setting 2: Schools

Schools are identified as a key setting for public health strategies to prevent and decrease the prevalence of overweight and obesity. Malaysian children spend a fairly large portion of time in school. Schools are in the position to provide opportunities to educate children in healthy eating and physical activity. These healthy practices can be reinforced in school settings. Public health measures should extend beyond health and physical education to include improvement in physical and social environment in school, and links with families and communities.

Education

a. Increase awareness among teachers, canteen operators and parents-teachers associations (PTA / PIBG) about the contribution of good nutrition and physical activity to the maintenance of healthy weight. 

b. Educate teachers to be role models for children, to adopt healthy eating and regular physical activity. 

c. Educate staff to be sensitive to the problems encountered by the overweight child. 

d. Educate schoolchildren, teachers and parents about unhealthy body size perceptions

and inappropriate weight control practices.

Action

a. Include healthy living education into the school curriculum, emphasising on healthy eating and physical activity.

b. Review the School Canteen Guidelines and reinforce its implementation in all schools. Adopt policies ensuring that healthy food choices are made available in schools.

c. Schools should organise regular programmes on healthy eating by incorporating talks by nutritionists, interactive sessions such as games, quizzes and debates. Adopt existing nutrition educational packages that are age-appropriate and culturally sensitive. 

d. Vending machines should not be encouraged in schools. However, if these are available, schools should ensure that healthy snacks, food and drinks are provided in these machines.

e. Provide all children, from pre-school through secondary schools, with dedicated time for physical education with qualified teachers to help develop the knowledge, attitudes, skills, behaviours, and confidence needed to be physically active for life.  

f. Provide more co-curricular physical activity programs, and encourage the use of facilities offered by the school and/or community-based organisations outside of school hours.

g. Provide incentive to children with overweight problem for participation in physical activities.

Setting 3: Health care

The health care system provides a powerful setting for interventions aimed at reducing the prevalence of overweight and obesity and their consequences. Nutrition education given by health care providers can influence dietary choices and physical activity patterns. In collaboration with schools and workplace, health care providers and institutions can reinforce the adoption and maintenance of healthy lifestyle behaviours. Health care providers also can serve as effective public policy advocates and further catalyse intervention efforts in the family and the community and in the media communications settings.

Education

a. Sensitise health care providers and administrators of the burden of overweight and obesity on the health care system in terms of mortality, morbidity and cost. 

b. Emphasize to the health care community about the importance of being role models for public on healthy eating and regular physical activity.

c. Educate health care providers and administrators to identify and promote opportunities for public to have access to effective nutrition and physical activity programs. 

d. Inform and educate the health care community about assessment of weight status and the risk of inappropriate weight change. 

e. Educate health care providers on effective ways to promote and support breastfeeding.

Action

a. Train health profession students and provide continuous professional development for health care providers in effective prevention and treatment techniques for overweight and obesity. 

b. Encourage partnerships between health care providers, schools, religious groups, and other community organisations in prevention efforts targeted at social and environmental causes of overweight and obesity. 

c. Explore mechanisms in health insurance policies that will partially or fully cover reimbursement for health care services associated with weight management, including

nutrition education and physical activity programs. 

d. Intensify effective nutrition and physical activity programmes targeting at the prevention of obesity.

Setting 4: Media and communications

Public health efforts to promote healthy lifestyle must be carried out in close collaboration with the media. Continuous public education using relevant mass media on the rising problem of obesity will increase awareness and encourage the community to take steps to prevent and manage the problem. The mass media can play an effective role in communicating intervention measures for dietary improvement and promotion of physical activity to the community. 

Education

a. Educate media professionals that the primary concern of overweight and obesity is one of health rather than physical appearance. 

b. Emphasise to media professionals that the burden of overweight and obesity is similar in rural-urban populations and among ethnic groups. However, there is a need for culturally appropriate health messages. 

c. Communicate the importance of prevention of overweight through balancing food intake with physical activity at all ages. 

d. Educate the media professionals about the health implication of undesirable weight change. 

e. Build awareness of the importance of social and environmental influences on appropriate diet and physical activity choices. 

f. Educate media professionals on policy areas related to diet and physical activity.

g. Emphasise to media professionals the need to develop uniform health messages about

diet and physical activity that are consistent with the guidelines (Appendix A and B).

h. Emphasise the role of media in promoting behavioural changes in the population.

Action

a. Collaborate with the media in conducting national public awareness campaigns on the health benefits of regular physical activity, healthy dietary choices, and maintaining a healthy weight, consistent with the Malaysian Dietary Guidelines. 

b. Media should promote healthy and realistic goals for weight loss programmes as well as scientifically substantiated claims on weight management products. 

c. Media should incorporate messages about healthy eating and regular physical activity consistent with the Malaysian Dietary Guidelines, more frequently.

d. Media to help train health professionals in advocacy skills to effectively disseminate their knowledge to a broad audience. 

e. Media to conduct advertising campaigns to counter messages that promote consumption of excess calories generated by food industries, and physical inactivity by industries that promote sedentary behaviours. 

f. Media, in collaboration with health professionals, should utilise celebrities’influences as role models to demonstrate healthy eating and physical activity for health rather than for appearance. 

Setting 5: Workplace

The workplace has the potential to provide opportunities to reinforce the adoption and maintenance of healthy lifestyle behaviours. Public health measures should extend beyond health education and awareness to improve physical and social environment in the workplace.

Education

a. Employers should be informed on direct and indirect costs of obesity. 

b. Communicate to employers the return-on-investment (ROI) for obesity prevention and treatment programmes.

Action

a. Adopt flexible working hours to create opportunities for regular physical activity during working days. 

b. Observe ‘dedicated’ lunch time for employees. 

c. Promote healthy eating by ensuring healthy food options are made available at staff cafeteria / canteen.

d. Promote physical activity by providing exercise and changing facilities, or subsidise cost of employees to join local fitness centres

e. Employers should ensure that health insurance contract for employees include weight management and counselling. 

f. Create work environments that promote and support breastfeeding. 

g. Government workplaces should promote healthy eating and physical activity that will

set examples for others.

h. Employer to provide programmes to help employee with weight problem

i. Tax reduction/rebate for enrolment in fitness club

References

WHO. (1998). Obesity: Preventing and managing the global epidemic.Report of a WHO Consultation on Obesity. Geneva: World Health Organisation. 

US DHHS. (2001). The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.