More than a Sugar Rush: The Impact of Globalisation on Type 2 Diabetes in Malaysia

Over the last several decades, globalisation has generated unprecedented changes across society. These changes are particularly profound in developing nations, in which marked epidemiological changes in built environment, physical activity and diet have impacted morbidity and mortality patterns (Basch, Samuel, & Ethan, 2013; Noor, 2002). This change in disease pattern has seen noncommunicable diseases, such as Type 2 Diabetes (T2D), rather than infectious diseases become a significant public health concern (Noor, 2002). Type 2 Diabetes is a chronic disease, in which gradual insulin resistance results in ineffective management of blood glucose levels and consequent overproduction of insulin by the pancreas (Diabetes Australia, 2019; World Health Organisation, 2016b). As the disease progresses, insulin producing cells are reduced and the pancreas is no longer able produce sufficient insulin and is associated with several deleterious complications, including heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage (Diabetes Australia, 2019; World Health Organisation. 2016b).

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Once considered a disease of excess, T2D prevalence has risen rapidly across low- and middle-income countries and T2D now affects more people in developing nations, than people in developed nations, placing a tremendous financial burden of countries such as Malaysia (Basch et al., 2013; Unnikrishnan, Pradeepa, Joshi, & Mohan, 2017; World Health Organisation. 2016b). Given the direct (e.g., medical) and indirect (e.g., quality of life) costs of T2D, it is important for public health practitioners, policy makers and individuals to better understand the impact of globalisation on T2D in Malaysia in order to develop a strong and effective response (Basch et al., 2013; World Health Organisation. 2016b).

Globally, an estimated 422 million adults were living with diabetes in 2014, compared to 108 million in 1980, with 60% of world cases occurring in Asia (Hu, 2011; World Health Organisation. 2016b). In Malaysia, the prevalence of T2D continues to rise, with known cases increasing from 4.3% in 1996 to 9.8% in 2016 (Tee & Yap, 2017; World Health Organisation. 2016b). However, the true burden of disease is likely to be far greater, with the reported prevalence of total cases (i.e., known and undiagnosed) increasing from 8.9% to 17.5% across the same period (Tee & Yap, 2017). Moreover, Wan Nazaimoon et al. (2013) reported a false-negative frequency of 5.8% when diagnosis was based solely on a fasting plasma glucose test, highlighting the importance of accurate diagnostic measures.

In contrast to the Caucasians, Asians develop T2D at a younger age, at lower degrees of overweight/obesity (a known risk factor for T2D) and tend to progress from pre-diabetes to T2D at a faster rate (Hu, 2011; Unnikrishnan et al., 2017). It is of no surprise then, that the greatest increase in prevalence in Malaysia has occurred in the younger age groups; 5.9% and 8.9% for 20-24-year-olds and 25-29-year-olds, respectively (Tee & Yap, 2017). In terms of gender differences, the prevalence of diagnosed cases of T2D is greater among Malaysian men (10.2%), compared to women (9.5%), despite a higher prevalence of overweight (38.3%) and obesity (15.3%) among Malaysian women compared to men (36.2% and 10.3% respectively; World Health Organisation, 2016a). Given Malaysia’s multiethnic population, understanding potential differences between different ethnicities is an important factor in intervention development. By ethnicity, the overall T2D prevalence was highest among Indians (22.1%), followed by Malays (14.6%) and Chinese (12%; Tee & Yap, 2017). In terms of location, the urban-rural gap has continued narrow with total case prevalence rates of 17.7% and 16.7% reported in 2015 for urban and rural dwellers, respectively (Tee & Yap, 2017; Unnikrishnan et al., 2017; Zaini, 2000).

Risk for T2D is determined by several, often interrelated genetic and metabolic factors (World Health Organisation. 2016b). Encouragingly, although not without significant complexity, the majority of risk factors for T2D are behavioural and thus, highly modifiable (Popkin, 2006; Unnikrishnan et al., 2017). Both unhealthy dietary practices and overweight and obesity are independent risk factors for T2D (Basch et al., 2013; Hu, 2011). Specifically, excessive caloric intake and a diet high in refined grains, animal fats, processed foods, added sugar and low in fibre is associated with increased T2D risk (Hu, 2011; Popkin, 2006; Unnikrishnan et al., 2017).

Unsurprisingly, these same dietary characteristics contribute to overweight (i.e., BMI 25 – 29.9 kg/m2) and obesity (i.e., BMI 30 kg/m2; Basch et al., 2013; Chee Cheong et al., 2019). Once considered a public health concern of the West, overweight and obesity has reached epidemic proportions in developing nations and account for 44% of T2D cases globally (Basch et al., 2013). Indeed, Malaysia has the highest rate of overweight and obesity in South East Asia and alarming prevalence rates of 37.3% (overweight) and 12.9% (obesity), both of which are higher among women (Chong Tzyy Jiann & Lee, 2018; World Health Organisation. 2016a). In higher income countries overweight and obesity are more prevalent among rural and low SES populations, while in low-middle income nations, including Malaysia, the opposite has been observed (Popkin, Adair, & Ng, 2012). However, as with T2D prevalence rates, the gap between rural and urban populations is narrowing (Popkin et al., 2012; Unnikrishnan et al., 2017).

Overweight and obesity typically result from an energy imbalance, in which gradual but persistent weight gain occurs (Noor, 2002). In combination with excessive calorie intake, physical inactivity is a major contributing factor to overweight and obesity (Noor, 2002). Moreover, physical inactivity independently increases the risk of T2D across all ethnic groups in Malaysia (Tee & Yap, 2017; Unnikrishnan et al., 2017; World Health Organisation. 2016a). Likewise, cigarette smoking is an independent risk factor for T2D, with smokers experiencing a 45% increased risk than non-smokers (Hu, 2011; World Health Organisation. 2016b). This is of particular concern in developing countries, including Malaysia, where approximately 60% of males are regular smokers (Hu, 2011).

In contrast to high income nations, in Malaysia, T2D is most common among more affluent, urban populations (Basch et al., 2013; Unnikrishnan et al., 2017). While this mitigates some of the barriers to improvement (i.e., sufficient medical care and preventative measures) often experienced by individuals with reduced economic or social capital, as a developing nation, even the more affluent, urban populations remain at a distinct disadvantage. For example, despite the increasing prevalence of T2D, Malaysia does not have an operational policy or action plan to prevent or reduce the number of new T2D cases among adults or children, a population in which T2D cases is also rising (Basch et al., 2013; World Health Organisation, 2016a). Moreover, the increasing prevalence of T2D and the associated risk factors among the poor will likely have serious implications for health inequalities (i.e., state capacity for the delivery of health services, as well as accessibility and affordability of adequate health care for individuals; Basch et al., 2013; Unnikrishnan et al., 2017).

Globalisation, that is the freer movement of capital, technology, goods and services, has had marked and rapid impact on developing nations, including Malaysia (Popkin, 2006; Popkin et al., 2012). While there have been numerous enhancements to quality of living, the rapid modernisation that has occurred in Malaysia has also generated profound changes in built environment (i.e., urbanisation), physical activity and diet (Hu, 2011; Noor, 2002; Popkin, 2006; Popkin et al., 2012). The impact of these changes is reflected in the increasing prevalence of T2D and associated risk factors, specifically, overweight and obesity and physical inactivity (Chee Cheong et al., 2019; Delvarani, Ghazali, & Othman, 2013; Noor, 2002; Zaini, 2000).

Research has shown that built environment (i.e., environments modified by humans) influences the development of T2D (Unnikrishnan et al., 2017). Specifically, the rapid urbanisation that has occurred in Malaysia over the last several decades has led to a multitude of demographic changes associated with increased risk of T2D (Fournier et al., 2016; Popkin et al., 2012; Zaini, 2000). Interestingly, these changes are not inherently nor exclusively detrimental and have, in many cases, led to a better standard of living, improved quality of life (Zaini, 2000). For example, urbanisation is associated with better transportation systems, improved availability food (i.e., modern supermarkets), and increased access to information and technology (e.g., mass media, television etc.; Noor, 2002; Popkin, 2016; Unnikrishnan et al., 2017). However, urbanisation has also led to increased consumption of food outside the home (82% of urban dwellers), greater availability and consumption of energy-dense, nutritionally poor foods and reduced physical activity (Delvarani et al., 2013; Noor, 2002; Unnikrishnan et al., 2017). Furthermore, a reduction in average household size (M = 5.2 persons in 1980, M = 4.3 persons in 2010) and income growth have created a new middle class, with increased purchasing power and a greater ability to participate in a consumption economy (Fournier et al., 2016; Noor, 2002).

Occupational and lifestyle changes associated with urbanization have also led to a reduction in physical activity (Noor, 2002). Prior to modernization, levels of physical activity were high in developing nations where the majority of individuals engaged in unmechanised occupational activities (Unnikrishnan et al., 2017). However, industrial changes associated with globalisation have led to an increase in less physically demanding occupations, causing a significant decline in overall physical activity levels (Unnikrishnan et al., 2017). Furthermore, recreational physical activity levels tend to be low in developing nations; this has certainly been observed in Malaysia, with inadequate levels of physical activity for reported for both adults and children (Tee & Yap, 2017; Unnikrishnan et al., 2017). Moreover, improved transportation systems, increased car ownership and greater time spent in sedentary activities (occupational and leisure) also contribute to the maintenance of an obesogenic environment (Noor, 2002; Unnikrishnan et al., 2017).

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Similarly, dietary changes associated with globalisation promote an obesogenic environment (Basch et al., 2013). Indeed, as a consequence of globalisation, there is increasing adoption of the so called “Western diet” which typically includes increased consumption of animal-source foods, high intake of refined carbohydrates and added sugars (i.e., energy-dense foods) and decreased fibre intake (Hu, 2011; Popkin et al., 2012). This nutrition transition is advanced through food imports, the increasing presence of transnational food corporations (e.g., Coca-Cola, McDonalds, Kentucky Fried Chicken etc.) and changes in local food production (i.e., convergence with transnational production practices; Noor, 2002; Popkin, 2006; Popkin et al., 2012).

Specifically, Malaysia has high consumption of sugar-sweetened beverages ([SSB] e.g., soda) and fast-food (Noor, 2002). For example, the National School-based Nutrition Survey (2012), 82.5% of adolescents reported consuming fast-food at least once per week, 7% consumed more than three cups of SSBs per day and a staggering 96.3% had insufficient intake of fruits and vegetables (Chee Cheong et al., 2019). Similar consumption patterns have been reported for adults (Tee & Yap, 2017). Moreover, it has been reported that Malaysians generally consume fast-food as a snack, in addition to standard meals (Chee Cheong et al., 2019). This is likely to exacerbate the resultant risk of unhealthy diet on T2D.

Independently and in combination, urbanisation, insufficient physical activity and unhealthy dietary patterns promote and maintain an obesogenic environment and T2D (World Health Organisation. 2016b). Diet and lifestyle modification are highly effective in the prevention of T2D (Hu, 2011). To best support individual behavioural change, a combination of regulation (e.g., taxes) and capacity-building (e.g., knowledge) strategies is required.

In terms of regulation, several developed nations have successfully implemented so called “sugar taxes” designed to reduce the purchase and consumption of unhealthy food and drinks (Goryakin, Monsivais, & Suhrcke, 2017; Popkin et al., 2012; World Health Organisation. 2016b). Moreover, New York City restricted SSBs to 16oz and France imposed bans unlimited SSBs refills (Goryakin et al., 2017). Given the high level of consumption of SSBs in Malaysia and their association with T2D, similar policies could be of benefit to the Malaysian population (Goryakin et al., 2017). Indeed, Malaysia has only recently removed its sugar subsidy, with little reported change in consumption; a sugar tax may produce the desired outcome (FMT Reporters, 2017). Brand recognition and aggressive marketing by transnational corporations play a significant role in consumer purchasing behaviour (Abdullah & Asngari, 2011; Hu, 2011). As such, greater regulation of advertising and marketing of unhealthy food and beverages, as well as cigarettes, may be useful in T2D prevention.

In addition to regulation policies, public health strategies that empower individuals to make healthful choices may be beneficial (Delvarani et al., 2013; Hu, 2011). For example, creating spaces within the urban environment for exercise and maintaining safe walking/cycling paths could increase physical activity levels and reduce overweight/obesity and menu/front of package labelling may promote healthier food choices (Goryakin et al., 2017). Furthermore, nutrition education programs, as seen in Finland and South Korea, may be of benefit in addition to standard “food pyramid distribution” to support and maintain significant shifts in diet (Popkin, 2006). For example, nutrition education in schools could instruct students in food selection and preparation. Finally, it is important for these strategies to be underscored by the development of a strong knowledge base of T2D and the associated risk factors if healthful choices are to be maintained (World Health Organisation. 2016b). 

Like many other developing nations, Malaysia is in the grips of a T2D epidemic (Basch et al., 2013). Globalisation has had an unprecedented impact on the built environment, level of physical activity and diet of Malaysians, creating an obesogenic environment that that led to increasing T2D prevalence (Basch et al., 2013). Diet and lifestyle modification are an effective means of preventing T2D, however, strategies that systematically address the impact of globalisation on T2D in Malaysia (i.e., the causes of causes) are required to produce effective and lasting change (World Health Organisation. 2016b).

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