In 2019 the Ministry of Health (MOH) estimated that RM3.2 billion was spent on managing diabetes and hypertension in its outpatient facilities, or more than 10 percent of its annual budget. Given that hospital admissions and treatment of complications (heart disease, stroke, renal failure) were not included in this amount, MOH is justifiably concerned about the budgetary impact of diabetes on its services.
With each national health survey, conducted every couple of years, the projected number of Malaysians on track to get diabetes keeps rising; the latest estimate is 31.3 percent or nearly 1 in 3 of us by 2025.
Budgets and projections do not tell the whole story, and are neither personal nor present in the life of average Malaysians.
Type 2 diabetes is more than ageing and being fatalistic by accepting your genetics or ‘fate’. Early life, environment, and health-related behaviors as we grow up have been shown to play crucial roles in whether diabetes develops or not.
During counseling of a newly diagnosed patient, it is explained that his or her pancreas is now producing less insulin and the body is also less responsive to insulin. However, as clinic time in primary care is limited, often lasting only 15 minutes, more emphasis is made on secondary prevention: slowing the progression to complications like heart disease, stroke and renal failure. The patient is given advice to adhere to medications, balanced nutrition, physical activity, and target glucose level.
However, in the mind of the individual, their concern is almost always fixated on: can my condition be cured or reversed? Do I have to take these medications long term?
Unfortunately and disappointing for many patients to learn, most cases of type 2 diabetes are progressive and chronic.
Knowing how something major can impact you much earlier can sometimes be a missed opportunity. What if a couple of years before the same individual had enrolled in a programme for prediabetes or obesity?
Health educators and professionals would have responded differently by talking about changing risk factors. It would have changed that individual’s story.
In countries where national diabetes prevention programs are in place, the scenario above is far from an imaginative exercise. The Diabetes Prevention Program for high-risk individuals in the United States found that intensive lifestyle intervention reduced the risk of diabetes by 58 percent over 3 years and 34 percent after a follow-up of 10 years.
Most of the money being spent on healthcare in Malaysia is for curative care (68 percent), with only 6 percent spent on public health and prevention in 2018. Health services have become the battleground to treat diseases and complications rather than help people become healthier. Yet it is only part of the solution, as the actual field for practice lies outside of clinics and hospitals.
Diabetes prevention programmes involve adopting a low-calorie, low-saturated fat, high-fibre diet and doing moderate-intensity physical activity of at least 150 minutes per week. This would bring about a weight loss of 5 percent from the initial body weight.
If nutrition and exercise are key to filling the prescription for diabetes prevention, some important lessons can be gleaned here for Malaysians.
The balanced plate model of ‘suku suku separuh’ delivers a simple message: fill half your plate with sources of fibre, a quarter with protein, and a quarter with carbohydrates.
For many Malaysians, satiety is gained through simple carbohydrates – the idea of filling half the plate with sources of fibre is culturally alien. When eating out, it is often necessary to request for the rice portion size to be reduced, or needing to pay extra to add vegetables. Finding legumes and wholegrains at the average Malaysian eatery is even trickier. Most drinks arrive sweetened.
Hence, if we’re talking about the general population, to practice ‘suku suku separuh’ would require more willpower and effort. Imagine a canteen where healthy choices are tasty and affordable, with plain water or unsweetened beverages on the menu, and patrons are asked if they would like to add more servings of fibre to their plate. It may sound amusing, but what if this arrangement made it much easier for you to change your usual food choices at lunchtime.
Marketing and advertising would have you believe that our children and teenagers grow up active and fit. But in general, only 1 in 5 of teenagers actually achieve the minimum standard for physical activity. For adults, more than half surveyed reached the recommended standard. Research shows that more benefits can be gained for diabetes risk reduction when physical activity exceeds the minimum.
Women were also found to be engaged in lower total physical activity and at less intensity. Notably, the prevalence of diabetes in Malaysia was higher in women (18.3 percent) than men (16.7 percent) in 2015.
It is useful to remind ourselves why people are motivated to be active. You may be someone who enjoys nature and fresh air, or who feels good about being in shape. Perhaps you find it useful to reduce stress, or the activity can conveniently be done near your home, school or workplace. For others, the opportunity to socialize with teammates or friends could be the main driver.
Leveraging on these factors bypasses health literacy: you don’t need to know the health benefits to be active.
Our National Strategic Plan for Active Living states that “active living is supported by the places in which we live”. This plan is consistently held back by the continued deficiency in city planning which discourages cycling and walking, and emphasizes the use of motorized vehicles.
Patients also say that they do not know where to sign up for classes, and not all parks are equal in terms of activities and accessibility.
Positive signs on this front are workplaces that subsidize gym membership fees or organize fitness activities for employees.
Addressing diabetes prevention is not simply about ‘health’. Due to its epidemic scale, diabetes is first and foremost a tax on development. Without adequate investment in prevention, healthcare spending for curative care will continue to rise to the detriment of household savings, government revenue and other opportunities.