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