Wednesday, August 02, 2017

谁该为您的健康负责?

標题的答案似乎已呼之欲出。在正常的情况下,大部分人都可能这样答:当然是自己啦!。事与愿违,现实里很多人言行不一致,並没有好好照顾自己的健康。常人说:预防胜于治疗。如果国人都认真地遵照这常理智慧,那么政府在公共卫生和財政规划方面就轻鬆多了。

现实是残酷的。2015年度的《国家卫生和病情调查报告》(National Health and Morbidity Survey 2015)显示,有30%的大马人口超重(overweight),再有17.7%的人过胖(obese)。换言之,若按照世界卫生组织1998年的体重指数(BMI)指南標准,接近半数的大马人口拥有不健康的身形。若根据大马临床实践指南標准,不健康身形人口的比率更高,逼近2/3人口(64%)。

不爱运动爱美食

其中的问题是,国人不爱运动。如果依据《国际体力活动调查问卷》(IPAQ)的定义,估计有33.5%人口被鉴定为「非活跃」的。其实该问卷对于「活跃」的標准要求並不高,如国人能至少每週有5天每日步行超过半小时,或进行中等激烈的运动。然而,1/3的国人连这点都办不到。

不健康的饮食习惯与患上非传染性疾病的偏高风险息息相关。其中泰勒大学2014年的研究发现有64.1%的国人至少每天都在外吃一餐,同时又有31.9%的人习惯在晚餐后仍进食一餐高份量的饮食。

不少大马人常以马来西亚是美食天堂为借口,说这里拥有太多难以抗拒的美食怎能不多吃?那看似有道理,但放眼全世界再检视这说法,就可发现其实美食与肥胖並没有直接关联。
倘若属实,美国和英国其中这两个世界上最胖的国度应同时拥有最多最好吃的美食,何时轮到被公认为西方美食国度意大利和法国呢?看看泰国和印尼,两国的美食也可媲美大马一样载誉全球,却在肥胖国度的排位上低于我国,那又是为何呢?

公共健康危机

社会无法不重视缺乏运动和不健康饮食习惯对公共卫生所带来的严重祸害。仅仅是非传染性疾病病例,已佔据了大马73%的死亡人口。在2012年,至少有70%的大马人被诊断患上非传染性疾病。在2015年,涉及到呼吸管道、心臟血管、消化系统、泌尿生殖系统和癌症相关的非传染性疾病都挤上了十大入院的病例种类排名,病例总数为120万次。

就仅谈治疗糖尿病的花费,估计已达国家卫生预算的16%。2014年一份卫生部报告统计显示,若综合所有的直接和间接费用,政府需为每名糖尿病患者每年支出3750令吉充作治疗费。

那么,健康问题是否该全怪个人没照顾好自己,而政府就可以置身度外,对確保社区国民健康事宜毫无责任?非也,本人不这么认为。

政府难以推搪

大马政府已有很多宣传管道可整合设计出有效的推广健康运动,包括使用本身和官联公司旗下的电台、电视台以及纸媒。提倡活跃能动生活和良好饮食习惯,若在政府有效的宣传指挥下必能事半功倍。可惜,我们在日常生活体验到的反而是连环轰炸的各类快餐广告出现在各大电视台、电台、报纸和宣传看板上。政府其实可创意地鼓吹健康饮食文化,例如把健康讯息置入流行动画例如本地製作的《Upin dan Ipin》,让孩童从小就接触到正面的健康资讯培养良好习惯。学校食堂的饮食选项和营养更不可忽略,尤其是要阻止一些食堂经营者售卖太油或太甜的食物给学生。

至于小学和中学的体育课,我国政府仅安排每週80分钟,被拋于多个区域国家之后:新加坡和韩国拨出每週120分钟、中国105-135分钟,日本则是125-130分钟。问题在于我国的体育课鲜少被重视,只因它不是考试科。家长也应以身作则带领孩子走出並接触户外,以培养热爱运动的习惯。那么户外活动总需要个空间吧?

到了最后,从城市规划的角度来看,政府的责任更难以推搪。政府应根据人口密集度提供足够大小的公园和休閒空间,特別是在稠密的城市地区。据国家城市化政策下的標准,每1000人应享有2公顷的公共空间。地方政府应鼓励人民多步行和骑脚车,所以当务之急是改善行人道和脚车道的衔接网络。那么,能「动起来」的人民或许会更愿意使用公共交通,捨弃私家车。

总而言之,在改变社会行为以达至更好的公共卫生结果的角色上,政府其实能做的还有很多。但人民本身也该回应政府的呼吁,尽本分照顾自己的健康。若双方都配合得体,我国绝对能减少公共卫生和健康问题,那么或许再也不会有人说大马美食和健康不能兼得。

刊登于《東方日報》東方文薈版2017年7月22日

Who is responsible for your health?

The question seems like a no-brainer. Under normal circumstances, the answer is most likely ‘our own good self’.  But in reality, some people do not take care of their health as well as we would like to think. The common wisdom is ‘Prevention is better than cure’; if every Malaysian took this axiom seriously, it would surely ease the task of the government in terms of public health and financing.
The reality is stark. The National Health and Morbidity Survey 2015 recently showed that 30% of the Malaysian population is overweight, while a further 17.7% are obese. In other words, nearly half of the Malaysian population was found to have an unhealthy body size based on the World Health Organisation’s (1998) Body Mass Index (BMI) guidelines. The percentage goes even higher, at 64%, if we are to use the Malaysian Clinical Practice Guidelines).
Based on the definition given by the International Physical Activity Questionnaire (IPAQ), 33.5% of the population is identified as ‘inactive’. This is unsurprising news, given that one third of the Malaysian population do not practise moderate intensity level of physical activity such as walking for more than 30 minutes per day for minimally five days a week.
Unhealthy dietary practice is correlated with a higher risk of non-communicable diseases (NCDs). A study found that 64.1% Malaysian individuals eat at least one meal per day outside of the home daily, while 31.9% habitually eat a heavy meal after dinner.
As a natural defence, many Malaysians would be quick to claim that Malaysia has too much irresistable good food. But contrary to popular belief, there is no correlation between good food and obesity. If that were true, then countries such as the United States and Britain, two countries that currently top the obesity rankings, should also top the world for the best food, instead of countries renowned for their culinary fare such as Italy and France! On a more regional note, Thailand and Indonesia, countries which have equally tempting food choices as Malaysia, are in fact ranked lower than our country in the obesity rankings.
Society cannot afford to ignore the serious consequence of lack of exercise and bad eating habits to public health. NCDs are responsible for 73% of deaths among Malaysians. In 2012, at least 70% of Malaysians were diagnosed with NCDs. As of 2015, NCDs in respiratory, circulatory, digestive and genitourinary systems as well as neoplasms (cancer) made it to the top 10 principal causes of hospitalisation, totalling 1.2 million cases. The cost of treatment for diabetes alone is estimated to account for 16% of the national Malaysian healthcare budget, while the combined direct and indirect per-patient costs for diabetes was found to be RM3,750 in 2014.
Yet, is it right to place the blame solely on the individual, and claim that the government plays no role in attaining good health outcomes in the communities? I do not think so.
The Malaysian government has many tools at their disposal to coordinate effective health promotion, including TV and radio channels as well as newspaper press. These are effective channels through which the government can encourage active lifestyle and good dietary habits among society. These days, we are constantly bombarded by various fast food advertisements on TV, radio, newspaper and billboards. Perhaps the government should emulate the US Food and Drug Agency (USFDA) in regulating food providers, especially fast food outlets, to have compulsory nutritional list on their standard menus.
The government could also come up with creative ways to encourage healthy eating habits using commercial activities. For example, the use of popular animation series such as “Sesame Street” or the locally produced “Upin dan Ipin” to promote good eating habits and encouraging physical exercise could potentially lead to a shift in lifestyle habits among minors, and further reduction in NCDs.
School-based nutrition plays a great role in altering social norms and behaviours. It is not helpful if some school canteen operators could get away with selling foods which are either too oily or too sweet. Current programmes involving poor students such as “Rancangan Makanan Tambahan untuk Pelajar Miskin” are a good platform to educate canteen and cafeteria providers on the importance of including more nutritious food items in their menu. The sale of junk food should be banned if they follow the guidelines set by the government.
In terms of physical education in primary and secondary schools, the government allocates just 80 minutes per week. We are lagging behind other countries in the region – Singapore and South Korea both allocate 120 minutes, China, 105-135 minutes, and Japan, 125-130 minutes. In Malaysia, physical education is seldom prioritised because it is perceived as less important than studying and passing for examinations.
While there has been an increase in the number of running and cycling events in the Klang Valley, such events should be encouraged in other states in the country and younger participants should be encouraged to participate. Parents need to lead by example, by teaching their children to love physical activities . This could be done through enrolling them in running clubs, frequently enjoying indoor or outdoor sports as a family, and limiting screen or internet time so as to encourage outdoor activities.
Finally, from an urban planning perspective, the government must provide sufficient parks and recreational spaces per population density, especially in the urban areas. Local governments can encourage higher activity levels by improving the connectivity of pedestrian walkways and cycling paths, and encouraging the use of public transportation over that of private cars.
In conclusion, there is plenty that the government can do to shape desirable social behaviours towards better public health outcomes. But society, too, must do its part by responding to these calls. If both play their roles right, Malaysia will surely be on the right track to reducing public health issues and living up to the mantra of “prevention is better than cure”.