• Overview
  • Obesity prevalence
  • Trends over time
  • Population breakdowns
  • Drivers
  • Comorbidities
  • Health systems
  • Actions
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Obesity prevalence

Adults, 2019

Survey type:Measured
Age:18+
Sample size:14965
Area covered:National
References:NHMS 2019. Institute for Public Health (IKU) available at http://www.iku.gov.my/nhms-2019 (last accessed 17.09.20)
Notes:Sample size includes approx 5000 children
Definitions:Standard definitions. Malaysian Clinical Practice Guideline of Obesity (2004) cut offs are also available on MOH website
Unless otherwise noted, overweight refers to a BMI between 25kg and 29.9kg/m², obesity refers to a BMI greater than 30kg/m².

Adults, 2015

Survey type:Measured
Age:18+
Sample size:29460
Area covered:National
References:Institute for Public Health (IPH) 2015. National Health and Morbidity Survey 2015 (NHMS 2015). Vol. II: Non-Communicable Diseases, Risk Factors & Other Health Problems; 2015.
Unless otherwise noted, overweight refers to a BMI between 25kg and 29.9kg/m², obesity refers to a BMI greater than 30kg/m².

Adults, 2007-2008

Survey type:Measured
Age:18+
Sample size:4428
Area covered:National
References:Mohamud WN, Musa KI, Khir AS, Ismail AA, Ismail IS, Kadir KA, Kamaruddin NA, Yaacob NA, Mustafa N, Ali O, Isa SH, Bebakar WM.Prevalence of overweight and obesity among adult Malaysians: an update. Asia Pac J Clin Nutr. 2011;20(1):35-41.
Unless otherwise noted, overweight refers to a BMI between 25kg and 29.9kg/m², obesity refers to a BMI greater than 30kg/m².

Adults, 2006

Survey type:Measured
Age:18+
Sample size:33464
Area covered:National
References:Khambalia AZ, Seen LS. Trends in overweight and obese adults in Malaysia (1996-2009): a systematic review. Obesity Reviews 2010; 11:403-412
Unless otherwise noted, overweight refers to a BMI between 25kg and 29.9kg/m², obesity refers to a BMI greater than 30kg/m².

Adults, 1996

Survey type:Self-reported
Age:18+
Sample size:30165
References:Ismail MN, Chee SS, Nawawi H, Yusoff K, Lim TO and James WPT. (2002). Obesity in Malaysia. Onesity Reviews, 3: 203 - 208.
Unless otherwise noted, overweight refers to a BMI between 25kg and 29.9kg/m², obesity refers to a BMI greater than 30kg/m².

Adults, 1993-1994

Survey type:Measured
Age:18-64
Sample size:4747
References:Ismail MN, Zawaih H, Chee SS, Ng KK. Prevalence of obesity and chronic energy deficiency (CED) in adult Malaysians. Malays J Nutrition. 1995; 1:1-9
Unless otherwise noted, overweight refers to a BMI between 25kg and 29.9kg/m², obesity refers to a BMI greater than 30kg/m².

Children, 2019

Survey type:Measured
Age:5-17
Sample size:~ 3500
Area covered:National
References:NHMS 2019. Institute for Public Health (IKU) available at http://www.iku.gov.my/nhms-2019 (last accessed 17.09.20)
Definitions:WHO
Cutoffs:WHO

Children, 2012

Survey type:Self-reported
Age:13-17
References:Global School-based Student Health Survey (GSHS), available at https://www.cdc.gov/gshs/countries/index.htm (last accessed 28.04.20)
Notes:WHO cutoffs.
Cutoffs:WHO

Children, 2006

Survey type:Measured
Age:7-12
Sample size:7749
Area covered:National
References:Third National Health and Morbidity Survey (NHMS III, 2006) published in Naidu BM, Mahmud SZ, Ambak R et al. Overweight among primary school-age children in Malaysia. Asia Pac J Clin Nutr 2013;22 (3):408-415
Notes:IOTF International Cut Off Used for Overweight and obesity
Cutoffs:IOTF

Overweight/obesity by education

Children, 2006

Survey type:Measured
Age:7-12
Sample size:7749
Area covered:National
References:Third National Health and Morbidity Survey (NHMS III, 2006) published in Naidu BM, Mahmud SZ, Ambak R et al. Overweight among primary school-age children in Malaysia. Asia Pac J Clin Nutr 2013;22 (3):408-415
Notes:IOTF International Cut Off
Cutoffs:IOTF

Overweight/obesity by region

Children, 2006

Survey type:Measured
Age:7-12
Sample size:7749
Area covered:National
References:Third National Health and Morbidity Survey (NHMS III, 2006) published in Naidu BM, Mahmud SZ, Ambak R et al. Overweight among primary school-age children in Malaysia. Asia Pac J Clin Nutr 2013;22 (3):408-415
Notes:IOTF International Cut Off
Cutoffs:IOTF

Overweight/obesity by socio-economic group

Children, 2006

Survey type:Measured
Age:7-12
Sample size:7749
Area covered:National
References:Third National Health and Morbidity Survey (NHMS III, 2006) published in Naidu BM, Mahmud SZ, Ambak R et al. Overweight among primary school-age children in Malaysia. Asia Pac J Clin Nutr 2013;22 (3):408-415
Notes:IOTF International Cut Off Parental Income (RM)
Cutoffs:IOTF

Insufficient physical activity

Adults, 2016

References:Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet 2018 http://dx.doi.org/10.1016/S2214-109X(18)30357-7

Men, 2016

References:Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet 2018 http://dx.doi.org/10.1016/S2214-109X(18)30357-7

Women, 2016

References:Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet 2018 http://dx.doi.org/10.1016/S2214-109X(18)30357-7

Children, 2010

Age:11-17
References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A893?lang=en
Notes:% of school going adolescents not meeting WHO recommendations on Physical Activity for Health, i.e. doing less than 60 minutes of moderate- to vigorous-intensity physical activity daily.
Definitions:% Adolescents insufficiently active (age standardised estimate)

Boys, 2010

Age:11-17
References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A893?lang=en
Notes:% of school going adolescents not meeting WHO recommendations on Physical Activity for Health, i.e. doing less than 60 minutes of moderate- to vigorous-intensity physical activity daily.
Definitions:% Adolescents insufficiently active (age standardised estimate)

Girls, 2010

Age:11-17
References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A893?lang=en
Notes:% of school going adolescents not meeting WHO recommendations on Physical Activity for Health, i.e. doing less than 60 minutes of moderate- to vigorous-intensity physical activity daily.
Definitions:% Adolescents insufficiently active (age standardised estimate)

Average daily frequency of carbonated soft drink consumption

Children, 2010-2015

Survey type:Measured
Age:12-17
References:Beal et al. (2019). Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-food consumption: A meta-analysis of global school-based student health surveys. Food and Nutrition Bulletin. https://doi.org/10.1177/0379572119848287 sourced from Food Systems Dashboard http://www.foodsystemsdashboard.org/food-system

Estimated per-capita fruit intake

Adults, 2017

Survey type:Measured
Age:25+
References:Global Burden of Disease, the Institute for Health Metrics and Evaluation http://ghdx.healthdata.org/
Definitions:Estimated per-capita fruit intake (g/day)

Prevalence of less-than-daily fruit consumption

Children, 2010-2015

Survey type:Measured
Age:12-17
References:Global School-based Student Health Surveys. Beal et al (2019). Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-food consumption: A meta-analysis of global school-based student health surveys. Food and Nutrition Bulletin. https://doi.org/10.1177/0379572119848287. Sourced from Food Systems Dashboard http://www.foodsystemsdashboard.org/food-system
Definitions:Prevalence of less-than-daily fruit consumption (% less-than-daily fruit consumption)

Prevalence of less-than-daily vegetable consumption

Children, 2010-2015

Survey type:Measured
Age:12-17
References:Beal et al. (2019). Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-food consumption: A meta-analysis of global school-based student health surveys. Food and Nutrition Bulletin. https://doi.org/10.1177/0379572119848287 sourced from Food Systems Dashboard http://www.foodsystemsdashboard.org/food-system
Definitions:Prevalence of less-than-daily vegetable consumption (% less-than-daily vegetable consumption)

Average weekly frequency of fast food consumption

Children, 2010-2015

Age:12-17
References:Beal et al. (2019). Global Patterns of Adolescent Fruit, Vegetable, Carbonated Soft Drink, and Fast-food consumption: A meta-analysis of global school-based student health surveys. Food and Nutrition Bulletin. https://doi.org/10.1177/0379572119848287 sourced from Food Systems Dashboard http://www.foodsystemsdashboard.org/food-system

Estimated per-capita processed meat intake

Adults, 2017

Survey type:Measured
Age:25+
References:Global Burden of Disease, the Institute for Health Metrics and Evaluation http://ghdx.healthdata.org/
Definitions:Estimated per-capita processed meat intake (g per day)

Estimated per-capita whole grains intake

Adults, 2017

Survey type:Measured
Age:25+
References:Global Burden of Disease, the Institute for Health Metrics and Evaluation http://ghdx.healthdata.org/
Definitions:Estimated per-capita whole grains intake (g/day)

Mental health - depression disorders

Adults, 2015

References:Prevalence data from Global Burden of Disease study 2015 (http://ghdx.healthdata.org) published in: Depression and Other Common Mental Disorders: Global Health Estimates. Geneva:World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Definitions:% of population with depression disorders

Mental health - anxiety disorders

Adults, 2015

References:Prevalence data from Global Burden of Disease study 2015 (http://ghdx.healthdata.org) published in: Depression and Other Common Mental Disorders: Global Health Estimates. Geneva:World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Definitions:% of population with anxiety disorders

Oesophageal cancer

Men, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, oesophagus, adults ages 20+. ASR (World) per 100,000

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, oesophagus, adults ages 20+. ASR (World) per 100,000

Breast cancer

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, breast, females, ages 20+. ASR (World) per 100,000

Colorectal cancer

Men, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, colorectum, adults, ages 20+. ASR (World) per 100,000

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, colorectum, adults, ages 20+. ASR (World) per 100,000

Pancreatic cancer

Men, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, pancreas, adults, ages 20+. ASR (World) per 100,000

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, pancreas, adults, ages 20+. ASR (World) per 100,000

Gallbladder cancer

Men, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, gallbladder, adults, ages 20+. ASR (World) per 100,000

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, gallbladder, adults, ages 20+. ASR (World) per 100,000

Kidney cancer

Men, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, kidney, adults, ages 20+. ASR (World) per 100,000

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, kidney, adults, ages 20+. ASR (World) per 100,000

Cancer of the uterus

Women, 2018

Age:20+
References:Global Cancer Observatory, Cancer incidence rates http://gco.iarc.fr/ (last accessed 30th June 2020)
Definitions:Estimated age-standardized incidence rates (World) in 2018, cervix uteri, females, ages 20+. ASR (World) per 100,000

Raised blood pressure

Adults, 2015

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A875?lang=en
Definitions:Age Standardised estimated % Raised blood pressure 2015 (SBP>=140 OR DBP>=90).

Men, 2015

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A875?lang=en
Definitions:Age Standardised estimated % Raised blood pressure 2015 (SBP>=140 OR DBP>=90).

Women, 2015

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A875?lang=en
Definitions:Age Standardised estimated % Raised blood pressure 2015 (SBP>=140 OR DBP>=90).

Raised cholesterol

Adults, 2008

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A885
Definitions:% Raised total cholesterol (>= 5.0 mmol/L) (age-standardized estimate).

Men, 2008

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A885
Definitions:% Raised total cholesterol (>= 5.0 mmol/L) (age-standardized estimate).

Women, 2008

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A885
Definitions:% Raised total cholesterol (>= 5.0 mmol/L) (age-standardized estimate).

Raised fasting blood glucose

Men, 2014

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A869?lang=en
Definitions:Age Standardised % raised fasting blood glucose (>= 7.0 mmol/L or on medication).

Women, 2014

References:Global Health Observatory data repository, World Health Organisation, http://apps.who.int/gho/data/node.main.A869?lang=en
Definitions:Age Standardised % raised fasting blood glucose (>= 7.0 mmol/L or on medication).

Diabetes prevalence

Adults, 2017

References:Reproduced with kind permission of IDF, International Diabetes Federation. IDF Diabetes Atlas, 8th edition. Brussels, Belgium: International Diabetes Federation, 2017. http://www.diabetesatlas.org
Definitions:Diabetes age-adjusted comparative prevalence (%).

Health systems

Economic classification: Upper Middle Income

Health systems summary

Malaysia has a two-tier health system that is made up of a tax-funded public sector and a coexisting private sector. The public sector, which is led and funded primarily by the Malaysian government is available to all legal residents of Malaysia. Despite covering the bulk of the population, the public system is underserved by doctors and specialists compared to the private sector. The private sector, on the other hand, has thrived in recent years. Private care is mostly paid for with private health insurance and fee-for-service, out of pocket payments. The relatively high use of private care means that out of pocket expenditure is relatively high, making up approximately 34.5% of health financing in 2015.

Indicators

Where is the country’s government in the journey towards defining ‘Obesity as a disease’?Some progress
Where is the country’s healthcare provider in the journey towards defining ‘Obesity as a disease’?Some progress
Is there specialist training available dedicated to the training of health professionals to prevent, diagnose, treat and manage obesity?No
Have any taxes or subsidies been put in place to protect/assist/inform the population around obesity?Yes
Are there adequate numbers of trained health professionals in specialties relevant to obesity in urban areas?Some progress
Are there adequate numbers of trained health professionals in specialties relevant to obesity in rural areas?No
Are there any obesity-specific recommendations or guidelines published for adults?Some progress
Are there any obesity-specific recommendations or guidelines published for children?Some progress
In practice, how is obesity treatment largely funded?Not known

Perceived barriers to treatment

  • Food cost & availability
  • Lack of political will, interest and action
  • Influence of food industry
  • Social determinant of health
  • Lack of opportunity for physical activity

Summary of stakeholder feedback

There is reportedly no consensus on whether obesity is a disease in Malaysia, with differing views among clinicians and the general public. The government appears to have engaged in a few awareness campaigns but overall, there is much more to be done on obesity prevention.

Extent of treatment coverage and the availability of obesity treatment varies between the public and private sector. In the public sector, pharmacotherapy is covered as long as it was listed in the Ministry of Health Medicines Formulary, but it was noted that it currently contained few options for obesity. Bariatric surgery is partially covered but there is limited availability and treatment requires nominal out of pocket contributions to complement the government funding. Coverage in the private sector on the other hand was said to be dependent on clinical indication and type of insurance coverage. Behavioural modification, which was reported to be the most common type of treatment in Malaysia, is covered in both the public and private sector.

Stakeholders appreciated that Malaysia does have clinical practice guidelines for the management of obesity but noted that there was a disconnect between the guidelines and what happens in practice. It was said that people tended to enter primary care via community screening and if comorbidities are present, the person is referred onto hospital or tertiary care. One stakeholder raised concerns however that most do not enter the system and try out “fads” instead.

It was noted that there is no specialist obesity training in Malaysia, and so there are inadequate numbers of suitably qualified professionals to treat obesity in both urban and rural areas.

Based on interviews/survey returns from 5 stakeholders

Last updated: June 2020

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Actions

Malaysia Sugar Tax

Excise duty of RM0.40/litre (about US$0.095) was applied to all manufactured beverages, including carbonated drinks containing added sugar/other sweeteners and other non-alcoholic beverages, containing sugar exceeding 5g/100ml; and all fruit and vegetable juices regardless of whether the juices contain added sugar/other sweeteners which contain sugar exceeding 12g/100ml

Categories:Taxation/Subsidies on Food or Beverages or law relating to public health
Year(s):2019 (ongoing)
Target age group:Adults and children
Organisation:Customs Department Malaysia
Find out more:www.customs.gov.my
References:Information provided with kind permission of World Cancer Research Fund International from their NOURISHING framework https://www.wcrf.org/int/policy/nourishing-database

Recommended Nutrient Intakes for Malaysia. A report of the technical working group

Malaysia faces the double burden of malnutrition. The burden of NCDs continue to rise in Malaysia and unhealthy diet is one of the major risk factors for NCD. Malaysian nowadays are living in an obesogenic environment that leads to sedentary lifestyle and unhealthy eating habits. The report has been created to to assist Malaysians in achieving, sustaining and maintaining a certain level of health status as the RNI's as they form the basis in setting up or establishing nutrition requirement in any nutritional guidelines.

Categories:Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan
Year(s):2017 (ongoing)
Target age group:Adults and children
Organisation:Ministry of Healrh
Linked document:Download linked document

National Plan of Action for Nutrition of Malaysia III 2016-2025

Updated plan of action to ehnhance nutritional status of population and prevent or reduce NCD's

Categories:Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan
Year(s):2016-2025
Target age group:Adults and children
Organisation:National Coordinating Committee on Food and Nutrition (NCCFN), MINISTRY OF HEALTH MALAYSIA
Find out more:nutrition.moh.gov.my
Linked document:Download linked document
References:Ministry of Health Malaysia, 2016. National Plan Of Action For Nutrition Of Malaysia III 2016-2025. National Coordinating Committee on Food and Nutrition (NCCFN).

National Strategic Plan for Non-Communicable Disease Medium term Strategic Plan to further strengthen the NCD Prevention and Control program in Malaysia (2016-2025)

Categories:Evidence of NCD strategy
Year(s):2016-2025
Target age group:Adults and children
Organisation:Department of Public Health, Ministry of Health, Malaysia
Linked document:Download linked document

Malaysian Dietary Guidelines for Children and Adolescents

The Malaysian Dietary Guidelines for Children and Adolescents comprise 15 key messages and 67 key recommendations for healthy children and adolescents from birth to 18 years of age

Categories:Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan
Year(s):2013 (ongoing)
Organisation:NATIONAL COORDINATING COMMITTEE ON FOOD AND NUTRITION (NCCFN)
Linked document:Download linked document
References:MALAYSIAN DIETARY GUIDELINES FOR CHILDREN AND ADOLESCENTS. National Coordinating Committee on Food and Nutrition Ministry of Health Malaysia 2013

Malaysian Food and Beverage Industry's "Responsible Advertising to Children" Initiative

Voluntary self-regulatory pledge on responsible marketing of food and drink to children.

Categories:Evidence of Marketing Guidelines/Policy
Year(s):2013 (ongoing)
Target age group:Children
Organisation:Malaysian Food and Beverage Industry
Find out more:ifballiance.org
Linked document:Download linked document
References:Information provided with kind permission of The International Food & Beverage Alliance: www.ifballiance.org

Malaysia Dietary Guidelines 2010

The guidelines are aimed at health care providers to assist them in educating the public on improving their health through sound dietary practices. It is also intended to act as a tool for promoting healthy eating and achieving the National Plan of Action for Nutrition of Malaysia.

Categories:Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan
Year(s):2010 (ongoing)
Target age group:Adults and children
Organisation:Ministry of Health Malaysia
Find out more:www.moh.gov.my
Linked document:Download linked document
References:National Coordinating Committee on Food and Nutrition, Ministry of Health 2010.

National Plan of Action for Nutrition Malaysia (2006-2015) - NPANM

NPANM aims to enhance the nutritional status of the population and prevent and control diet-related non-communicable diseases.

Categories (partial):Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan
Year(s):2006-2015
Target age group:Adults and children
Organisation:Ministry of Health

Strategy for the Prevention of Obesity - Malaysia

This strategy contains recommendations to help prevent normal weight individuals from becoming overweight or obese.

Categories:Non-national obesity strategies
Year(s):2005 (ongoing)
Target age group:Adults and children
Organisation:Malaysian Association for the Study of Obesity (MASO) in collaboration with the Ministry of Health Malaysia
Find out more:www.maso.org.my
References:Malaysian Association for the Study of Obesity (MASO). http://www.maso.org.my/ (last accessed 29 Feb 2016)

Clinical Practice Guidelines on the management of Obesity 2004

Guidelines for obesity management, prevention and treatment for use by health professionals.

Categories:Evidence of Management/treatment guidelines
Year(s):2004 (ongoing)
Target age group:Adults and children
Organisation:Academy of Medicine of Malaysia
Find out more:www.acadmed.org.my
Linked document:Download linked document
References:Academy of Medicine of Malaysia. 2004. Clinical Practice Guidelines on management of Obesity 2004. Available from: http://www.acadmed.org.my/index.cfm?menuid=67. [Accessed 7th January 2019].

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