Food and Nutrition Situation in Malaysia

1. Food and Nutrition Situation in Malaysia Assoc. Prof. Dr Rokiah Mohd Yusof Department of Nutrition and Dietetics Faculty of Medicine and Health Sciences Universiti Putra Malaysia 43400 UPM Serdang, Selangor, Malaysia

2. Topics Present • Introduction • Nutritional Status • Food supply and Dietary Pattern • Diet Related Chronic Diseases • Intervention Activities for Promoting Healthy Nutrition

3. Introduction • Increasingly more developing countries world wide are undergoing nutritional changes, which are characterized by manifestation of both under and over nutrition. • While macronutrient and micronutrient deficiencies persist resulting in poor nutritional status and morbidity, the prevalence of overweight and obesity has been on the rise, in urban and rural areas in many countries.

4. Malaysia typifies a rapid developing country, which has undergone major demographic and socioeconomic changes since attaining independence in 1957. • Fertility rates have declined from 6.94 in 1955 to 2.94 in 2005 • Life expectancy at birth has increased from 48.5 (1955) to 73.1 years (2005)

5. Urbanization growth rate at 3% in recent years resulted in 62% of the present population, which estimated as 25.35 millions in 2005, living in urban areas. • The country also experienced epidemiological transition shifts from a situation with predominance of infectious disease to one distinguished by growing prevalence of chronic and degenerative disease • In recent years, coronary heart disease, cancers and stroke constitute the leading causes of mortality, accounting to more than 40% of total death.

6. Nutritional Status • Prior to the 1960s, severe forms of protein energy malnutrition, anemia and vitamin A deficiency were widespread especially in children and women from poor rural areas (Viswalingam, 1928; Reed, 1940; IMR, 1957; Thomson, 1960). • Since the 1980s, only mild to moderate forms of protein-energy malnutrition was found in children, manifested as under weight (too thin for age), stunting (too short for age) and wasting (too thin for height).

7. Such growth deficits are more common in poor households and interior communities that have low access to adequate and nutritious food and health facilities. • The prevalence of underweight and stunting in poor community has been on the decline in recent years. • In agriculture communities, such in rice growing areas, estates, rubber and coconut smallholdings, the prevalence of underweight and stunting among children below 6 years old in the 1980s was 37% and 43% respectively (Chong et al, 1984).

8. In the 1990s, studies found lower underweight, and stunting ranging from 31-33% and 26-27% respectively (Khor and Tee, 1997) • According to the Ministry of Health (MOH) and UNICEF survey nationwide in 1998-2000 among children less than 6 years, 19.2% were underweight (< -2SD weight-for-age) and 16.7% stunted (< -2SD height-for-age)

9. Based on surveillance data of MOH, the overall prevalence of underweight among children aged below 5 years was 17.3% in 2004 compared to 25% in 1990. • The prevalence of overweight in children is much lower than the adults.

10. The 1998-2000 MOH/UNICEF Survey recorded 2.9% male and 2.2% female children below 6 years as overweight , with higher prevalence in metropolitan (3%) and large urban areas (2.8%) than in rural areas (1.8%). • The MOH surveillance data showed that in 2004, 4.1% of children aged 5 years were overweight.

11. Meanwhile in adults, the problem of underweight has also been reported in urban and rural areas. • NHMS II (1996) determined the overall prevalence of underweight in adults as 25.2%, while other studies on smaller numbers of subjects reported underweight rates for men and women at 7% and 11% in urban, and 11% and 14% in the rural areas, respectively.

12. In relation to infant feeding, the overall prevalence of ever breastfeeding remains high at 88.6% according to the Second National Health and Morbidity Survey (NHMS II) in 1996, and compared to the Malaysian Family Life Survey (MFLS) prevalence of 85% in 1988. • However the duration of breastfeeding appears to have declined from 6 months (MFLS) to 4.5 months (NHMS II) • NHMS II also noted that the prevalence of exclusive breastfeeding through the first 4-6 months was low at 29% and bottle-feeding was high at 86% among children aged below 2 years.

13. While the country is still addressing under-nutrition problems, health problem associated with over nutrition have been on the rise in recent decades. • The NHMS II (1996) covering 28,737 adults aged 20 and older, found that 20.1% and 21.4% of the men and women are overweight (Lim, 2000)

14. The same survey also reported 4% of the men and 7.6% of the women were obese (BMI exceeding 30kg/m2). • Prior to the 1990s, overweight and obesity were more often reported among the urban adults and children only (Ismail et al, 1995; Bong and Safurah, 1996) but this problem has caught up with the rural adults too.

15. A survey of 4,595 adults from agriculture and fishing communities found that 19.8% of the men and 28% of the women to be overweight, whilst another 4.2% and 11.1% of the men and women respectively were obese (Khor et al, 1999). • Obesity of the poor may be due to various reasons including excess reliance on cheaper sources of energy, such as rice, flour, roots and tubers, increased sedentary lifestyles, and putting on excess weight during pregnancy.

16. Food supply and Dietary pattern • Fundamental changes in food supply patterns emerged in recent decades. • These changes have led to not only increasing amounts of food available but also to changes in the composition of the diet.

17. Important changes in food consumption between 1967 and 2000 are summarized below for energy and major foods: a) Total calories available for consumption has increased by 21.3% over the past three decades, from 2,407 calories to 2,919 calories per person per day b) Percentage of energy from fat increased from 17.9% to 26.9 % with about 60% from vegetables oil and 40% from animal products.

18. c) The proportion of calories from cereals has declined from 57.1% of the total calories to 43.6%. d) The proportion of calories from animal products increased from 11.2% of total calories to 19.4% e) Poultry meat availability rose over six fold from 5.7kg to 36.7kg per person per year.

19. f) Availability of eggs (hen) has almost tripled from 5.0kg per person per year to 14.4 kg. g) The amount of milk available per person per year has risen from 28.9kg to 52.7kg. h) Availability of fish and other seafood has doubled from 29.5kg to 57.9kg per person per year. i) The amount of available sugar (raw) and refined) has increased from 28 kg to 47.6kg per person per year.

20. Some studies found that the lower income groups tend to depend on a limited range of food items for calories such as rice, flour (like noodles, local cakes and snacks), cooking oil and sugar. • Rice and other cereals followed by chicken and fish constitute their main source of protein.

21. In contrast, people in higher income tend to consume a wider variety of food including more dairy products, fruits and vegetables. • Past studies also showed that the vulnerable groups, comprising growing children, pregnant and lactating mothers and the elderly, from low-income communities generally consume inadequate calories, iron, calcium and the B vitamins (Soon & Khor, 1995; Poh et al, 1996; Suriah et al, 1996; Chee et al, 1997). • Adequate consumption of vitamin A and C tends to vary depending upon day to day and seasonal fluctuations in the intake of fruits and vegetables.

22. Diet-Related Chronic Diseases • Malaysia faces the challenges arising from increasing prevalence of the diet-related chronic diseases including cardiovascular disease (CVD). • Heart diseases have been the leading cause of deaths in Malaysia since 1970s, and together with the death due to cerebrovascular disease, constitute 28% of all medically certified deaths.

23. Although CVD mortality rate in Malaysia ranks lower than that in other Asia Pacific region (Khor, 2001), the upward trend of the prevalence of its risk factors is a matter of public health concern. • The major risk factors are hypertension, diabetes, dislipidaemia and obesity.

24. Hypertension • Overall prevalence of hypertension among adults aged 30 years and above in all states in Malaysia was 29.9% with self reported hypertension at 14% and undiagnosed hypertension at 15.9% (NHMS II) (MOH, 1997) • In comparison, the NHMS 1 in 1987 had reported 14% of adults 25 years and above had elevated blood pressure.

25. Diabetes • The prevalence of diabetes appears to have risen from 6.3% in 1987 (NHMS1) to 8.7 % in 1997 (NHMS II). • Given that the population of Malaysia in 1996 was about 21 million, the total number of diabetics is estimated at 1.7 million.

26. Dyslipidaemia • Dyslipidaemia, the most commonly assessed component being total cholesterol or hypercholesterolemia. • In comparing some studies, Ng and co-researchers (2000) noted that the mean total cholesterol values of the rural adults in 1990s were edging closer to the levels of their urban counterparts.

27. The prevalence of hypercholesterolemia (total cholesterol >6.2 mmol/L) among rural males (n=3153) and females (n=4033) were 11.6% and 16% respectively. • There is an upward shift in the mean total cholesterol values for the rural communities of various age groups during the 1980s and 1990s.

28. Intervention Activities for Promoting Healthy Nutrition • Programs and activities aimed at the promotion of sound dietary practices towards the achievement of good nutritional and health status are carried by Ministry of Health, while others including Ministries of Agriculture, Rural Development and Education. • Universities and research institutes contributes in research, training and providing extension and consultancy services.

29. Professional societies like the Nutrition Society of Malaysia and Malaysian Dieticians’ Association are active in advocacy and dissemination of information to the public.

30. National Plan of Action for Nutrition • The formation of the National Coordinating Committee on Food and Nutrition of Malaysia (NCCFN) in 1995 has stimulated active collaboration among the various agencies and groups which carry out nutrition and related activities, towards achieving the general objectives of improving nutritional status and health of Malaysians.

31. The NCCFN was formed following the FAO/WHO International Conference on Nutrition in Rome in 1992, whereby members countries were committed to developing their own National Plan of Action for Nutrition (NPAN) (Ministry of Health, 1996). • The NPAN of Malaysia was completed in 1996 and one of its major recommendations was the formation of the four Technical Working Groups: Research, Training, Dietary Guidelines and Nutrition Policy

32. Each Technical Working Groups (TWG) comprises members from agencies wth nutrition activities including universities, the private sector, government and non-government organizations. • Some of the activities of TWG are: 1) The research TWG coordinated a workshop in identifying the priority research areas in nutrition under the 8th Malaysian Plan (2001-2005). 2) The Training TWG developed five nutrition modules and has been conducting training courses for trainers and community workers from various agencies. 3) The Dietary Guidelines TWG published the Malaysia Dietary Guidelines in 1999, and is coordinating efforts in revising the Malaysian recommended dietary allowance (RDAs) 4) The Policy TWG has the task of preparing an important milestone namely, “The National Nutrition Policy of Malaysia”, launched in 2003.

33. Malaysian Dietary Guidelines • Dietary guidelines are useful principles to guide consumers in making informed choices in food selection and feeding practices. • There are 8 principles in the Malaysian Dietary Guidelines:

34. Enjoy a variety of foods. • Maintain healthy body weight by balancing food intake with regular physical activity. • Eat more rice and other cereals products, legumes, fruits and vegetables. • Minimize fat in food preparation and choose foods that are low in fat and cholesterol. • Use small amounts of salts and choose foods low in salt. • Reduce sugar intake and choose foods low in sugar • Drink plenty of water daily • Practice and promote breastfeeding.

35. Ministry of Health through its Division o Family Health Development implements several nutrition intervention programs and activities as follows: • Supplementary Feeding Programs: • MOH provided full cream milk powder to undernourished children under 7 years of age, pregnant and lactating mothers. • Ministry of Education provides subsidized milk and free meals to primary school children from poor families. • The Ministry of Rural development through its KEMAS programs provide meals for preschool children, and food assistance to poor families.

36. Multiple Nutrient Supplementation. The Ministry of Health distributes iron, folic acids, vitamin C and B complex to pregnant women during their antenatal check-ups. • Nutrition Rehabilitation Program. Moderately and severely malnourished childen under 7 years of age are given food aid comprising essential items such as rice, anchovies, biscuits, milk powder, cooking oil, sugar and green gram worth RM 60 every month.

37. Iodine Deficiency disorder Control program. Several approaches were used towards the effective control of iodine deficiency disorder (IDD) in Sabah, Sarawak and Peninsula Malaysia: • Legislation requiring that all salt sold in IDD gazetted areas be iodized. • Free distribution of iodized slat by government clinics. • Use of iodinators to iodized water supplied by gravity-freed system to villages and boarding schools in rural areas

38. Nutrition Education and Health Promotion • 1) The Ministry of Health through its network of hospitals, health centers and family health clinics as well as at the community level routinely conducts nutrition education and food preparation classes. • 2) The Ministry of Health coordinating an annual Healthy Lifestyles Campaign since 1990 with nutrition either directly or indirectly as the central theme in the “Healthy Eating Campaign” (1998), “Cardiovascular Diseases” (1991), “Food Safety” (1993), “Cancer” (1995) and “Diabetes mellitus” (1996), and “Healthy Family” (2001)

39. 3) The Ministry of Education includes aspects of nutrition in the primary and secondary curriculum e.g. in Physical and Health education and Home Economics subjects. • 4) The Ministry of Rural Development through KEMAS carries out classes and home visits involving food and nutrition components. • 5) Professional societies such as the Nutrition Society of Malaysia, Malaysian Dieticians’ Association, Malaysia Association for the Study of Obesity and the Heart foundation of Malaysia are involved in disseminating information on food and nutrition and health to members and general public through talks, seminars, and exhibitions.

40. Conclusion • From the above overview, it can be seen that Malaysia has a multitude of nutrition and public health intervention programs and activities, aimed at the promoting healthy eating and nutrition of the general population as well as specific vulnerable groups (e.g. the poor, the malnourished, and the children below 7 years of age). • Whatever future programs plan for promoting healthy eating could be incorporated into the existing programs carried out in the various ministries and agencies.

41. Thank you for your attention.