Presentation Outline. Data Sources MATERNAL DIETARY INTAKE AND NUTRITIONAL STATUS IN MALAYSIA

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ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MATERNAL DIETARY INTAKE AND NUTRITIONAL STATUS IN MALAYSIA Zalilah Mohd Shariff Department of

1 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MATERNAL DIETARY INTAKE AND NUTRITIONAL STATUS IN MALAYSIA Zalilah Mohd Shariff Department of Nutrition and Dietetics Faculty of Medicine and Health Sciences Universiti Putra Malaysia Malaysia Presentation Outline v Dietary intake energy, macro-, micronutrients, dietary supplements v Nutritional Status BMI, micronutrient deficiency v Data limitations and gaps Data Sources v National Health and Morbidity Surveys (26 216) v General population health and nutrition survey (NHMS 26 21) v Maternal and child health survey (MCHS 216) v Adult nutrition survey (MANS 214) v School-based nutrition survey (SNS 212) v Other MOH data (surveillance / program data) v Research studies NON-PREGNANT / NON-LACTATING FEMALE ADOLESCENTS AND ADULTS (1 49 YEARS)

(Females, 18-9 years) 12 1 8 7 Dietary Intake RNI 6 4 2 62.1 94.9 4. 2. 8.6 8.

2-29 3-39 4-49 - 9 MANS 214 Median macronutrients (Females, 18-9 years)

2 Age (years) Carbohydrate (g) ( TEI) Fat (g) (TEI) Protein (g) (TEI)

) 48.6 (29.1) 6.7 (1.1) 3-39 19. (2.9) 46.2 (29.) 4.6 (1.2) 4-49 192.

2 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MANS 214 Median energy and nutrients (Females, 18-9 years) Dietary Intake RNI Energy Protein Calcium Iron Vit C Vit A Vit B1 Age (years) MANS 214 Median macronutrients (Females, 18-9 years) SNS 212 Median energy and nutrients (Girls 1-17 years old) Iodine 1.2 Age (years) Carbohydrate (g) ( TEI) Fat (g) (TEI) Protein (g) (TEI) Iron Calcium (.) 43.4 (3.) 1.4 (1.8) (3.) 48.6 (29.1) 6.7 (1.1) (2.9) 46.2 (29.) 4.6 (1.2) (3.9) 44.7 (28.1).1 (1.4) (2.2) 4.3 (28.1) 6. (1.6) TEI Total Energy Intake; CHO -7, Fat 2-3, Protein 1-1 Vit A 426 Vit B1 8.2 Vit C.3 Protein 1.2 Energy RNI TEI Carbohydrate 1.8 Fat 32. Protein 1.3

3 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand Food group Recomm. servings Girls, 1 17 years Median servings ( with lower and higher than recommended servings) All, 1 12 years Median servings ( with lower and higher than recommended servings) All, years Median servings ( with lower and higher than recommended servings) My Breakfast Study 213 RNI of micronutrients (6 17 years) Grains & cereals (L 13.2, H 42.7) 8. (L 11.3, H 4.7) 8.1 (L 12.2, H 47.) Fruits (L 1.3, H 48.7) 2.2 (L 2., H 47.) 2.4 (L 1.1, H 48.6) Vegetables (L 92.7, H 7.1) 1.1 (L 93.2, H 6.7) 1.1 (L 93.9, H.8) Meat, poultry & egg (L 9.9, H 4.) 2.2 (L 1.3, H 41.4) 2. (L 6.8, H 1.1) Fish (L 1.7, H 47.6) 1.1 (L 2,6, H 46.1) 1.2 (L 48., H 1.2) Legumes.-1.6 (L 9.7, H 2.2).6 (L 63.3, H 19.4).7 (L.4, H 23.4) Milk & dairy products (L 82.2, H 3.1).6 (L 8.8, H 4.3). (L 82., H 3.1) MANS 214 Vitamins & Minerals (Females, 18-9 years) MANS 214 Non-vitamins & Non-minerals (Females, 18-9 years) Vitamin C 4 86 Fish oil Folic acid ~ 23 commonly used VM Multi V/M 2 32 Age group (years) Prevalence () of use Primrose oil No data commonly used NVNM Collagen Age group (years) Prevalence () of use Overall 32.1 Overall 38.4 B complex 2 26 Calcium 22 3 Spirulina ~ 19 Royal jelly ~ 17

supplement use (Girls 1-17 years & All 1-12 years, 13-17 years)

1 7 69 69. () 6 4 3 2 1 1.1 44.3 11. 1.4 11.1 4.9 6.8 7.

3 11. 1. 11.3 Nutritional Status Prevalence Multi V/M Vit C Iron

1-12 y 13-17 y Girls 1-12 y 13-17 y NHMS 26-21 Underweight,

4 3 3 28.6 27.8 28.3 2 2 Prevalence () 2 1 14 1.1 17.

4 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand SNS 212 Dietary supplement use (Girls 1-17 years & All 1-12 years, years) Vitamins / Minerals Non-vitamins / Non-minerals () () Nutritional Status Prevalence Multi V/M Vit C Iron Prevalence Spirulina Fish oil Bee products Chicken essence Girls 1-12 y y Girls 1-12 y y NHMS Underweight, overweight and obesity (> 18 years ) 3 3 NHMS Prevalence () Prevalence () Year UW OW OB Year UW OW OB

ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MANS 214 Underweight, overweight and obesity (18-9 years) Prevalence () 4 43.2 4 3 33.7 29.

5 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MANS 214 Underweight, overweight and obesity (18-9 years) Prevalence () Age group UW OW OB NHMS Thinness, Stunting and Obesity (< 18 years) () Thinness Girls 1-17 yr () () Obesity Girls 1-17 yr Stunting Girls yr 12.7 SNS 212 Thinness, Stunting and Obesity (1-17 years) Stunting Moderate Severe Thinness Moderate Severe Girls (1 17 years) Boys & Girls (1 12 years) Boys & Girls (13 17 years) Overweight Obesity Anemia Severe Moderate Mild Overall 1. NHMS 21 Females > 1 years Hemoglobin (g/l): Mild : g/l Moderate : g/l Severe : < 8. g/l (Prevalence () (Yusof et al., 212) N=8 (16-17 years) Anemia 9.6 Girls (44.4) Boys (1.2) 3. (Foo et al., 24) N=91 (Girls, years) 12 1 years Anemia 23.7; IDA years Anemia Anemia 32.1; IDA 28.3

6 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand Folate deficiency Beijing (N=22) Kuala Lumpur (N=389) Jakarta (N=129) RBC folate (nmol/l) 63 (24,61) 674 (644,74) 872 (833,91) Predicted NTD rate (/1,) *M (9 CI) 3 (27,33) 24 (22,2) 1 (14,1) Folate deficiency (< 3 nmol/l): Beijing (18) Kuala Lumpur (8) Jakarta () RBC folate (nmol/l), M (SD) Folate (ug of DFE), M (SD) Malay (N=137) Chinese (N=127) Indian (N=121) Total (38) (228) 7.2 (319) 76. (31) (32) (16) (13) (93) (143) Taking supplement RNI 4 ug/day Percentage () (Green et al., 27) Malay Chinese Indian Total < 363 nmol/l > 96 nmol/l (Khor et al., 26) Iodine deficiency Urinary Iodine (UI) (ug/l) Median UI < 1 ug/l Malaysia Peninsular Malaysia 14.7 Sabah Sarawak Girls National IDD Survey 28 School children 8-1 years (N=1878) Vitamin D insufficiency Authors (year) Sample size (N) / Age 2(OH)D < nmol/l () Khor et al (211) Girls, N=222 / 7-12 years 77. Poh et al (213) Girls, N=123 / 7-12 years Urban 66.7; Rural 2.9 Al-Sadat et al (216) Girls, N=836 / 13 years 98.8 Moy & Bulgiba (211) Females, N=222 / > 3 years 87 Shafinaz & Moy (216) N=88 (Females=781) / 2-6 years 67.4 (MOH, 29)

7 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand PREGNANT / LACTATING FEMALE ADOLESCENTS AND ADULTS (1 49 YEARS) Dietary Intake Energy and nutrient intakes of pregnant women (developing countries) Nutrient intake of Inadequacy (range) Energy Macronutrient CHO (gram) (Mean) Protein Fat (gram) (Mean) Micronutrient Thiamine Riboflavin Niacin Vitamin A Vitamin C Calcium Iron Iodine.8 Zinc Oguntona & Akinyele, 22; Piammongkol et al., 24; Cheng et al., 29; Jaruratansirikul et al., 212; Sukchan et al., 21 Energy and macronutrients Seremban Cohort Study (SeCOST) Recommended range (Trimester 1, N=629) (Trimester 2, N=1) (Trimester 3, N=484) Energy (kcal) (39.1, 19.1) 1866 (28., 29.1) 1717 (36.6, 7.6) CHO energy (41.7, 11.1) 2.1 (39.8, 6.4) 47.4 (48.1, 9.) Protein energy (6., 21.) 16.4 (4.7, 17.3) 18.4 (3.3, 27.1) Fat energy (22.3, 6.9) 31.6 (19.4, 7.9) 34.4 (19.8, 63.4) Sat. fat energy < (49.) 11. (3.4) 1.4 (3.) Sugar energy < (2.) 1.1 (62.1) 11.4 (48.8) Dietary fiber (g) 2 3g 1. (9.8, 2.) 1.6 (91.1, 1.7) 11.9 (86.8, 4.8) (Zalilah et al., unpublished))

8 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand Micronutrients Recommended range (Trimester 1, N=629) (Trimester 2, N=1) (Trimester 3, N=484) Iron (mg) Calcium (mg) (69., 1.4) (., 29.7) 68. (66., 14.3) Folate (ug) (8.9, 3.) 29.2 (79.2,.4) (73.6, 12.4) Vitamin C (mg) (47.2, 4.1) 124.( ) 97.9 (49.6, 39.9) Vitamin A (ug) (3.7, 29.9) 64.7 (6.7, 27.) 74. (.2, 24.2) Food groups Recommended range (Trimester 1, N=629) (Trimester 2, N=1) (Trimester 3, N=484) Grains & cereals (73.1, 18.8) 8.3 (2., 37.3) 6.7 (68.6, 19.8) Fruits (78.4, 8.1) 1. (81.7,.).9 (77.7,.) Vegetables (9.6, 1.6) 1.3 (9., 1.6) 1.4 (9.,.4) Meat & poultry (8., 1.6) 2.1 (47.6, 21.7) 2.1 (.6, 2.2) Fish (.1, 19.2) 1.6 (43.9, 3.1) 1.6 (1.2, 27.9) Legumes (87.1, 1.7).2 (93.6, 1.6). (74.8, 6.8) Milk & dairy (98.3,.2).8 (94.,.8).9 (9.7,.8) (Zalilah et al., unpublished)) Folate / Folic acid intake in early pregnancy (1-13 th week) N=294 Vitamin D intake (food and supplement) in 2 nd / 3 rd trimester, N=314 M (SD) Food folate (ug/day) (17) RNI (food folate) 46.1 taking folic acid supplement 81.6 Folic acid supplement (ug/day) (2387) Total folate intake (ug/day) (247) *RNI (pregnancy) - 6 ug/day *Hematinic mg folic acid weekly or daily depending on anemia status Respondents Intake of food folate < > 1 Recommended intake (Zalilah et al., unpublished) n () Mean ± SD Vitamin D (µg) 11.4 ±.4 Food 6. ± 4.43 Supplement 149 (47.) 4.99 ±.9 Percentage RNI for vitamin D ± 8.9 < 7 (17.) 7 1 * 2 (8.) (8.) > (66.) Vitamin D categories Below recommendation (< µg/day) 8 (2.) Above recommendation ( µg/day) 234 (74.) (Heng Yaw et al 217, in press)

ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand Associations of pre-pregnancy BMI and gestational weight gain with pregnancy outcomes and

, 214); Gestational Weight Gain MOH Health Clinic Data Pre-pregnancy BMI (kg/m 2 ) * Underweight (n=224) 11.48 ±.26 Normal weight (n=14) 1.96 ±.13 Overweight (n=634) 9. ±.17 Obese (n=347) 7.71 ±.

9 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand Associations of pre-pregnancy BMI and gestational weight gain with pregnancy outcomes and postpartum weight retention: A prospective observational cohort study Nutritional Status (Haugen et al., 214); Gestational Weight Gain MOH Health Clinic Data Pre-pregnancy BMI (kg/m 2 ) * Underweight (n=224) ±.26 Normal weight (n=14) 1.96 ±.13 Overweight (n=634) 9. ±.17 Obese (n=347) 7.71 ±.24 Total (N=229) 9.9 ± 4.47 I= Inadequate; N= normal; E= excessive Total weight gain in kg I M ± SD Median p(2, 7) n () 11.2 (8.-14.) 9. ( ) 7. (4.-1.4) 9.7 (7.-13.) N n () 13 (6.3) 79 (3.3) 38 of pregnant women with 1. recommended (8.-14.) gestational weight gain (MOH, 216) E n () 1 (4.4) 74 (7.2) 312 (31.1) 118 (11.7) 2 (31.) 273 (43.1) 161 (2.4) 99 (28.) 12 (36.) 123 (2.) 18 (4.6) 789 (3.7) 412 (18.7) (Zalilah et al., Unpublished data) (Yong et al., 216)

ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MCH Survey 216 Maternal health (1-49 years old) Common medical conditions among pregnant women:

10 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand MCH Survey 216 Maternal health (1-49 years old) Common medical conditions among pregnant women: Anemia 29.3 Maternal obesity 14.6 Hyperglycemia (GDM / DIP) 13. Hypertension.8 Age (years) Anemia Obesity Hyperglycemia Hypertension Overall Anaemia at 36 weeks of gestation Vitamin D status Zalilah et al. (unpub) SECOST (N=29) 1 st trimester Jan et al. (214) (N=12) 2 nd & 3 rd trimester Bukhary et al. (216) (N=396) 1 st trimester < 2 nmol/l 2 - < nmol/l - < 7 nmol/l > 7 nmol/l &..9 & & &

11 ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition, July 24, 217, Bangkok, Thailand Data Limitations and Gaps v General o Limited data on pregnant and lactating women ü1 19 years ülactating women o Available published data require further analysis üage groups (NHMS, SNS) Data Limitations and Gaps v Dietary intake o Under-reporting o Certain nutrients are not commonly reported e.g. iodine, zinc, vitamin D o Limited use of other diet quality analysis e.g. dietary diversity, dietary pattern, energy density o Contribution of dietary supplements to intake of nutrients Data Limitations and Gaps vnutritional Status o Lack of data on micronutrient deficiency o Self-reported data e.g. anemia and other medical conditions during pregnancy (MCH survey) THANK YOU

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