Insights into Child Nutritional Status and Programmes in Malaysia

Insights into Child Nutritional Status and Programmes in Malaysia Khor Geok Lin International Medical University, Malaysia Kuala Lumpur 6-7 Nov 2012 1

Child nutritional status in Malaysia including changing trends over the decades Nutrition policies, action plans and programmes of the Ministry of Health, particularly in relation to promoting optimal child health and nutrition Child nutrition intervention programmes by other stakeholders 2

Infant mortality rate (per 1,000 live births) 1990 2000 2010 % reduction 1990-2010 Myanmar 79 64 50 37 Timor Leste 127 82 46 64 Lao PDR 100 64 42 58 Cambodia 87 77 43 51 Indonesia 56 38 27 52 Philippines 42 30 23 45 Vietnam 37 27 19 49 Thailand 26 16 11 58 Malaysia 16 9 5 69 (WHO Health Statistics 2012) 3

U5MR (per 1,000 live births) 1990 2000 2010 % reduction 1990-2010 Myanmar 112 87 66 41 Timor Leste 169 104 55 68 Lao PDR 145 88 54 63 Cambodia 121 103 51 58 Indonesia 85 54 35 59 Philippines 59 40 29 51 Vietnam 51 35 23 55 Thailand 32 18 13 59 Malaysia 18 11 6 67 (UNICEF, 2009, 2012) 4

Stunting (%) 2003-2008 2006-2010 % reduction Myanmar 41 35 15 Timor Leste - 58 - Lao PDR 48 48 0 Cambodia 42 40 5 Indonesia 37 37 0 Philippines 34 32 6 Vietnam 36 31 14 Thailand 16 16 0 Malaysia - 17 - Globally, childhood stunting decreased from 39.7 (95% CI 38.1, 41.4) % in 1990 to 26.7 (95% CI 24.8, 28.7) % in 2010. (UNICEF, 2009, 2012) 5

Malaysia 7

Total population 2011 Population by age groups Below 15 years 15-64 years Above 64 years Life expectancy at birth (years) 28.96 million 26.9 68.0 5.1 72 (m); 77 (f) Infants low birth weight (%) 11.1 Childhood immunisation coverage BCG (infants) DPT, polio (infants) MMR (< 2 years) HPV (< 13 years girls) 98.7 99.5 95.2 87.1 8

Data from the National Health and Morbidity Surveys (NHMS), MOH NHMS included nationally representative samples of all ages in rural and urban areas in all states NHMS 2006 - Number of children measured: Weight : 21,249; Length/Height : 21,078 NHMS 2011 - Number of children measured: Weight : 9,717; Length/Height : 9,510 Classification of nutritional status based on WHO (2006) for < 5 years, and WHO (2007) for 5 years to < 18 years 11

0-6 7.0-11.9 12.0-23.9 24.0-35.9 36.0-47.9 48.0-59.9 5.0-5.9 6.0-6.9 7.0-7.9 8.0-8.9 9.0-9.9 10.0-10.9 11.0-11.9 12.0-12.9 13.0-13.9 14.0-14.9 15.0-15.9 16.0-16.9 17.0-17.9 % 25 20 15 10 5 0 Months Years AGE 12

Overall stunting prevalence: male 12.0% female 12.1% (NHMS, 2006) % 20 15 NHMS, 2011 11.3%; 0-4 years, m & f Male Female 10 * *(p<0.05) 5 0 Age (months) 14

Overall stunting prevalence: male 17.7% female 15.2% (NHMS, 2006) % 30 25 NCHS, 2011 stunting 13.8% 5-17.9 yrs m & f * *P <0.05 20 15 * * * Male Female 10 5 0 Age (years) 15

Thinness prevalence male 14.6%; female 12.3% (NHMS, 2006) 25 20 Male % 15 10 NHMS, 2011 thinness at 0-4 years 18.2% m & f Female 5 0 Age (months) *(BMI-for-age< -2SD)

14 14 male female 12 10 8 % NHMS, 2011 thinness 10.9% m & f 6 4 2 0 * * * * * AGE (years) 17

Regional disparities in stunting prevalence among children below 18 years (male & female combined) (NHMS, 2006) Penang 9.8% *8.2% Kuala Lumpur 11.4% *8.1% * NHMS, 2011 Kelantan Terengganu 16.2% National prevalence 14.0% Sabah 27.1% 18.6% *13.4% *18.9% *19.8% N Sembilan 10.6% *9.3% *19.4% Sarawak 15.5% *16.6% 18

UNDP: 'High levels of poverty and inequality in Sabah' At the UNDP-CPDS Roundtable Dialogue entitled Overcoming Challenges and Devising Sustainable Strategies and Programmes for Poverty Alleviation in Sabah Kota Kinabalu on Jan 7 2008. 19

Regional disparities in thinness prevalence among children below 18 years (m & f) (NHMS, 2011) Penang 9.9% Kuala Lumpur 11.3% Kelantan 12.3% Terengganu 11.4% National prevalence 12.2% Sarawak 10.4% Sabah 15.0% N Sembilan 12.5% Johor 11.5% 20

Incidence of poverty in 2007 (Economic Planning Unit) Kedah 3.1% Penang 1.4% Perak 3.4% Kelantan 7.2% Terengganu 6.6% Country average 3.6% Sarawak 4.2% Sabah 16.4% Selangor 0.7% Kuala Lumpur 1.5% 21

Disparity in obesity prevalence among children below 18 years (m & f) (BMI-for-age >2SD) (NHMS, 2011) Penang 3.4% Kedah 5.8% Perak 9.0% Selangor 7.3% N Sembilan 5.0% Kelantan 6.4% Terengganu 5.5% Pahang 7.2% National prevalence 6.1% Sabah 3.2% Sarawak 8.0% Melaka 4.7% Johor 5.5% 22

% 15,8 Urban Rural 12,3 12,8 11.0 16 14 12 10 8 6,5 5,5 6 4 2 0 Stunting Thinness Obesity (HAZ < - 2SD) (BMI-for-age < -2SD) (BMI-for-age > 2SD) 23

Malaysia 72% urban 24

Anemia (Hb ( < 11.0 mg/dl) Prevalence (%) 95% CI Myanmar 63.2 28.1-88.3 Timor Leste 31.5 29.7-33.3 Lao PDR 48.2 34.8 61.8 Cambodia 63.4 59.8-66.8 Indonesia 44.5 15.6 77.6 Philippines 36.3 33.9 38.8 Vietnam 34.1 10.3 68.1 Thailand 25.2 23.2 27.4 Malaysia 32.4 10.0 67.5 26

Biochemical vitamin A deficiency (retinol) as a public health problem by country 1995 2005: Preschool-age children Biochemical vitamin A deficiency (retinol) as a public health problem by country 1995 2005: Preschool-age children Countries and areas with survey data and regression-based estimates Countries and areas with survey data and regression-based estimates 27

Iron deficiency Vitamin A deficiency Iodine deficiency disorders Vitamin D insufficiency 28

% 40 20.8 18,3 4,5 20 2,5 female 0 male (Hb < 11g/dl) Anaemic Vitamin A deficiency (Serum retinol 0.7µmol/L) KGL 2012

WHO Classification of vitamin A deficiency % with low serum retinol Result of MOH/UNICEF study in 2000 Mild 2 - <10 3.4% Moderate 10 - <20 Severe 20 KGL 2012

A national IDD survey in 1996 reported widespread serious goitre problem. This led to universal salt iodization (USI) implemented in Sabah and majority of the endemic districts in Sarawak. IDD was not considered a problem in Peninsular Malaysia then, but recent studies have indicated the need for USI in the peninsula. 31

(IDD Newsletter 2010) 32

National IDD Survey undertaken in 2008. Urinary iodine concentration was determined in 1,200 children aged 8-10 years. (IDD Newsletter 2010) KGL 2012

(IDD Newsletter 2010) KGL 2012

Most children showed adequate concentrations of haemoglobin, serum ferritin, zinc, folate and vitamin B12. In contrast, 35.3% of the children had vitamin D deficiency ( 37.5nmol/L) and a further 37.1% had insufficiency concentrations (>37.5-50nmol/L). (Khor et al., 2011) KGL 2012

100 80 60 40 20 0 high normal suboptimal Primary school boys & girls in Kuala Lumpur, (n=402) KGL 2012

High prevalence of vitamin D insufficiency and its association with BMI-for-age among primary school children in Kuala Lumpur aged 7-12 years (N=402) Among the boys, a significant inverse association was found between serum vitamin D status and BMI-for-age (χ2 = 5.958; P =0.016). A total of 17.9% were overweight and 16.4% obese. Prevalence of obesity was significantly higher among the boys (25%) than in the girls (9.5%) (χ2 = 22.949; P <.001). (Khor et al., 2011) KGL 2012

MOH Healthy Public Policies 1. Control of Tobacco Products Regulations in 1993 2. Nutritional Labelling 3. Wellness Policy 4. National Breast Feeding Policy 5. Policies on Control of HIV and AIDS 6. Food Hygiene and Safety Policy in Schools 39

National Breast Feeding Policy A National Breastfeeding Policy was formulated in 1993 and revised it in 2005 in accordance with the World Health Assembly Resolution 54.2 (2001) recommending exclusive breastfeeding in the first six months of life and continued up to two years. In addition, complementary foods should be introduced at 6 months of age. 40

Food Hygiene and Safety Policy in Schools Several policies and activities for schools have been developed through the joint venture efforts between Ministry of Health and Ministry of Education The Program Bersepadu Sekolah Sihat (PBSS) is aimed at empowering the school community to ensure safe food for school children and prevention of food poisoning. 41

Nutrition Improvements Nutrition Improvements is administered through four functional areas of nutrition planning and development, nutrition promotion, nutrition rehabilitation and nutrition surveillance. Activities under nutrition planning and development include planning, developing and evaluating nutrition programs and activities, and monitoring and evaluating the implementation of the National Plan of Action for Nutrition of Malaysia (NPANM) 2006-2015. Nutrition promotion encompasses promoting infant and young child nutrition, adolescent nutrition, nutrition in institutions and adult nutrition through healthy eating and nutrition for the elderly and those with special needs. Healthy eating is also propagated through the establishment of Nutrition Information Centers. 42

KGL 2012

National Plan of Action for Nutrition for Malaysia (NPAN II) 2006-2015 This is the second master plan of the Ministry of Health (MOH) aimed at promoting optimal well-being of Malaysians, in particular in improving breast-feeding and complementary feeding reducing protein-energy malnutrition and micronutrient deficiency reducing overweight and obesity preventing and controlling diet-related non-communicable diseases. KGL 2012

Objective TO ACHIEVE AND MAINTAIN THE NUTRITIONAL WELL-BEING OF MALAYSIAN Specific objectives Improving nutritional status of all Preventing and controlling diet-related non-communicable diseases Enabling strategies Improving household food security especially among the low income Promoting optimal infant & young children feeding practices Preventing and controlling nutritional deficiencies Promoting healthy eating and active living Supporting efforts to protect consumers in food quality & safety Facilitating strategies Foundation strategy Ensuring all have access to nutrition information Continuous assessment and monitoring of the nutrition situation Promoting continuous research and development Ensuring nutrition & dietetics practised by trained professionals Strengthening institutional capacity in nutritional activities Incorporating nutrition objectives and strategies into policies and programmes of relevant agencies KGL 2012

Indicators for action Targets for improvement Status Anemia: - Children below 5 years - Reduce from 18% in 1999 to 9% Data? - Pregnant women Iodine deficiency disorders: -School children 8-10 years - Reduce from 43.8% in 2003 to 30% -- Median urinary iodine excretion between 100-200 µg/l 21.5% (MOH, 2009) -109 µg/l (MOH, 2009) Vitamin A deficiency: - Children below 5 years - Reduce from 19.8% in 2000 to 10.0% (low serum retinol less than 20ug/dl) Data? KGL 2012

Pregnant & lactating mothers: - folic acid + multivitamins + full cream milk powder (1kg/month for 3 months) Underweight children 6 months to 6 years: - full cream milk powder (1kg/month) Very poor family with underweight child below 6 years: - Food Basket monthly KGL 2012

Rice 6 (kg per month) Wheat flour 4 Anchovy 1 Green gram/equivalent 1 Cooking oil/margarine 4 Sugar 3 Biscuits 3 Full cream milk powder 1 KGL 2012

School children from low income family (7-12 years): milk and supplementary food Milk (plain or chocolate/strawberry flavoured) (250 ml packet) is made available to primary school children The milk is given free to children from low income families while others pay a subsidized price Problems: irregular supply, lack of refrigeration facility in school, and side effects (an evaluation study of 8,000 children found ~20% claimed they had stomach ache after drinking school milk). KGL 2012

Provides free food daily to primary school children from low income families Each meal meets ¼ -⅓of Malaysian RDI for calories and 1/5-2/3 RNI for protein for children 7-12 years Cost of each meal is about RM1.00 (~US25 ) per child; extended to all schools since 1989 Problems: non-compliance with set menus by providers KGL 2012

Global target 1: reduction of childhood stunting Global target 2: reduction of anaemia in women of reproductive age Global target 3: 50% reduction of low birth weight Global target 4: No increase in childhood overweight Global target 5: Increase exclusive breastfeeding rates in the first six months of life to at least 50% 53

Global target 1: reduction of childhood stunting Target: 40% reduction of the global number of children under five who are stunted, by the year 2022, compared to the baseline of 2010. This would translate into a 5.1% relative reduction per year between 2012 and 20226 and implies reducing the number of stunted children from the 171 million in 2010 to approximately 100 million. Global target 4: No increase in childhood overweight Target: 0% increase in the prevalence of overweight in children under five. Target setting: the target implies that the global prevalence of 6.7% (95% CI 5.6-7.7) estimated for 2010 should not rise to 9.1% (in 2020) as per current trends23 and that the number of overweight children under 5 should not increase from 43 to approximately 60 million as forecasted 54

Factor Obesity WCRF International recommendation Support and retain. Integrate and cross reference target and indicator on infant obesity (aged 0-5) and include indicator on child obesity (aged 5-18). Cross reference to indicators on total fat and sugar consumption, fruit and vegetable consumption, marketing to children, physical activity and breastfeeding. Overweight and obesity in children (aged 5-18) We recommend the inclusion of a new indicator on overweight and obesity in children aged 5-18. Further work is needed to determine how best to report on obesity in school-aged children and young people. We recommend that this work is taken forward. 55

In the case of a rapidly expanding economy such as Malaysia, it is shown that: Overall, indicators of the health and nutritional status of young children are relatively better than several countries in Southeast Asia. Nonetheless, national average values tend to mask significant disparities in malnutrition across geographical regions. Stunting and thinness prevalence disparities shown between higher and lower income regions Overweight/obesity prevalence also showed regional differentials, but not as distinctly mapped to lower income areas, as for under-nutrition status. 56

These findings have implications for intervention programmes, especially the need to be sensitive to populations with a double burden of malnutrition. Intervention strategies for further improvement of the nutritional status of Malaysian children should continue to target the indigenous and minority groups, and the poor in urban and rural areas. It is recommended that long-term studies which relate dietary intake/lifestyles in early childhood to risks of chronic diseases in adulthood be supported in the region. 57