Insights into Child Nutritional Status and Insights into Child Nutritional Status and Insights into Child Nutritional Status and Insights into Child Nutritional Status and Programmes in MalaysiaProgrammes in MalaysiaProgrammes in MalaysiaProgrammes in Malaysia

KhorKhorKhorKhor GeokGeokGeokGeok LinLinLinLinKhorKhorKhorKhor GeokGeokGeokGeok LinLinLinLin

International Medical University, MalaysiaInternational Medical University, MalaysiaInternational Medical University, MalaysiaInternational Medical University, Malaysia

Kuala LumpurKuala LumpurKuala LumpurKuala Lumpur

6666----7 Nov 20127 Nov 20127 Nov 20127 Nov 2012

KHOR GL 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 particularly in relation to promoting optimal child health and nutrition

� Child nutrition intervention programmes by other stakeholders

KHOR GL 2012 2

Infant mortality rate (per 1,000 live births)Infant mortality rate (per 1,000 live births)Infant mortality rate (per 1,000 live births)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

KHOR GL 20123

(WHO Health Statistics 2012)

U5MR (per 1,000 live births)U5MR (per 1,000 live births)U5MR (per 1,000 live births)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

KHOR GL 20124

(UNICEF, 2009, 2012)

Stunting (%)Stunting (%)Stunting (%)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 -

KHOR GL 20125

(UNICEF, 2009, 2012)

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.

KHOR GL 2012 6

Malaysia

KHOR GL 20127

Total population 2011 28.96 million

Population by age groups

Below 15 years

15-64 years

Above 64 years

26.9

68.0

5.1

Life expectancy at birth (years) 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

KHOR GL 20128

KHOR GL 20129

KHOR GL 2012

10

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: � 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

KHOR GL 201211

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15151515

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0-6

7.0-11.9

12.0-23.9

24.0-35.9

36.0-47.9

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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

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Months YearsMonths YearsMonths YearsMonths Years

KHOR GL 201212

AGEAGEAGEAGE

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13.0-13.9

14.0-14.9

15.0-15.9

16.0-16.9

17.0-17.9

Months YearsMonths YearsMonths YearsMonths Years

KHOR GL 2012 13

AGEAGEAGEAGE

15

20

%

Male

Female

Overall stunting prevalence: male 12.0% female 12.1% (NHMS, 2006)

* *(p<0.05)

NHMS, 201111.3%; 0-4 years, m & f

0

5

10

Age (months)

* *(p<0.05)

KHOR GL 2012

14

20

25

30%

Male

Overall stunting prevalence: male 17.7% female 15.2% (NHMS, 2006)

**

*

*

*P <0.05

NCHS, 2011 stunting 13.8%NCHS, 2011 stunting 13.8%NCHS, 2011 stunting 13.8%NCHS, 2011 stunting 13.8%5555----17.9 17.9 17.9 17.9 yrsyrsyrsyrs m & fm & fm & fm & f

0

5

10

15

20

Age(years)

Male

Female

**

KHOR GL 2012 15

15

20

25

%

Male

Female

Thinness prevalence male 14.6%; female 12.3% (NHMS, 2006)

NHMS, 2011thinness at 0-4 years 18.2% m & f

0

5

10

%

Age (months)

KHOR GL 2012*(BMI-for-age< -2SD)

6666

8888

10101010

12121212

14141414 male female*

**

**

%%%% NHMS, 2011 thinness 10.9% m & f

0000

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6666

AGE (years) AGE (years) AGE (years) AGE (years)

KHOR GL 201217

27.1%

Sabah

18.6%

16.2%

National

prevalence 14.0%

9.8%

Regional disparities in stunting prevalence among children

below 18 years (male & female combined) (NHMS, 2006)

Kelantan

Terengganu

Penang

*8.2%

*18.9% *19.8%*13.4%

Sarawak

11.4%

10.6%

Kuala Lumpur

N Sembilan

KHOR GL 201218

*8.1%

*9.3%

* NHMS, 2011

*19.4%

*16.6%

15.5%

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.

KHOR GL 2012 19

15.0%12.3%

11.4%

National prevalence

12.2%

Regional disparities in thinness prevalence among children

below 18 years (m & f) (NHMS, 2011)

SabahKelantan

Terengganu

Penang

9.9%

Sarawak

Kuala Lumpur

11.3%

Johor

11.5%

Sarawak

10.4%

N Sembilan

12.5%

KHOR GL 201220

Country average

3.6%

Penang

1.4%

Incidence of poverty in 2007 (Economic Planning Unit)

Sabah

16.4%

Kelantan

7.2%

Terengganu

6.6%

Sarawak

4.2%

Kedah

3.1%

Perak

3.4%

Kuala Lumpur

1.5%

Selangor

0.7%

KHOR GL 2012 21

4.2% 3.4%

National

prevalence 6.1%

Disparity in obesity prevalence among children below 18 years

(m & f) (BMI-for-age >2SD) (NHMS, 2011)

Kelantan

6.4%

Sarawak 8.0%

Terengganu 5.5%

SabahSabahSabahSabah3.2% 3.2% 3.2% 3.2%

Penang

3.4%Perak

9.0%

Kedah

5.8%

Sarawak 8.0%

Selangor 7.3%

N Sembilan

5.0%

Pahang

7.2%

KHOR GL 2012 22

9.0%

Melaka

4.7%

Johor

5.5%

10

12

14

16

12,3 12,8

15,8

11.0

Urban Rural

%

0

2

4

6

8

Stunting Thinness Obesity

6,55,5

(HAZ < - 2SD) (BMI-for-age < -2SD)

KHOR GL 2012 23

(BMI-for-age > 2SD)

KHOR GL 201224

Malaysia 72% urban

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Anemia (Anemia (Anemia (Anemia (HbHbHbHb < 11.0 mg/dl)< 11.0 mg/dl)< 11.0 mg/dl)< 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

KHOR GL 201226

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

Biochemical vitamin A deficiency (retinol) as a public health problem by

country 1995–2005: Preschool-age children

KHOR GL 2012 27

Countries and areas with survey data and

regression-based estimates

� Iron deficiency

� Vitamin A deficiency

� Iodine deficiency disorders� Iodine deficiency disorders

� Vitamin D insufficiency

KHOR GL 201228

20

40

18,3

20.8

4,5

%%%%

malemalemalemale

femalefemalefemalefemale

0

20

AnaemicAnaemicAnaemicAnaemicVitamin A Vitamin A Vitamin A Vitamin A

deficiencydeficiencydeficiencydeficiency

2,5

((((HbHbHbHb < 11g/dl)< 11g/dl)< 11g/dl)< 11g/dl)

(Serum retinol (Serum retinol (Serum retinol (Serum retinol ≤≤≤≤ 0.70.70.70.7µµµµmol/L)mol/L)mol/L)mol/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 � IDD was not considered a problem in Peninsular Malaysia then, but recent studies have indicated the need for USI in the peninsula.

KHOR GL 201231

KHOR GL 201232

(IDD Newsletter 2010)

National IDD Survey undertaken in 2008.

Urinary iodine concentration was determined in 1,200

children aged 8-10 years.

KGL 2012

(IDD Newsletter 2010)

(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 � 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).

KGL 2012

(Khor et al., 2011)

40

60

80

100

high

0

20

40normal

suboptimal

Primary school boys & girls in Kuala Lumpur, (n=402)

KGL 2012

� 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%

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)

KGL 2012

(Khor et al., 2011)

� 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 GL 2012 38

MOH Healthy Public Policies

1. Control of Tobacco Products

Regulations in 1993

2. Nutritional Labelling

3. Wellness Policy

KHOR GL 201239

4. National Breast Feeding Policy

5. Policies on Control of HIV and

AIDS

6. Food Hygiene and Safety Policy

in Schools

National Breast Feeding PolicyNational Breast Feeding PolicyNational Breast Feeding PolicyNational 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 the first six months of life and continued up to two years.

◦ In addition, complementary foods should be introduced at 6 months of age.

KHOR GL 2012

40

Food Food Food Food Hygiene and Safety Policy in Hygiene and Safety Policy in Hygiene and Safety Policy in Hygiene and Safety Policy in Schools Schools Schools 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.

KHOR GL 2012

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

KHOR GL 201242

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.

KGL 2012

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 � reducing protein-energy malnutrition and micronutrient

deficiency

� reducing overweight and obesity

� preventing and controlling diet-related non-communicable

diseases.

KGL 2012

• Improving household food security especially among the low income

• Promoting optimal infant & young children feeding practices

• Preventing and controlling nutritional deficiencies

Specific objectives Improving

nutritional

status of all

Preventing

and controlling

diet-related

non-communicable diseases

TO ACHIEVE AND MAINTAIN THE NUTRITIONAL WELL-BEING OF MALAYSIAN

Objective

Enabling strategies

Incorporating nutrition objectives and strategies into policies and programmes of relevant agencies

Foundation

strategy

Facilitatingstrategies

• Preventing and controlling nutritional deficiencies

• Promoting healthy eating and active living

• Supporting efforts to protect consumers in food quality & safety

Ensuring Ensuring Ensuring Ensuring

all have all have all have all have

access to access to access to access to nutrition nutrition nutrition nutrition

informationinformationinformationinformation

Continuous Continuous Continuous Continuous assessment assessment assessment assessment

and and and and monitoring monitoring monitoring monitoring

of the of the of the of the nutrition nutrition nutrition nutrition situationsituationsituationsituation

Promoting Promoting Promoting Promoting continuous continuous continuous continuous research research research research and and and and

developmentdevelopmentdevelopmentdevelopment

Ensuring Ensuring Ensuring Ensuring nutrition & nutrition & nutrition & nutrition & dietetics dietetics dietetics dietetics practisedpractisedpractisedpractisedby trained by trained by trained by trained

professionalsprofessionalsprofessionalsprofessionals

Strengthening Strengthening Strengthening Strengthening

institutional institutional institutional institutional

capacity in capacity in capacity in capacity in

nutritional nutritional nutritional nutritional

activitiesactivitiesactivitiesactivities

KGL 2012

Indicators for action Targets for improvement Status

Anemia:

- Children below 5 years

- Pregnant women

- Reduce from 18% in 1999 to 9%

- Reduce from 43.8% in 2003 to

30%

Data?

21.5% (MOH, 2009)

Iodine deficiency Iodine deficiency

disorders:

-School children 8-10

years

-- Median urinary iodine excretion

between 100 -200 µg/L

-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:� 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 childrenchildren

� 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 - ⅓ of Malaysian RDI for calories and 1/5-2/3 RNI for protein for children 7-12 yearschildren 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

KHOR GL 2012 52

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%

KHOR GL 201253

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.

KHOR GL 2012 54

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

FactorFactorFactorFactor WCRF International recommendationWCRF International recommendationWCRF International recommendationWCRF International recommendation

Obesity Support and retain. Integrate and cross referencetarget 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 sugarCross reference to indicators on total fat and sugarconsumption, fruit and vegetable consumption, marketing to children, physical activity and breastfeeding.

KHOR GL 201255

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”.

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.

KHOR GL 201256

� 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.

KHOR GL 201257

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