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 Malaysia Programmes in Malaysia Programmes in Malaysia Programmes in Malaysia Khor Khor Khor Khor Geok Geok Geok Geok Lin Lin Lin Lin Khor Khor Khor Khor Geok Geok Geok Geok Lin Lin Lin Lin International Medical University, Malaysia International Medical University, Malaysia International Medical University, Malaysia International Medical University, Malaysia Kuala Lumpur Kuala Lumpur Kuala Lumpur Kuala Lumpur 6 6 6- - -7 Nov 2012 7 Nov 2012 7 Nov 2012 7 Nov 2012 KHOR GL 2012 1
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Insights into Child Nutritional Status and Programmes in Malaysia
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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
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
10101010
15151515
20202020
25252525
%%%%
0000
5555
10101010
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
Months YearsMonths YearsMonths YearsMonths Years
KHOR GL 201212
AGEAGEAGEAGE
10101010
15151515
20202020
25252525
%%%%
0000
5555
10101010
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
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
2222
4444
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
� 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
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