Triple burden of malnutrition among Malaysian children aged 6 months to 12 years: Current findings from SEANUTS II Malaysia

OBJECTIVE

This paper aims to report South East Asian Nutrition Surveys (SEANUTS) II Malaysia data on nutritional status, dietary intake, and nutritional biomarkers of children aged 6 months to 12 years.

DESIGN

Cross-sectional survey conducted in 2019-2020.

SETTING

Multistage cluster sampling conducted in Central, Northern, Southern, and East Coast regions of Peninsular Malaysia.

PARTICIPANTS

2989 children aged 0.5-12.9 years.

RESULTS

Prevalences of stunting, thinness, overweight, and obesity among children aged 0.5-12.9 years were 8.9%, 6.7%, 9.2%, and 8.8%, respectively. Among children below 5 years old, 11.4% were underweight, 13.8% had stunting, and 6.2% wasting. Data on nutritional biomarkers showed a small proportion of children aged 4-12 years had iron (2.9%) and vitamin A deficiencies (3.1%). Prevalence of anaemia was distinctly different between children below 4 years old (40.3%) and those aged 4 years and above (3.0%). One-fourth of children (25.1%) had vitamin D insufficiency, which was twice as prevalent in girls (35.2% vs. boys: 15.6%). The majority of children did not meet the recommended dietary intake for calcium (79.4%) and vitamin D (94.8%).

CONCLUSIONS

Data from SEANUTS II Malaysia confirmed that triple burden of malnutrition co-exists among children in Peninsular Malaysia, with higher prevalence of overnutrition than undernutrition. Anaemia is highly prevalent among children below 4 years old, while vitamin D insufficiency is more prevalent among girls. Low intakes of dietary calcium and vitamin D are also of concern. These findings provide policymakers with useful and evidence-based data to formulate strategies that address the nutritional issues of Malaysian children.

A Comparative Policy Analysis of the Adoption and Implementation of Sugar-Sweetened Beverage Taxes (2016-2019) in 16 Countries

Taxes on sugar-sweetened beverages (SSBs) are recommended as part of comprehensive policy action to prevent diet-related non-communicable diseases (NCDs), but have been adopted by only one quarter of World Health Organization (WHO) Member States. This paper presents a comparative policy analysis of recent SSB taxes (2016–19) in 16 countries. This study aimed to analyse the characteristics and patterns of factors influencing adoption and implementation of SSB taxes and policy learning between countries, to draw lessons for future SSB taxes. The data collection and analysis were informed by an analytical framework that drew on ‘diffusion of innovation’ and theories of policy learning. Qualitative data were collected from policy documents and media, in addition to national statistics. Qualitative data were thematically analysed and a narrative synthesis approach was used for integrated case study analysis. We found adaptation and heterogeneity in the approaches used for SSB taxation with a majority of countries adopting excise taxes, and consistent health framing in media and policy documents. Common public frames supporting the taxes included reducing obesity/NCDs and raising revenue (government actors) and subsequent health system savings (non-government actors). Opposing frames focused on regressivity and incoherence with other economic policy (government actors) and posited that taxes have limited health benefits and negative economic impacts on the food industry (industry). Evident ‘diffusion networks’ included the WHO, predominantly in middle-income countries, and some regional economic bodies. We found indications of policy learning in the form of reference to other countries’ taxes, particularly countries with membership in the same economic bodies and with shared borders. The study suggests that adoption of SSB taxation could be enhanced through strategic engagement by health actors with the policy-making process, consideration of the economic context, use of consistent health frames by cross-sector coalitions, and robust evaluation and reporting of SSB taxation.

Motivations, barriers and exercise preferences among female undergraduates: A need assessment analysis

Introduction

The decreasing level of physical activity among female undergraduates is worrying as it is associated with the increased risk of non-communicable diseases. Thus, this study aimed to identify the motivations, barriers and preferences towards exercise among female undergraduates in Malaysia.

Methods

A non-probability purposive sampling was used for the recruitment process. The inclusion criteria of the participants were registered female undergraduates and aged between 18–30 years old. A semi-structured in-depth interview was used to collect topic-related information from the participants and signed consents were obtained prior to the interview. The interview questions were on respondents’ understanding of exercise, motivation and barriers to exercise, and exercise preferences. The recruitment process was conducted until the data was saturated. All interviews were audio recorded and manually transcribed verbatim. NVivo 11 was used to conduct the inductive analysis of the data to develop themes for motivation and barriers to exercise. For exercise preferences, four predetermined themes were used.

Findings

A total of 26 respondents participated in this study. Eight themes were found for motivation to exercise, with the most common themes being maintaining or improving appearance, health benefits and togetherness. For barriers of exercising, five themes were found, and the most common ones were disliking exercise and no motivation. For exercise preferences, most respondents preferred a structured exercise program with flexibility in terms of when and where the exercise could be conducted. Light or moderate intensity exercise for 10–30 minutes with a frequency of 1–2 times a week was desired the most among the respondents.

Conclusion

In conclusion, personal and environmental factors play important roles in motivating or hampering female undergraduates to exercise, and a structured program was the preferred mode of exercise of these respondents. A new exercise module was designed based on this needs assessment with a 70% acceptance rate among the participants. These findings can help the future development of more exercise modules tailored to female university students.

Identifying Opportunities for Strategic Policy Design to Address the Double Burden of Malnutrition through Healthier Retail Food: Protocol for South East Asia Obesogenic Food Environment (SEAOFE) Study

Effective policies that address both the supply and demand dimensions of access to affordable, healthy foods are required for tackling malnutrition in South East Asia. This paper presents the Protocol for the South East Asia Obesogenic Food Environment (SEAOFE) study, which is designed to analyze the retail food environment, consumers' and retailers' perspectives regarding the retail food environment, and existing policies influencing food retail in four countries in South East Asia in order to develop evidence-informed policy recommendations. This study was designed as a mixed-methods sequential explanatory approach. The country sites are Malaysia, Indonesia, the Philippines, and Thailand. The proposed study consists of four phases. Phase One describes the characteristics of the current retail food environment using literature and data review. Phase Two interprets consumer experience in the retail food environment in selected urban poor communities using a consumer-intercept survey. This phase also assesses the retail food environment by adapting an in-store audit tool previously validated in higher-income countries. Phase Three identifies factors influencing food retailer decisions, perceptions, and attitudes toward food retail policies using semi-structured interviews with selected retailers. Phase Four recommends changes in the retail food environment using policy analysis and semi-structured interviews with key stakeholders. For the analysis of the quantitative data, descriptive statistics and multiple regression will be used, and thematic analysis will be used to process the qualitative data. This study will engage stakeholders throughout the research process to ensure that the design and methods used are sensitive to the local context.

Consumers' Perceptions of Healthy Food Availability in Online Food Delivery Applications (OFD Apps) and Its Association With Food Choices Among Public University Students in Malaysia

This retrospective cross-sectional study was conducted to study consumers' perceptions of healthy food availability in online food delivery applications (OFD apps) among public university students in Malaysia and its association with their food choices. A total of 290 subjects aged 19–29 years old were recruited from 20 public universities in Malaysia via snowball sampling. Data was collected through an online questionnaire which consisted of socio-demographic status, use of OFD apps (most frequently used brand, usage frequency, food choice, and expenditure per transaction), factors affecting food choice in OFD apps, consumers' perceptions of healthy food availability in OFD apps and recommendation for improvements. The most frequently used apps among the subjects was Food Panda (46.6%), however, majority of the subjects in this study (41.4%) rarely used OFD apps. Also, most of the subjects ordered unhealthy food (77.6%) and spent up to RM15–RM19 for each transaction (43.1%). There was no significant difference between the use of OFD apps and gender (p > 0.05). Among the five food choice motives, “price and convenience” motive was the most influencing food choice factor in OFD apps. Majority of the subjects (76.9%) had a negative perception of healthy food availability (variety, price, and quality of healthy food) in OFD apps. No significant association was found between consumers' perceptions of healthy food availability in OFD apps and their food choices made in OFD apps among the subjects in this study (p > 0.05). Also, majority (85.9%) responded they are keen to purchase healthy foods through OFD apps if they are given an option. However, most Malaysian public university students perceived that there were not much variety of healthy food, of good quality and affordable price, available in OFD apps. This finding suggests that the online food environment in Malaysia are perceived as unhealthy. Future studies can explore the online food environment particularly its impact on community health and well-being. Public health professionals and policymakers need to address the online food environment issues as part of the obesogenic food environment in Malaysia especially when OFD is one of the most convenient service in this country.

Needs Assessment Towards Development of an Integrated Diabetes-Oral Health Nutrition Education Module: A Qualitative Study

INTRODUCTION

The diabetes mellitus-periodontitis relationship has advocated several strategic management approaches on effective glycaemic control and oral health improvement for diabetic patients and periodontitis patients with diabetes. We aimed to identify the challenges of providing health education to patients with diabetes and/or periodontitis among healthcare professionals and needs for an integrated nutrition-oral health education module.

METHODS

This study involved semi-structure in-depth interview with fifteen healthcare professionals from a training hospital focused on: (i) the existing issues and challenges encountered while managing patients for their nutrition and care and (ii) issues related to the current practice among healthcare professionals. Details pertaining to the participants' verbal and non-verbal responses were recorded, transcribed ad verbatim and analysed using themes codes.

RESULTS

Patients' attitude and behaviour, language barriers and prioritising time were found as the common problems with patients, while limited knowledge on the relationship between diabetes-periodontitis, limited availability of appropriate and cultural-based health educational tools, lack of inter-professional multidisciplinary collaboration in managing patients, and constrains in time as well as costly therapy were common issues in the current practice.

CONCLUSIONS

Cost-effective efforts must be focused on overcoming these issues besides emphasizing the needs on developing an integrated module to achieve better management outcomes.

Development and evaluation of an integrated diabetes-periodontitis nutrition and health education module

BACKGROUND

A good understanding of the bi-directional relationship between diabetes and periodontitis is essential to ensure the successful management of both diseases. This study aimed to develop and evaluate an integrated diabetes-periodontitis nutrition and health education module.

METHODS

The module was developed as an iterative and review process by five experts in nutrition and dietetics, periodontics, and dental public health. It consisted of three phases: (i) needs assessment on module contents and characteristics, (ii) module development and (iii) module evaluation by experts. Twelve healthcare professionals aged between 30 and 53 years (average 13.5 years of working experience) validated the module contents and its comprehensibility using the Patient Education Materials Assessment Tool for printable materials (PEMAT-P) and audio-visual materials (PEMAT-A/V). Scores of 0 (disagree) or 1 (agree) were given for sets of understandability and actionability statements and presented as a total percentage.

RESULTS

Seventeen infographic-flip charts and 13 short-videos were developed in the Malay language and grouped into four topics: (i) Introduction to Diabetes and Periodontitis, (ii) Diabetes and Periodontitis Care, (iii) Lifestyle Modification, and (iv) Myths and Facts. Flip charts were rated between 76-100% for understandability and 80-100% for actionability, while videos rated between 90-100% for understandability and 100% for actionability, respectively.

CONCLUSION

Overall, the newly developed module ranked high median scores for understandability and actionability. This finding reflects positive acceptance of the integrated module among the various healthcare professionals involved in managing patients with diabetes and periodontitis.

Barriers towards Sun Exposure and Strategies to Overcome These Barriers in Female Indoor Workers with Insufficient Vitamin D: A Qualitative Approach

The prevalence of vitamin D insufficiency is significant even in tropical countries such as Malaysia. Sun exposure is the primary source of vitamin D for most people due to limited intakes of food containing vitamin D and supplements. This study explored the perception of barriers towards sun exposure and strategies to overcome these barriers among vitamin D insufficient women workers in Kuala Lumpur, Malaysia. Twenty-five female indoor workers with serum 25-hydroxyvitamin D < 50 nmol/L participated in seven focus group discussions (FGDs). Barriers towards sun exposure were lack of accurate knowledge of vitamin D, health concern towards sun exposure, time constraints, desire to have fair and beautiful skin, sedentary lifestyle, indoor workplace, weather, lack of social support, living arrangement, safety concerns, and religious or cultural practices. The improvement strategies were classified into lifestyle changes and workplace opportunity for sun exposure. Public education on safe sun exposure to produce an optimal level of vitamin D is necessary. Future studies should evaluate the effectiveness of sunlight exposure program at workplace for the high-risk vitamin D deficiency group.

Correction to: Comparing and assessing physical activity guidelines for children and adolescents: a systematic literature review and analysis

An amendment to this paper has been published and can be accessed via the original article.

Comparing and assessing physical activity guidelines for children and adolescents: a systematic literature review and analysis

Background

The impact of declining physical activity and increased sedentary behaviour in children and adolescents globally prompted the development of national and international physical activity guidelines. This research aims to systematically identify and compare national and international physical activity guidelines for children and adolescents and appraise the quality of the guidelines to promote best practice in guideline development.

Methods

This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only national, or international physical activity and/or sedentary behaviour guidelines were included in the review. Included guidelines targeted children and adolescents aged between 5 and 18 years. A grey literature search was undertaken incorporating electronic databases, custom Google search engines, targeted websites and international expert consultation. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II).

Results

The search resulted in 50 national or international guidelines being identified. Twenty-five countries had a national guideline and there were three international guidelines (European Union, Nordic countries (used by Iceland, Norway and Sweden), World Health Organization (WHO)). Nineteen countries and the European Union adopted the WHO guidelines. Guidelines varied in relation to date of release (2008 to 2019), targeted age group, and guideline wording regarding: type, amount, duration, intensity, frequency and total amount of physical activity. Twenty-two countries included sedentary behaviour within the guidelines and three included sleep. Total scores for all domains of the AGREE II assessment for each guideline indicated considerable variability in guideline quality ranging from 25.8 to 95.3%, with similar variability in the six individual domains. Rigorous guideline development is essential to ensure appropriate guidance for population level initiatives.

Conclusions

This review revealed considerable variability between national/international physical activity guideline quality, development and recommendations, highlighting the need for rigorous and transparent guideline development methodologies to ensure appropriate guidance for population-based approaches. Where countries do not have the resources to ensure this level of quality, the adoption or adolopment (framework to review and update guidelines) of the WHO guidelines or guidelines of similar quality is recommended.

Trial registration

Review registration: PROSPERO 2017 CRD42017072558.

Causative factors of eating problems among adolescents with type 1 diabetes mellitus: A qualitative study

Adolescents with type 1 diabetes mellitus are prone to have eating problems. This study aimed to determine factors of eating problems among this population in University Malaya Medical Centre. Fifteen adolescents who scored more than 20 marks in the Diabetes Eating Problem Survey - Revised questionnaire were invited for an in-depth interview. Questions were asked based on their questionnaire's response. The interview sessions were recorded, transcribed verbatim, and thematic analysis was used. Five main themes emerged: pressure, physiological factor, psychological factor, patient's low compliances to insulin intake and food control and fear. Early referral to child psychologist would prevent it from developing.

Obesogenic television food advertising to children in Malaysia: sociocultural variations

BACKGROUND

Food advertising on television (TV) is well known to influence children's purchasing requests and models negative food habits in Western countries. Advertising of unhealthy foods is a contributor to the obesogenic environment that is a key driver of rising rates of childhood obesity. Children in developing countries are more at risk of being targeted by such advertising, as there is a huge potential for market growth of unhealthy foods concomitant with poor regulatory infrastructure. Further, in developing countries with multi-ethnic societies, information is scarce on the nature of TV advertising targeting children.

OBJECTIVES

To measure exposure and power of TV food marketing to children on popular multi-ethnic TV stations in Malaysia.

DESIGN

Ethnic-specific popular TV channels were identified using industry data. TV transmissions were recorded for each channel from November 2012 to August 2013 (16 hr/day) for randomly selected weekdays and weekend days during normal days and repeated during school holidays (n=88 days). Coded food/beverage advertisements were grouped into core (healthy), non-core (non-healthy), or miscellaneous (unclassified) food categories. Peak viewing time (PVT) and persuasive marketing techniques were identified.

RESULTS

Non-core foods were predominant in TV food advertising, and rates were greater during school holidays compared to normal days (3.51 vs 1.93 food ads/hr/channel, p<0.001). During normal days' PVT, the ratio of non-core to core food advertising was higher (3.25 food ads/hr/channel), and this more than trebled during school holidays to 10.25 food ads/hr/channel. Popular channels for Indian children had the lowest rate of food advertising relative to other ethnic groups. However, sugary drinks remained a popular non-core product advertised across all broadcast periods and channels. Notably, promotional characters doubled for non-core foods during school holidays compared to normal days (1.91 vs 0.93 food ads/hr/channel, p<0.001).

CONCLUSIONS

This study highlights non-core food advertising, and predominantly sugary drinks are commonly screened on Malaysian TV channels. The majority of these sugary drinks were advertised by multinational companies, and this observation warrants regulatory attention.