This article first appeared in The Edge Malaysia Weekly on March 14, 2022 - March 20, 2022

WHEN poring over the 2022 Economic Outlook report last October, one particular data point stood out for Dr Neoh Soon Kean.

“I was shocked when I saw that for 2019, 21.8% of Malaysian under-fives were stunted (low height for age). Even with my limited knowledge of statistics, this figure was quite shocking as in a normal population, a country’s rate of stunting among children under five years of age should be around 2.25%. This means in Malaysia, the percentage of under-fives who are stunted is nearly 10 times the normal,” says Neoh, founder and executive chairman of Penang-based investment consulting firm Dynaquest Sdn Bhd.

“At first, I thought this must have been a typo, so I went through the statistics more carefully and cross-checked with the data from Unicef’s website. There was no mistake, the figures were identical. Frankly, even though I don’t know much about childhood nutrition, I do know that childhood stunting is caused by malnutrition, and malnutrition would have a very serious emotional, physical and intellectual long-term impact on children. Imagine, all these young children, when they become adults, would be seriously impaired emotionally, physically and intellectually.”

Aside from stunting, the Ministry of Finance report also indicated other aspects of malnourishment among Malaysian children. For example, the prevalence of wasting (low weight for height) among children under five years of age increased to 9.7% in 2019 from 8% in 2015, while for this same age category, the percentage of those who were underweight (low weight for age) also increased to 14.1% in 2019 from 12.4% in 2015.

The chances are that these numbers, which were compiled before the outbreak of Covid-19, have worsened post-Covid-19.

But what caused this problem in the first place?

“The growth of children in the first five years of life is closely related to nutrition. Hence, if the nutritional status is not optimised, the children in our country would be at a disadvantage. We will continue to see the rise in the prevalence of stunting, wasting and underweight. Based on the NHMS (National Health and Morbidity Survey) 2011 and NHMS 2015 data, all three parameters showed a downward trend. However, when comparing NHMS 2015 and MCHS (Maternal and Child Health Survey) 2016, all three parameters showed a rise in their respective prevalence. This is of course a worrying trend,” Datuk Dr Musa Mohd Nordin, consultant paediatrician and neonatologist at KPJ Damansara Specialist Hospital, tells The Edge.

Why should we be worried about these numbers?

“There are a number of complications that may arise from growth problems during early childhood. The short-term problems include impaired brain development, which may lead to lower IQ. The undernourished children also may have a weakened immune system, which may lead to recurrent infections, hence further worsening their growth. In the long term, these children may have smaller adult stature and lower productivity (owing to lower IQ and academic performance). Stunted children have an increased risk of becoming overweight and obese adults, which causes greater risk of diabetes and cancer, and premature death,” says Dr Musa.

This problem isn’t exactly new, so why has it not been resolved? More importantly, why has it got worse, or been allowed to get worse?

“At a glance, it appears that malnutrition problems can be overcomed by ensuring a healthy and balanced diet among children, but in reality, the solutions in addressing the issue can be trickier, says Khazanah Research Institute deputy director of research Hawati Abdul Hamid.

“They require not only access to healthy foods but also addressing the several socioeconomic factors that can shape population health outcomes. It has been estimated that up to 60% of health outcomes are shaped by social, economic and environmental factors. Among the biggest contributors to poor health are low income, since there is a strong link between poverty and ill-health, with one begetting the other.

“Other major contributors to poor health are poor housing conditions, inadequate early years support and a poor diet. Even though the primary objectives of many social policies, such as education, housing and food security, may not necessarily focus on health promotion, they can have an outsized impact on shaping the health outcomes of the population,” she says.

The next question that arises here is who should take charge in addressing these issues — the government, the food industry, the schools or the parents?

Hawati says policymakers need to recognise the malnutrition problem among Malaysian children and be adaptive in policy responses.

“For example, most of our spending has been on curative care services but more should be spent on public health services, including preventive and promotive health services. In 2019, 67.7% of total healthcare spending was on curative care services while only 6.8% was on preventive care.

“While curative care services such as delivering medical care and surgeries are important, public health services that focus on the prevention of diseases and health promotion through nutrition and education are important in their own right. It is important that we shift away from this focus on curative care to preventive care. Investing in these preventive services has been shown to have high value for money,” she says.

Dr Musa says improving the nutrition of children, starting from exclusive breastfeeding in the first six months of life, followed by optimum complementary feeding practice in the first two years of life and optimisation of family-based diet for those aged two to five years, is the way to go. “Good antenatal care is important,” he adds.

Hawati notes that it is important to identify the gaps that exist and ensure that all children are protected and on the same level playing field.

“One policy option that can be improved on is the Rancangan Makanan Tambahan (RMT) or Supplementary Food Programme. RMT targets children from poor families and aims to address undernutrition and classroom hunger, a situation in which children study on an empty stomach.

“Undeniably, RMT has achieved much over the years, with the most notable impact being the reduction in the protein-energy malnutrition among poor children,” she says.

However, she notes that a feeding programme that solely targets the poor runs the risk of excluding those with real nutritional needs.

“As Malaysia becomes more developed, our nutritional challenges have involved not only undernutrition but also obesity and micronutrient deficiencies, leading to higher diet-related non-communicable diseases (NCDs) such as diabetes and heart diseases. While undernutrition is arguably more concentrated among the poor, overeating and obesity is a problem for the rest of the population, making malnutrition — which includes excesses or imbalances in a person’s intake of energy and/or nutrients — a problem that cuts across all income classes.

“We also need to acknowledge that non-poor children could also go to school on an empty stomach due to parents’ time constraints to prepare breakfast early in the morning. NHMS data for 2017 shows that only 30% of students eat breakfast on a daily basis before going to school while the remaining either have breakfast irregularly (60%) or not at all (10%). Making breakfast available to all will ensure students are equipped with the necessary energy and nutrition to kickstart the day,” she says.

Shalini Yeap is the lead coordinator and project manager for Happy Tummies, a breakfast programme serving a neighbourhood kindergarten near a plantation estate in Jeram, Selangor.

When she first came to know about this kindergarten, the teacher running it was sponsoring meals for the children — mostly Indian because their parents work in the plantation estate — out of her own pocket.

“I was quite attracted to the idea of helping them because I was told that some children were motivated to come to schools as they knew there would be food. I thought, why don’t I remove the expenses from her so that she and the other teachers could focus on the teaching part, whereas I would run a breakfast programme for them as a proper end-to-end project,” Yeap tells The Edge.

After consulting clinical nutritionist Dr Rohini Pathmanathan, Yeap was planning to feed the children sandwiches, but she soon realised that this wasn’t what they normally ate.

“Instead, they were used to eating thosai and traditional foods. We try to eliminate roti canai because thosai has higher nutritional value. Sometimes, we would replace thosai with idli, bihun and nasi lemak as the main food,” she says.

Besides that, the children would also get one fruit, which came later in the day as a snack. They also get a box of milk once a week, which is quite similar to the RMT in schools.

Yeap opines that RMT should be extended to kindergartens.

“I don’t know how much it would cost, but I think it would be a good idea. On average, we are providing RM2 to RM2.50 per meal per child every day. I think when it comes to RMT or children’s food programmes, there is always a disconnect between providing food to fill their stomachs, or providing food that is nutritious,” she points out.

To her, nutritious food should be the end result. While most people have a perception that nutritious foods are expensive, Yeap believes this shouldn’t be the case, given the fact that Malaysia has plenty of agricultural land and natural resources.

“I don’t think we should just blame the situation entirely on the country’s system. Sometimes, it also has to do with the family, such as the eating habits of the adults and their ways of cooking, which would affect the children’s health as well. That’s why I think education is very important,” she says.

Notably, the Economic Outlook 2022 report highlighted the ineffectiveness of the campaign to educate the public on the importance of a balanced and nutritious diet.

“There have been concerns about stunting among children, especially among vulnerable urban groups. One of the contributing factors is malnutrition,” it stated.

While the government has implemented soft policies, such as public education programmes and campaigns to increase awareness of a healthy diet and lifestyle, it has not been effective in discouraging more people from consuming unhealthy processed foods.

“Health promotion and education alone are inadequate to change people’s behaviour compared to enacting related laws and regulations supported by effective enforcement,” the report stressed.

In general, says consultant dietitian Goo Chui Hoong, children in Malaysia are getting enough protein in their diet from meat and poultry, but they are eating fats and salt in excess.

What they are not getting enough of are vitamins and minerals from the recommended five servings of fruits and vegetables per day, as well as calcium from three servings of milk or dairy products per day.

“When children are born, they are like a blank canvas. They can be groomed to enjoy clean and healthy foods. However, it is not uncommon that when parents themselves do not like to eat vegetables, they do not offer vegetables to their children,” she remarks.

It does not help when unhealthy fare, such as nuggets and fried foods, is more convenient to prepare, says Goo.

She insists that eating healthy is not expensive, as a simple meal of rice with stir-fried cabbage and omelette is affordable to the average Malaysian. Unfortunately, for lower-income families, eating healthy may be the last thing on their minds.

“That’s why we need programmes like RMT, which provides children with at least one nourishing meal a day,” Goo says.

She suggests that parents and schools could play a bigger role in offering experiential activities to promote healthy eating, such as growing vegetables at home or in school, and getting the child involved in food preparation.

“Children can also try a new vegetable a week during nutrition month in school. Educating parents and creating awareness on the importance of good nutrition for children are key to improving the nutritional status of children in Malaysia,” Goo reiterates.

Pharmacist Ding Yen-Nee concurs.

“To be fair, I think the government has great initiatives to bring better nutrition to children and expectant mommies. I do believe it has taken nutrition-related issues seriously over the years and has done its best in its capacity to cope with the growing needs of its young population,” she tells The Edge.

Ding is of the view that while there is a real need for the government to monitor, regulate and enforce, all other sectors should also make more effort to work together towards a shared goal of bringing better nutrition to the country.

“The burden is inevitably greatest on the government, but the citizens should also be proactive in educating themselves and help spread nutrition information within their own communities too,” she says.

A self-professed protective mother, Ding admits that she does not expect everyone to have the privilege of feeding their child the same, best level of nutrition.

“Hence, I truly think RMT is a fantastic way to provide extra nutrition to our children, especially those from households that are struggling to put food on the table,” she says. She adds that canteen vendors also play an important role here.

“Besides making sure the food being prepared for the children adhere to the national dietary guidelines, these vendors should also be economically protected as well, so they are not forced to cut corners at the expense of the innocent young ones,” Ding notes.

Interestingly, a marketing manager of a European-based food and beverage multinational corporation points out that nowadays, the MNCs are no longer allowed to engage with schoolchildren.

He recalls that a few years ago, the Ministry of Education had discouraged the MNCs from promoting their brands by distributing free food and beverages to students in school premises. Although the companies could still seek approval from the MoE, it is learnt that the process is rather stringent.

“Those days, we could just give a phone call to the school principals and tell them we were going to their schools. Today, the MNCs are still willing to help, but oftentimes, the stricter control from the government does make us feel like it isn’t worth our time and effort,” the manager complains.

He acknowledges that one of the government’s intentions is to make sure that the MNCs do not promote their brands directly to the children, which he thinks is reasonable.

“But from the MNCs’ perspective, we cannot be doing charity without getting any return at all. We have certain branding and marketing KPIs to meet. It would be good if the MNCs and the government could find a middle ground,” the manager notes.

For the promise of the demographic dividend to materialise, we have to adequately prepare our youths for the economy, says Professor Niaz Asadullah of the Faculty of Business and Economics at Universiti Malaya.

Given the prevalence of malnourished children in our country, concerns that we could be at risk of losing that dividend is not unfounded, he adds.

“However, even before the pandemic, we had faced critical deficits in human development. Malaysia is not only the most obese nation in Asia, we are also one of the top three countries with a high share of obese children. Given the pre-existing trends in wasting and stunting statistics, our children are more vulnerable to a further increase in the double burden of undernutrition and overnutrition.

“The other pillar for the acquisition of human capital during childhood is education, where we have also performed unsatisfactorily in ensuring access and quality. School closure also means missing school meals, which are critical for the nutritional security of B40 children. So, yes, there is a genuine fear over losing our demographic dividend,” he says.

Dynaquest’s Neoh says the issue of childhood malnutrition is the best example of how the weakest members of a nation are given the least.

“I always remember a quote from a famous philosopher: “The mark of a truly civilised society is how a country treats its weakest members.” Likewise, I truly believe that in a truly civilised society, the weak should be protected and helped — that’s why you won’t see these terrible childhood malnutrition issues in countries such as Sweden, Switzerland and Japan.

“The most important aspect of a country’s future development is the children. Their intellectual and physical developments are crucial to our country’s future. If our children are weak and poorly developed, how can our country possibly be a truly successful country?” he asks.

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