KUALA LUMPUR, June 23 — Experts have attributed anaemia and the rise of childhood stunting in Malaysia to poor nutrition for low-income women and children, amid a widening gap between the rich and poor.
According to the National Health and Morbidity Survey (NHMS), the prevalence of stunting in children under five years of age in Malaysia increased from 17.2 per cent in 2006 to 20.7 per cent in 2016. In 2019, Malaysia’s stunting rate among children below five years grew to 21.8 per cent.
The NHMS 2019 also found that one out of five Malaysians, or 21.3 per cent, are estimated to have anaemia, or 4.6 million people. Three out of 10 women of reproductive age from 15 to 49 years have anaemia. Anaemia among the general population was highest in Kelantan at 27.2 per cent, while anaemia among women aged 15 to 49 was highest in Penang at 14.4 per cent.
Former Malaysian Medical Association (MMA) president Dr Milton Lum pointed out that inadequate nutrition and recurrent infections or chronic diseases, which cause poor nutrient intake, absorption or utilisation, are the direct causes of stunting among children.
“Whilst the government has addressed rural poverty for decades, there has been few or no concerted attempts at addressing urban poverty, which is the root cause,” Dr Lum told CodeBlue in an interview.
A 2014 report by Malaysian Dietary Guidelines for Children and Adolescents shows that the infant feeding practice is still suboptimal in our country. Only 55.9 per cent of children aged 9 to 23 months received at least 3 meals a day.
A study conducted by the South East Asian Nutrition Surveys (SEANUTS) revealed that only three in five children aged two to 12 years eat breakfast every day, which shows that skipping breakfast has become relatively common among Malaysian children.
“Childhood stunting is associated with multiple factors. Strongest among them are family socioeconomic status and parental nutritional status,” said Dr John Teo, an obstetrician & gynaecologist, from Kota Kinabalu, Sabah.
Malaysia’s national poverty line is set at RM980 monthly household income; and RM1,020 for Sarawak and RM1,180 for Sabah. A research study on Malaysia’s poverty rate shows that countries with average incomes similar to Malaysia have absolute poverty lines equivalent to RM2,550 per month for a family of four.
“The reason why we are getting worse in stunting is because the gap between the rich and poor in Malaysia is getting worse over time,” senior consultant paediatrician Dr Amar-Singh HSS told CodeBlue.
“The relative income of the bottom 40 per cent of our population is in bad shape, especially the bottom 10 per cent of the people,” he added.
The World Bank also stated that the multidimensional poverty index (MPI), which includes monetary and non-monetary aspects such as education standard, living conditions and health in Malaysia, is too low.
A study on urban child poverty and deprivation in low-cost flats in Kuala Lumpur conducted by Unicef showed that more than one in 10 children have fewer than three meals a day. Approximately 97 per cent of households living in low-cost flats are unable to prepare healthy meals for children, due to the high cost of food.
“If the disparity of income grows more, then the possibility of stunting grows even higher.”
Dr Amar-Singh HSS, consultant paediatrician
The World Health Organization (WHO) has identified exclusive breastfeeding practice for babies for the first six months of their life as one of the important ways to prevent stunting, overweight and obesity among children.
According to the Department of Statistics Malaysia (DOSM), in the first quarter of 2019, females represented a third or 39.0 per cent (6.06 million) of the nation’s labour force. Working women may not necessarily pursue exclusive breastfeeding, especially in a non-conducive work environment.
“Exclusive breastfeeding in the first six months at least certainly decreases the risk of stunting by decreasing the risk of infections in the infant or child,” said Dr Teo.
However, he also stated that maternal nutritional status — before, during and after delivery, including the presence of anaemia — affects the risk of childhood stunting.
This is consistent with Dr Lum’s statement that well-balanced nutrition, especially in pregnancy and during breastfeeding, helps in the prevention of stunting, but it is just a starting point.
“There has to be well-balanced nutrition for breastfeeding mothers and in early childhood. A child who is bottle-fed with well-balanced nutrients is very unlikely to be stunted,” Dr Lum added.
The veteran physician stated that the policy under the Ministry of Health (MOH) encourages all mothers to exclusively breastfeed their babies from birth to six months and to continue breastfeeding until the baby is two-years-old.
Yet Dr Amar emphasised that inadequate facilities at the workplace hinders working women from practicing breastfeeding.
“If you have to work, breastfeeding is an extremely difficult thing to do.”
Dr Amar-Singh HSS, consultant paediatrician
MOH aims to increase the percentage of babies being exclusively breastfed to 70 per cent by 2025. But Kelantan State Health Director Dr. Zaini Hussin stated that only 47.1 per cent of babies, or infants under six months old, were exclusively breastfed in 2018.
“The pillars of this policy are the Code of Marketing of Infant Formula Products (Code) and Baby Friendly Hospital Initiative (BFHI). However, the prevalence of exclusive breastfeeding in infants under six months does not even reach 50 per cent,” Dr Lum stated.
As an effort to support women’s maternal needs, Budget 2020 increased paid maternity leave in the private sector to 90 days. But there are no amendments to Section 37 of the Employment Act 1955 and the mandatory maternity period for private sector employees remains at 60 days.
Vietnam offers 180 days maternity leave for mothers with full salary, followed by Singapore, Philippines, Brunei and Laos that provide more than 100 days leave with full salary.
When working mothers do not have sufficient leave to practice exclusive breastfeeding, child care services become an essential component.
In 2018, then-Women, Family and Community Development Minister Dr Wan Azizah Wan Ismail stated that 80.19 per cent of Malaysian child care workers who take care of children below four-years-old do not possess minimum qualification.
Dr Amar-Singh said free access to quality child care services is essential to address stunting problems among children.
“If we do free child care, we then will offer them food routinely. So, one meal at least of a day will be taken care at the child care centre and the poor will benefit enormously from it,” the paediatrician said.
“Right now, we have free school meals. It is terribly important for our children. It benefits a large proportion of our children because you don’t get enough nutrition at home, but it is a bit late for stunting, so we have to bring down the free meals at nursery and kindergarten level.
“Besides one good meal with protein we can add supplements. Iron is probably the most important supplement to add in a child diet,” he added.
The recent 2020 Global Nutrition Report found that Malaysia is off-course to meet the targets for stunting among under-five children. Malaysia also made no progress or is worsening in global targets for anemia among women of reproductive age and low birth weight.
“The low-lying fruit is to ensure that the haemoglobin of all pregnant women is at normal levels. This is immediately achievable as almost all women have antenatal care at public and private health care facilities,” said Dr Lum.
Apart from that, Dr Teo suggested effective strategies that include high-level accessibility of reproductive care, decreasing unplanned pregnancies or short inter-pregnancy intervals, ensuring the participation of women and their families in gainful employment, as well as meaningful economic activities to combat stunting issues among children.
A stunting policy brief by the World Health Assembly Global Nutrition Targets 2025 stated that stunting children develop diminished cognitive and physical development, have reduced productive capacity and poor health, and an increased risk of degenerative diseases such as diabetes.
