Love Our Children With Healthy Affirmative Action Now (Part 3) — Dr Musa Mohd Nordin, Dr Abu Bakar Suleiman, Dr Tee Ee Siong, Dr Zulkifli Ismail & Prof Dr Muhammad Yazid Jalaludin

What is the case for change?

• Our children are our future generation.
• The optimal health and welfare of our children today will map the future wellbeing and prosperity of our nation.
• Many of the chronic diseases in adults have their origins in childhood.
• Pregnancy and early childhood in the first 1,000 days presents a window of opportunity towards improving long-term health outcomes.
• It makes economic sense to intervene early because prevention is better than cure, and prevention in childhood is better than prevention in adulthood.
• In the Ministry of Health (MOH), health spending for curative health care far supersedes preventative health care. (see Graph I)
• In 2019, 68 per cent of health spending was on curative health care. Public health programmes focusing on preventative health care only utilised a meagre 6.8 per cent.
• The investment in child health and wellbeing has been wanting in terms of budget allocations, whether in the MOH or the Ministry of Finance. Only a paltry 1.7 per cent of the total health budget of MOH in 2023 was on child health.
• Budget 2024 can rectify this inequity, trigger a shift from a “sickness to wellness” paradigm, and make improvements in child health, invest in our future generation’s health and wellbeing, and future-proof the prosperity and sustainability of our nation. This will be in line with the MOH’s Health White Paper 2023.
• The future of health care is: “It’s health first, then care”.
• “The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick, the needy and the handicapped.”

What is the problem?

• About one in five (21.8 per cent) Malaysian children under 5 years old are stunted (low height for age, resulting from chronic under-nutrition).
• One in seven (14.1 per cent) are underweight (low weight for age, resulting from acute and chronic undernutrition).
• One in 10 (9.7 per cent) are wasted (low weight for height, resulting from acute undernutrition).
• One in seven (14.8 per cent) are obese, resulting from excessive energy intake. Malaysia is the second highest in Southeast Asia.
• All indicators, except for wasting, worsened from 2011 (see Graph II).
• Malaysia scored moderately for hunger in the 2022 Global Hunger Index. There was an increase in the Hunger Index from 10.9 in 2014 to 12.5 in 2022, due to food insecurity caused by the pandemic.

In addition, micronutrient deficiencies continue to affect large number of children below 5 years old. The National Health and Morbidity Survey 2022 reported that a worrying high prevalence (46.5 per cent) of mild and moderate iron deficiency anaemia among children less than 5 years old.

There is therefore a triple burden of malnutrition, wherein children below 5 years old suffer from both under and over-nutrition problems and micronutrient deficiencies. Urgent intervention needs to be implemented to rehabilitate these children, as well as preventing a further worsening of the situation.

Why we need to act now? In the short term, stunting leads to:

• Impaired brain development, leading to lower intelligence quotient (IQ).
• Weak body immunity, causing recurrent infections, leading to further growth impairment.
• Being stigmatised due to weight, which can lead to bullying, poor mental health, and poorer educational outcomes.

In the long term, stunting leads to:

• Smaller stature adults.
• Lost productivity.
• Increased risk of non-communicable diseases (NCD), especially diabetes and cancer.
• Increased health care costs.
• Premature deaths.

Food insecurity increases the risk of children being malnourished.

Child malnutrition cuts across the income groups (see Graph III):

• 22.4 per cent in B40 and 16.8 per cent in T20 households are stunted.
• 14.1 per cent in B40 and 13.2 per cent in T20 households are underweight.
• 10.5 per cent in B40 and 16.1 per cent of T20 households are wasted.
• 15.6 per cent in B40 and 17.8 per cent in T20 households are obese.

These data indicate that nutrition intervention programmes need to be implemented for all income groups, including the T20 group.

What are the compounding socio-economic-political factors?

• Low income or poverty.
• Poor housing, clean water supply, sanitation, and environment.
• Poor social security net.
• Poor food security.
• Poor health education.
• Curative and sickness-centric political and health care policies.

Drivers of malnutrition include:

• Healthy foods are more expensive calorie-for-calorie than less healthy foods. Limited availability and affordability of sufficient, nutritious food may be leading to unhealthy eating habits, as cheaper, more enticing, ultra-processed foods become more accessible.
• The increasingly carbon-intensive food systems are driving the non-communicable disease epidemic.
• Children are more likely to have diets which are high in sugar, saturated fat and salt, and low in fruits and vegetables.
• Poor awareness, literacy, and consequently, the practice of healthy eating and lifestyle among Malaysian children, adults, parents, and families.
• Easily available meals high in fat or oil, salt, and sugar, and low in fruits and vegetables in a wide variety of eating places, including hawker centres, cafes, fast food outlets, and restaurants.
• Reduced access to green spaces, which reduces opportunities for undertaking physical activities.
• Lack of attention given to physical activity among schoolchildren.

Proposed solutions to childhood malnutrition which must be urgently addressed in Budget 2024:

• The prompt establishment of an independent Children’s Commission.
• The appointment of a cabinet minister for children and young people.
• Both the Children’s Commission and minister must ensure and drive a “child health in all policies” approach to all forms of policy development and coordinate cross-ministry and agency strategies to enhance child health and wellbeing.
• Since 60 per cent of health outcomes are shaped by social, economic, and environmental factors, Budget 2024 must rectify the social determinants of health.

Addressing the first 1,000 days of life:

• Optimal antenatal care is “directly associated with improved birth outcomes and longer-term reductions of child mortality and malnourishment”. We must intervene early to abort the vicious cycle of stunting.

Exclusive breastfeeding for the first six months of life:

• According to the Maternal and Child Health Survey 2016, the overall prevalence of exclusive breastfeeding among infants under six months old was 47.1 per cent.
• By ethnicity, the highest prevalence of exclusive breastfeeding was among Malays (48.9 per cent), followed by other bumiputeras (46.0 per cent), Indians (41.8 per cent), and Chinese (29.6 per cent).
• This prevalence could be improved by establishing a more supportive breastfeeding environment, especially at workplaces and public places, making available facilities to breastfeed or express breast milk, and to store expressed breast milk for working mothers.
• Mandating an adequate period of paid maternity leave of at least three months for working mothers to improve an exclusive breastfeeding rate.
• Other efforts to support and encourage breastfeeding should be undertaken, including making available counseling services to all women in need.

Optimum complementary feeding for the first two years of life and optimise a family-based diet for two-to-five-year-olds:

• More than 50 per cent do not fulfil the recommended servings of meat and poultry, fish, and milk and dairy products (proteins) that are essential for growth.
• It is important to create awareness among parents or caregivers about the importance of dietary diversity and meal frequency for children under two years, and to provide specific infant feeding training for health care providers.
• We also need to educate parents or caregivers on how to fulfil dietary diversity requirements and food groups based on family diets for children three to six years old, in order to improve their nutritional status.
• According to the Family Health Development Division Annual Report 2018, 75 per cent of children under 1 year old were treated at health clinics, while the rate for toddlers one to three years old was 48.3 per cent and pre-school children was 24.1 per cent.
• HCP and parents should be educated on the importance of “healthy-child clinic visits” especially for those children aged 2-5 years, so that any growth issues in this age group could be identified early.

Expand free school meals to all children in primary schools. This is to ensure everyone is provided with a nutritious meal since child malnutrition cuts across all income groups:

• Presently, only children from households where incomes are less than RM1,169 are eligible for Rancangan Makanan Tambahan (RMT), and even this was based on Paras Garis Kemiskinan Makanan 2019, which was devised pre-pandemic, and therefore not relevant nor sensitive to the severe financial constraints post-pandemic.
• Rancangan Makanan Tambahan (RMT) only targets the poor and runs the risk of excluding those with other nutritional needs.
• Our children suffer the triple burden of malnutrition, namely undernutrition, being overweight and obese, and micro-nutrient deficiency (lack of essential minerals and vitamins), especially anaemia (according to the National Health and Morbidity Survey 2022, 46.5 per cent of children below 5 years old are anaemic).
• NHMS data for 2017 has shown that only 30 per cent of students eat breakfast on a regular and daily basis before going to school, while the remaining either have breakfast irregularly (60 per cent) or not at all (10 per cent). Making breakfast available to all will ensure students are equipped with the necessary energy and nutrition to kick-start the day.
• An alternative approach to RMT in promoting primary school child nutrition could be the one that is being implemented by the Nutrition Society of Malaysia (NSM). It is branded as the Malaysia School Child Nutrition Promotion Programme (MySNPP).
• MySNPP provides a short nutrition education session for schoolchildren. The education module has nine topics and simple messages and is taught during break time, after class, or during Pendidikan Jasmani dan Keshatan class.
• MySNPP also provides nutritious meals for all children during the mid-morning or afternoon break. The meals are controlled by nutritionists and prepared by canteen operators and/or parents-teachers associations. With this approach, the school does not sell any unhealthy or unbalanced foods during the break.
• MySNPP is now implemented in several schools in Johore by NSM and several nutritionists in the state.
• To implement these nutrition-based activities in schools, nutritionists should be assigned to schools. They should visit the assigned schools several times in a week to conduct nutrition education activities, which can include interactive activities, to supervise the school meals implemented, and to make use of the weight and height data collected. A strong nutritional presence during school has a long-lasting impression on the child in the years to come.

Improve food security and/or availability:

• The cost of fruits and vegetables, or even fish, meat, and poultry are high and unaffordable, and the accessibility for the poor is very limited. This is mainly related to the high cost of transport and the middleman, and worsened during the Covid-19 pandemic. The government needs to actively look into this, and a strict policy needs to be implemented.
• Climate change has impacted negatively on the agricultural industry and worsened food insecurity, and the poor, who are food vulnerable to begin with and often work in agriculture and the food production industry, has suffered the most.
• Food, environment, and health are intimately related, and the agricultural ecosystem must address the challenges of climate change in order to protect the nutritional health of our children.

This article was written by:

• Dr Musa Mohd Nordin, chairman, Federation of Islamic Medical Associations Advisory Council (FIMA).
• Dr Abu Bakar Suleiman, former Director General of Health, Ministry of Health.
• Dr Tee Ee Siong, president elect, Federation of Asian Nutrition Societies (FANS).
• Dr Zulkifli Ismail, secretary general, Asia Pacific Pediatric Associations (APPA).
• Prof Dr Muhammad Yazid Jalaludin, past president, Asia Pacific Association of Pediatric Society (APPES).