Whole School Mapping to Investigate the School Environment's Potential to Promote a Healthy Diet and Physical Activity in Malaysia

Introduction: The school is a vital part in the development of children's dietary practices as children consume a substantial proportion of their daily intake at school. The school environment offers an ideal location for health education and intervention against physical inactivity and poor nutritional intake. Methods: A mapping tool was developed to map the school environment on four levels: physical, economic, political, and socio-cultural that can potentially affect healthy eating and physical activity. The mapping was piloted and completed by interviewing twelve teachers (responsible for student affairs and the school curriculum), followed by observation at twelve randomly selected schools (six urban, six rural) in Terengganu, Eastern Peninsular Malaysia. Results: For physical environment, 55.0% of the criteria were met and while all schools taught nutrition and physical activity, this was not backed up with actual facilities for practising physical activity or food preparation. For economic environment, 17.7% of the criteria were met and eleven out of twelve schools had mobile caterers outside their front gates selling energy-dense food/drink. For political environment, 52.1% of the criteria were met and all teachers were aware of the existence of the national catering and nutrition guidelines, but they reported a lack of resources for implementation and monitoring. For socio-cultural environment, 59.2% of the criteria were met and all schools used sweet foods and drinks as rewards at large events. Conclusion: The findings suggest potential avenues exist for intervention in schools to provide a supportive environment that promotes healthier eating and physical activity to prevent obesity.

Association of Body Weight Status and Socio-Demographic Factors with Food Habits among Preschool Children in Peninsular Malaysia

Introduction: Changes in children's food habits are largely attributed to changes in the family and social environment. This cross-sectional study was carried out to determine the association of socio-demographic factors with food habits among preschool children in Peninsular Malaysia. Methods: A total of 1,933 preschool children aged 4-6 years old participated in the study. Parents or guardians were interviewed on the socio-demographic characteristics and food habits of their children. Height and weight of the preschoolers were measured; BMI-for-age, weight-for-age and height-for-age were determined. Results: The mean monthly household income was RM3,610 with 59.6% of parents having attained secondary education. The prevalence of possible risk of overweight, being overweight and obesity were 3.9%, 7.9% and 8.1%, respectively while the prevalence of underweight and stunting was 8.0% and 8.4%. A majority of the preschoolers consumed breakfast, lunch and dinner every day, with the proportion of children skipping their main meals at about 15.0%. Parents' education level and household income were significantly associated with intakes of fruits, vegetables, milk and dairy products, as well as fast food. However, there was no significant association between children's body weight status and frequency of main meals intake, fruits, vegetables, milk and dairy products, and fast food intake. Conclusion: The preschoolers demonstrated moderately healthy food habits; nevertheless even at this young age, they were inclined towards fried foods, snacking and fast foods intake. Parents and guardians should play a more significant role in educating and promoting good nutrition and food habits among preschoolers.

Stool Patterns of Malaysian Adults with Functional Constipation: Association with Diet and Physical Activity

Introduction: Diet and lifestyle modification is commonly used in constipation management. As there is a dearth of studies on this topic in Malaysia, we aim to elucidate the relations between stool patterns, dietary intake and physical activity levels among adults with functional constipation. Methods: From a database collected via surveys at public events, a convenience sample of 100 adults diagnosed with Rome II-defined functional constipation was enrolled in this cross-sectional study. After severity assessment using the Chinese Constipation Questionnaire, subjects completed 2-week bowel movement diaries to determine stool frequency, consistency and output. Dietary intake and physical activity levels were assessed twice using three-day 24-hour diet recalls and International Physical Activity Questionnaire, respectively. Ninety subjects who completed the study were included in the analysis. Results: Mean weekly stool frequency was 3.9±1.9 times, consistency score was 2.6±0.6 (range 1.0-4.0), output was 11.0±6.3 balls (40 mm diameter) and severity score was 10.3±3.3 (range 5.0-22.0). Mean daily dietary intakes were: energy 1,719±427kcal, dietary fibre 15.0±4.9g and fluid 2.5±0.8L. The majority of subjects were physically inactive. Stool frequency and output were positively associated with dietary fibre (rs=0.278, P<0.01; rs=0.226, P<0.05) and fluid intake (rs=0.257, P<0.05; OR=3.571, 95% CI [1.202-10.609]). Constipation severity was associated with higher physical activity levels (OR=2.467, 95% CI [1.054-5.777]). Conclusion: Insufficient intake of dietary fibre and fluid are associated with aggravated constipation symptoms. Further studies are necessary to confirm usefulness of dietary intervention in treatment of constipation as dietary factors alone may not influence overall severity and stool consistency, an integral element of constipation.

Meal Patterns of Malaysian Adults: Findings from the Malaysian Adults Nutrition Survey (MANS)

Introduction: Meal patterns have received little attention in nutrition studies. The aim of this study is to present the findings on general meal patterns of Malaysian adults. Methods: The Malaysian Adults Nutrition Survey (MANS), carried out in 2002 and 2003, involved 6,928 adults selected by stratified random sampling from all households by zone in Peninsular Malaysia, Sabah and Sarawak. Results: In general, the results showed that most respondents (74.16%) ate three meals per day; 89.20% of the respondents consumed breakfast, while 88.57% consumed lunch and 91.97% consumed dinner with no significant difference in terms of sex. In Peninsular Malaysia, the Northern Zone had the highest number of people consuming breakfast compared to other zones. Meanwhile, the population in Sarawak had the largest proportion of people consuming lunch and dinner, but the smallest proportion of people consuming breakfast. A significantly higher number of the rural population consumed breakfast and lunch than urbanites; however there was no significant difference in dinner consumption. Generally, breakfast consumption increased with age whereby significant difference existed between the 18 to 19 years age group and the age group of 30 years and older. Lunch intake among the age groups showed no significant difference. In contrast, dinner consumption was significantly lower among the 18 to 19 years age group compared to all other age groups. Comparison among the ethnic groups showed that the Indian population had the lowest percentage of having breakfast and lunch while the Orang Asli had the lowest percentage of consuming dinner. However, the Orang Asli recorded the highest percentage for taking breakfast and lunch while the Chinese had the highest percentage of taking dinner. Conclusion: Considering that Malaysian adults consumed their conventional breakfast, lunch and dinner, these findings indicatethat Malaysians are maintaining their traditional meal patterns.

Association of Iron Deficiency with or without Anaemia and Cognitive Functions among Primary School Children in Malaysia

Iron deficiency and anaemia affect millions of children worldwide. This study aimed to investigate the effect of iron deficiency with or without anaemia on cognitive functions, specifically with short-term memory, attention and visualmotor coordination in children. A total of 173 primary school children was enrolled. Cognitive functions were assessed using the Wechsler Intelligence Scale for Children. Three sub-tests were selected to assess processing speed (coding test), immediate auditory memory (digit span test) and visual processing and problem solving ability (maze test). The results showed significant correlation between age and coding test (r =0.38, p<0.001), digit span test (r =0.16,p = 0.028), and maze test scores (r =0.28, p<0.001), and the total sub-test scores (r=0.43, p <.001). After age adjustment of the cognitive function tests, iron deficient children without anaemia scored significantly lower than the healthy children (p<0.001) on coding test, while iron deficient children with anaemia and iron deficient children without anaemia scored significantly lower (p<0.001) than the healthy counterparts on maze test. No significant differences were observed on digit-span score among the groups. This study confirms the negative effect of both iron deficiency and iron deficiency anaemia on processing speed and visualmotor coordination in children.

Association of Energy Intake and Macronutrient Composition with Overweight and Obesity in Malay Women from Klang Valley

This cross-sectional study investigates the association between energy intake and macronutrient composition of the diet with overweight and obesity among Malaysian women. One hundred and fifteen adult Malay women aged 20 to 59 years (mean age 37.2±7.6 years) were interviewed. Dietary intake was assessed using the food history method. Body weight status was assessed using weight, height, waist circumference and fat percentage measurements. When energy intake was assessed for accuracy, only 41% of the subjects (n=47) were normal energy reporters. Among the normal energy reporters, 55% were of normal weight whereas 32% and 13% were overweight and obese. Mean energy intake for normal weight, overweight and obese subjects was 1685±199 kcal/day, 1810±166 kcal/day and 2119±222 kcal/day, respectively. Energy intake increased with body mass index (BMI) category. Among the overweight and obese, energy intake was respectively higher by 125 kcal/day and 434 kcal/day as compared to their normal weight counterparts (p<0.001). There was also a significant, moderate and positive correlation between energy intake and BMI (r=0.635), waist circumference (r=0.545), and body fat percentage (r=0.534). When macronutrient composition of diet was analysed (% energy and g/1000 kcal), there was no significant difference in carbohydrate, protein or fat intake between the obese, overweight and normal weight subjects. There was also no significant correlation between macronutrient composition of the diet and body weight status. Based on these findings, we conclude that the subjects’ body weight status is likely to be influenced by energy intake rather than the macronutrient composition of the diet.

Messages of the Newly Proposed Malaysian Dietary Guidelines (MDG): Do Adults in Kuala Lumpur Understand Them?

The Malaysian Dietary Guidelines (MDG) with eight key messages were first published in 1999. An updated version consisting of 14 key messages is being developed. The objective of this study was to evaluate the understanding of five key messages of the updated MDG among adults aged 18-59 years in Kuala Lumpur. A total of 773 adults comprising 330 Malays, 364 Chinese and 79 Indians were included in the study. A self-administrated questionnaire was used to obtain demographic data and to determine the level of understanding of key words and messages to be included in the new MDG. The results showed that 63% of the subjects were not aware of the existence of the MDG published in 1999. Overall, the understanding of the five messages in the updated MDG was moderate with a mean score of 60.0 ± 16.5. Between 52% to 93% of the subjects did not understand such key words as serving size, sedentary habits, blended vegetable oil and shortenings. The mean scores of understanding were significantly higher (p< 0.05) among the Chinese subjects (61.3 + 17.8) than Malays (58.6 + 14.2) and Indians (60.0 + 18.9). The younger subjects (61.2 + 16.0) scored significantly (p< 0.05) higher than the older (58.7 + 17.0) counterparts. There was also a significant association between the level of understanding of MDG with education level (p<0.001) and occupational status (p<0.001), respectively. This study suggests that some key words and messages in the updated MDG should be simplified to ensure that they are understood by Malaysians.

Physical Activity Pattern and Energy Expenditure of Malaysian Adults: Findings from the Malaysian Adult Nutrition Survey (MANS)

This paper aims to report the physical activity pattern and energy expenditure of adults aged 18 – 59 years in the Malaysian Adults Nutrition Survey (MANS) carried out between October 2002 and December 2003. The survey included 7349 adults representative of Peninsular Malaysia (Northern, Southern, Central and East Coast), as well as Sabah and Sarawak. A total of 6926 adults, comprising 3343 men and 3583 women, completed the physical activity section of the survey. Physical activity data was obtained using a physical activity questionnaire and 24-hour physical activity recall. Basal metabolic rate (BMR) was calculated from Ismail et al. (1998) predictive equations; total energy expenditure (TEE) was then estimated through factorial calculations based on time allocated and energy cost of various activities. Physical activity level (PAL) was calculated as the ratio of TEE to BMR. It was found that almost three-quarters of Malaysian adults travelled by passive modes of transportation. Only a third reported having ever-exercised, and an even smaller proportion of the population (14%) had adequate exercise. The population also spent the majority of their time (74% of the day) in sedentary activities, such as sleeping or lying down; doing light intensity activities (15% of the day), and doing moderate to vigorous intensity activities (10% of the day). Mean BMR and TEE was significantly higher amongst men than women, while mean PAL values were similar for men [1.6 (1.6 – 1.7)] and women [1.6 (1.6 – 1.6)]. More men (16%) were categorised as having active PAL compared to women (10%), while more women (43%) were categorised as having sedentary PAL compared to their male counterparts (37%). The present study provides the first in-depth report of the physical activity pattern, and national estimates of energy expenditure and physical activity levels of Malaysian adults, and concluded that Malaysian adults are generally sedentary. It is thus important that physical activity be further promoted and integrated into the lives of the population, preferably through various health promotion efforts as well as through the commitment of the authorities in providing a suitable environment for an active lifestyle.

Body Mass Index (BMI) of Adults: Findings of the Malaysian Adult Nutrition Survey (MANS)

The Malaysian Adults Nutrition Survey (MANS) was carried out between October 2002 and July 2003, involving 6,775 men and 3,441 women aged 18 – 59 years. Anthropometric assessment showed that the overall mean body weight and BMI were 62.65 kg (CI: 62.20, 63.09) and 24.37 kg/m2 (CI: 24.21, 24.53) respectively. Based on the WHO (1998) classification of BMI, 12.15% (CI: 11.26, 13.10) were obese (BMI > 30 kg/m2), and 26.71% (CI: 25.50, 27.96) overweight (BMI > 25 - 29.9 kg/m2). Significantly, more women were obese [14.66% (CI: 13.37, 16.04)] while significantly more men were overweight [28.55% (CI: 26.77, 30.40)]. Ethnicitywise, prevalence of obesity was highest among the Malays [15.28% (CI: 13.91, 16.77)] while overweight was highest for the Indians [31.01% (CI: 26.64, 35.76)]. Both obesity and overweight were highest among those aged 40 - 49 years. Obesity was highest for those whose household income was between RM1,500 - 3,500 while overweight was more prevalent for those whose household income exceeded RM3,500. The prevalence of overweight was highest for those with primary education [31.90% (CI: 29.21, 34.72)]. There was no significant urbanrural differential in both obesity and overweight. The study found 9.02% (CI: 8.82, 10.61) with chronic energy deficiency (CED) (BMI < 18.5 kg/m2). The prevalence of CED was relatively higher in the indigenous population (Orang Asli) [14.53% (CI: 5.14, 34.77)], subjects aged 18-19 years [26.24% (CI: 21.12, 32.09)], and with monthly household income of < RM1,500 [10.85% (CI: 9.63, 12.20)]. The prevalence of CED was not significantly different among the geographical zones and educational levels, and between urban/rural areas and sexes. The results call for priority action to address the serious problem of overweight and obesity among Malaysian adults as it poses a grave burden to the country’s resources and development.

Food Consumption Patterns: Findings from the Malaysian Adult Nutrition Survey (MANS)

This study reports the food consumption patterns of adults aged 18 to 59 years in the Malaysian Adults Nutrition Survey (MANS) carried out between October 2002 and December 2003. A total of 6,742 subjects comprising 3,274 men and 3,468 women representing the northern, central , southern and east coast of Peninsular Malaysia as well as Sabah and Sarawak were interviewed. A semiquantitative food frequency questionnaire (FFQ) which consisted of 126 food items was used to evaluate the food consumption pattern (habitual food intake) of the respondents during the previous one- year period. The results demonstrate that nasi putih (cooked rice) was consumed by 97% of the population twice daily (average 2½ plates per day). Other food items consumed daily were marine fish, (one medium fish per day), green leafy vegetables (one cup per day) and sweetened condensed milk (three teaspoons per day. The mean frequencies for daily intake of rice, leafy vegetables, marine fish, local kuih, anchovy(ikan bilis) and biscuits were significantly higher among the rural compared to the urban adults. In contrast, more urban dwellers consumed chicken and eggs more frequently than their rural counterparts. More men than women consumed chicken and eggs more frequently. Malaysian adults showed a satisfactory habit of drinking plain water, with 99% drinking at least six glasses of plain water daily. Other beverages such as tea (47%), coffee (28%), chocolate-based drinks (23%) and cordial syrup (11%) were also consumed on daily basis, however, in a smaller proportion of the population. There were differences in the prevalence of daily consumption of foods when comparing urban and rural population, and also between men and women. The prevalence of daily consumption of marine fish among rural and urban adults was 51% and 34% respectively. For sweetened condensed milk, men and women consumed 43% and 28% respectively; however, more women drank full cream milk than men. Between the age groups, 21% of adults below 20 years old consumed chicken at least once a day, while this pattern of intake was not shown in the older age groups. Our findings show that adults, aged 50 to 59 years old, had the highest prevalence of daily consumption of full cream milk with 24% while those aged 18 to 19 years old had the lowest prevalence of daily consumption at 15%. The food consumption pattern of Malaysian adults appears to be satisfactory. However, some changes in food habits are recommended especially in substituting the less wholesome sweetened condensed milk with the more nutritious full cream or skimmed milk.