Childhood Stunting in Malaysia: Policy and Multisector Interventions

Childhood Stunting in Malaysia

Cloe Coker, Sophie Goodgion, Kathleen Peterson, Simryn Sahota

Nutritional Sciences Program, University of Washington

NUTR 420 A: Global Nutrition: Challenges and Opportunities

Dr. Adam Drewnowski

November 1, 2023

Abstract

Despite rapid economic improvement, Malaysia has experienced worsening childhood stunting, a result of chronic undernutrition with implications such as the risk of being immunocompromised, economic implications, and increased risk of morbidity. Using a multi-sectoral approach to address underlying factors reaching both maternal and adolescent levels, we composed a plan of four targets, which include targeting anemia through iron supplementation, implementation of mandated lactation breaks in professional settings, provision of nutritious balanced meals in schools, as well as educational seminars for parents. This adaptable framework cultivates a comprehensive plan to tackle the increasing prevalence of stunting in Malaysia.

Introduction

Due to the rapidly growing economy of Malaysia, a concerning phenomenon is occurring - a "nutritional transition." Since emerging, it has presented a dual burden of both over and undernutrition. This transition, a consequence of rapid economic progress, has led to a complex scenario where stunting and obesity coexist, stemming from insufficient intake of essential foods and the overconsumption of unhealthy options. Studies consistently highlight the country's struggle with this dual burden, emphasizing the poor diet quality prevalent across all age groups. The impact is particularly alarming during the early stages of life, as growth faltering in children not only results in immediate health issues but also has lasting effects on the nation. This nutritional imbalance affects educational performance, and directly impacts economic productivity. Maternal micronutrient deficiencies, coupled with the lack of proper prenatal care, contribute significantly to childhood stunting. The inadequate supply of nutritious foods in schools exacerbates the problem, hindering children's overall development and productivity. Furthermore, the widespread issue of anemia among pregnant mothers magnifies the challenges, affecting both maternal and child health. Therefore, addressing the dual burden of malnutrition in Malaysia is vital. It requires a holistic approach that combines nutritional education, healthcare interventions, and policy reforms to ensure a healthier future for the nation's children.

Main Nutritional Challenges

In Malaysia, a primary nutritional challenge we are researching is childhood stunting because, despite Malaysia's economic improvements, childhood stunting is a worsening condition. Children who experience stunting, experience developmental delays, they are shorter in height than expected and there is a possibility of cognitive delays. Stunting is a result of long-term chronic undernutrition that negatively impacts the growth and development of children mainly under the age of five; many implications can arise from stunting such as an increased risk of being immunocompromised, and an increased risk of mortality and morbidity from infections (Kok, 2019). An economic implication that stems from stunting is potentially earning 20% less than non-stunted individuals and countries lose 7%, on average, per capita income due to stunting (Kok, 2019). Stunting can become a never-ending cycle as stunted girls who grow up to become stunted adult women are more likely to birth stunted children and this cycle continues. This significant concern in stunting stems from various determinants, a notable one being a poor diet. In Malaysia, 20.7% of children under the age of 5 suffer from stunting much of this is due to poor diet as it is the biggest risk for stunting in children (UNICEF, 2019) and 97% of Malaysians mentioned that high food prices are preventing them from preparing healthy meals at home (Kok, 2019). Due to high food prices, many children are not consuming foods rich in nutrients, rather they are being fed whatever their families can afford which oftentimes is not nutrient-dense foods and 19.2% of Malaysian children ages 6-23 months do not consume the minimum meal frequency of two meals per day (Kok, 2019). Changing food environment is a huge factor that is significantly contributing to childhood stunting. In Malaysia, there has been an increase in fast food consumption and this is due to the advertising and food trends having a large impact on children. Especially in urban areas, there is a large consumption of street food which is high in fat and sodium and there is an abundance of high-calorie, low-nutrient, processed foods within these areas creating a food swamp (UNICEF, 2019). Poor health literacy is another contributor to stunting as this leads to inadequate and inappropriate eating habits within families and it was reported that only 6.6% of Malaysian adults have adequate health literacy (Kok, 2019). This lack of knowledge and lack of resources is having a detrimental impact on children in Malaysia and this can be physically damaging as well as psychologically distressing which is why it is essential to create change and adopt solutions to decrease this burden of childhood stunting in Malaysia.

Proposed Approach

When examining solutions to address Malaysia’s main nutritional challenge, we decided that a multi-sectoral approach was necessary to ensure an effective result. The reason being that, although the immediate cause of stunting is inadequate nutrition, there are several underlying factors that are contributing to the prevalence of this issue. As a result, our proposed approach targets four different concerns- both at the maternal and adolescent levels. These four targets include anemia, breastfeeding, nutrition in schools, and education for parents. The World Health Organization attributes 20% of maternal malnutrition to stunting (Kok, 2019). Taking this into consideration, the first layer of our approach targets maternal anemia. Malaysia has quite a high prevalence of anemia among women of reproductive age, with the FAO finding 32% of women in this category suffer from this condition (FAOSTAT, 2019). Additionally, a systematic review conducted on several studies from 2014-2021 highlights that 7 out of 9 studies found an association between maternal anemia and stunting in children (Nadhiroh et al., 2023). Because of this, we decided that working towards lowering the prevalence of anemia in the population would be a great first step to potentially lowering the prevalence of stunting in the population. In order to do this, we suggest funding for doctors or other healthcare professionals to provide iron supplementation pills to pregnant mothers during their first antenatal care visit. UNICEF states that 97% of pregnant women in Malaysia attended at least 4 antenatal visits during pregnancy (UNICEF, 2023), so we figure that this effort would effectively target the right population. Our second target in our proposed approach is breastfeeding. Research shows an association between exclusive breastfeeding and stunting prevalence. In a study of children in Bangladesh, groups that had a higher prevalence of exclusive breastfeeding for six months reported a 7.3% decrease in stunting prevalence (Arifeen et al., 2009). Currently in Malaysia, there is only a 40% prevalence of exclusive breastfeeding (UNICEF, 2023). This is likely due to the lack of regulations and legal guidance on breastfeeding breaks, as well as a lack of facilities or private spaces in Malaysia. Our approach for this target is to enact regulation that mandates lactation breaks and requires all employment facilities to have a space for lactation breaks. Beyond focusing on maternal nutrition, we wanted our approach to follow all the way through when children are of school age. Currently, 33.6% of Malaysian children do not consume at least four food groups (Kok, 2019). This statistic is alarming as it shows a high prevalence of inadequate nutrition intake which is an immediate cause of stunting. Our third target in our approach aims to require all schools to include all four food groups on the lunch plate each day. This includes carbohydrates, protein, dairy products, and fruits and vegetables. Guidance and meal suggestions would be provided and extra assistance would be given to schools that may not be able to afford as diverse of meals. Our last target in our proposed approach is education for parents. We wanted to target this specific group as adolescent children are often not the ones providing meals for themselves, and much of what they eat is at the discretion of their parents or guardians. In order to ensure that adequate nutrition is being reached, we must ensure that the parents are well-informed on what constitutes a nutritious meal to feed their child. Our approach for this target is to create a framework for schools to adopt an after-school, once a month, educational nutrition session that informs parents about the importance of nutritious meals and the prevalence of stunting within the country. The framework would include a comprehensive lesson plan with evidence-based nutrition strategies and guidance for families. We would also work with schools to develop tailored lesson plans that effectively speak to what is culturally appropriate and readily available in that area to make the most helpful suggestions. While there are several elements of malnutrition that need to be addressed in order to tackle the prevalence of childhood stunting in Malaysia, we believe that our four-target approach is a great and effective start to reducing this statistic.

Conclusion

Malaysia has experienced increases in childhood stunting, where children are experiencing physical and cognitive delays as a result of chronic undernutrition. This leads to a wide array of implications that negatively impact the health of future generations children who experience stunting are less likely to be healthier long term and are more likely to have lower income, creating generational issues for the nation. The connection between maternal malnutrition, exclusive breastfeeding, health literacy, and the provision of diverse, nutrient-rich diets led us to create an adaptable four-tiered framework that reaches underlying issues of stunting for maternal and adolescent health.

References

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