The nutrition transition in Malaysia; key drivers and recommendations for improved health outcomes | BMC Nutrition

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It is evident from the preceding data that Malaysia is a nation in the midst of transition. The demographic and epidemiological transitions that have taken place over the 34 year period in review have the hallmark of transitions taking place in other rapidly evolving economies. Currently, there is very little sign that this is going to change. The prevalence of obesity and associated NCD has continued to increase amongst Malaysians, frequently surpassing the global average (Prevalence of Selected NCD and NCD Risk Factors (NHMS I-V and MANS 2003 and 2014)). In comparison to the WHO 2014 global average, diabetes mellitus was three times more prevalent in Malaysia [62]. While the prevalence of overweight was on par with the [62] global average, obesity was about 2.5 times more prevalent in Malaysia [64]. Hypercholesterolaemia was also approximately 50% more prevalent in Malaysia compared to the WHO 2008 global average [63]. Since 2014, Malaysia has topped the league tables as the most obese nation in South East Asia [40].

The next section of the discussion examines the underlying causes of the nutrition transition in Malaysia. It is divided into three main areas: The food environment; Changes in lifestyle and behaviour; Government policies, including taxes and subsidies. After examining the underlying factors, recommendations are made for policy changes to address the issues and provide better health outcomes for Malaysians.

The food environment

An abundance of food

A decreasing rate of population growth (Transitioning Demographic (DoSM)) in combination with a strong growth in GDP (Rapid Economic Growth and Transition (DoSM)) has increased access to and availability of more and cheaper food, also known as the “expansion” stage of nutrition transition [34]. For the period under review, there has been an abundance of calories available, indicating that Malaysia has been in the expansion stage of transition for over 35 years. Between 2010 and 2013, the average Malaysian woman and man had access to around 93 and 45% more calories than needed (Changes in Trends of Energy and Nutrient Supply (FBS Review)). Vandevijvere et al. [54] warned that the obesity epidemic in around 80% of countries surveyed is fuelled by the sheer abundance of food as it was found that an increase in the amount of per-capita food energy available has created excesses that alone can account for increases in average body weight. Only countries hit by famine, natural disasters or civil war did not follow the trend [54]. The ever-increasing prevalence of obesity and persistent surplus of per capita food energy supply in Malaysia is consistent with the findings of Vandevijvere et al. [54].

Change in types of foods consumed

During the period under review, Malaysia entered the ‘substitution phase’ of the nutrition transition. This phase is typified by a shift in the types of food consumed with no major change in the overall energy supply [34]. The shifts in food groups are usually described as an increase in consumption of refined carbohydrates, added sweeteners, edible oils, and animal-sourced foods, together with a reduction in legumes, other vegetables and fruits [47]. This transition may differ from one country to another due to differences in culture, beliefs and religious traditions [34].

In Malaysia, there are several reasons for the preference for chicken and fish over red meat, not least the price, but also the convenience, versatility, ready availability and acceptability to all ethnicities. Malaysia is a multiracial and multi-religion nation, in which all populations accept fish, seafood and chicken compared to red meat, such as pork and beef that are prohibited among the Muslims and Hindus, respectively. It is also a norm among Chinese who adopt some Buddhism beliefs to avoid beef. The Malaysian climate and topography (no grassland) is not suited to the rearing of beef or dairy cattle. Poultry farming, for meat and egg production takes place on an intensive scale, making chicken meat and eggs available at very attractive prices. With regards to fish consumption, Malaysia is an island nation, thus it makes sense that fish are the traditional form of animal protein. Locally caught or farmed fish are cheap and plentiful.

Modern healthy eating advice has advocated the consumption of lean white meat (chicken) over red meat, which is perceived to contain a higher concentration of saturated fats. While this may have been the case 60–70 years ago, the modern chicken, fast growing and intensively reared, has a very different nutrient composition profile to its ancestors. They provide more energy from fat than protein and contain more than twice as much fat as it did in 1940, a third more calories and a third less protein [57]. The method of cooking also has a significant impact on the nutritional value of the meat consumed. Deep fried chicken tastes better than boiled or steamed chicken, and is a favourite snack and meal. Not only chicken that is deep fried, the most preferred fish cooking style by Malaysians is deep-frying [4]. During frying, fish will absorb some of the oil, increasing its calorie content and changing the types of fat it contains, with the amount of beneficial fatty acids particularly adversely affected.

Another trend also common in transitioning countries is the increase in wheat consumption [43, 45, 49]. Malaysia too is consuming more wheat at the expense of rice. It is important to note that wheat is usually consumed in its highly processed form of flour, whereas rice is traditionally polished and boiled or steamed before consumption. Different varieties of wheat are imported and refined to produce noodles, cakes, cookies, crackers, buns and breads – all of which are commodities that have roles to play as convenience foods. To put things into perspective: a bowl of steamed rice is less processed and less “value-added” than any one of the wheat-based products available in Malaysia. Wheat-based foods are also consumed in a more calorific but less nutritious way. For instance, the ubiquitous breakfast item, “Roti Canai” or Malaysian flatbread, is made from refined-wheat-flour dough which is repeatedly kneaded, flattened, oiled, and folded before proofing and shallow frying in more oil. In addition, white toast is not complete without margarine spread. Coincidentally or not, partially hydrogenated oil that is linked to the development of NCD is one common vital ingredient in the aforementioned wheat-based products. This industrial source of trans-fat is not banned in Malaysia, unlike most high income countries that have heeded WHO’s call on eliminating it in our diets by 2023.

While other studies of the nutrition transition in developing economies [43, 45, 49] found an increase in milk intake, the opposite holds true in Malaysia. Per capita milk supply has reduced from two-third to half a glass a day. Akin to cattle rearing, dairy farming is equally not suited to the Malaysian climate, hence there has been no culture of milk production or consumption. Whilst there is some locally produced fresh milk, the majority of milk and dairy products are made from imported milk powder and hence are not affordable by all [51]. Additionally, the rate of lactose intolerance among adults in Malaysia is extremely high at over 80% [6, 16], therefore most adults choose to avoid milk and dairy products. Malaysian adults tend to substitute milk in beverages such as tea and coffee with sweetened “condensed milk” that is easier on the palate, stomach and pocket but is poorer for health. It is important to highlight that the ubiquitous sweetened “condensed milk” widely consumed in Malaysia is actually the non-dairy creamer, made from palm oil derivatives. The dairy version of condensed milk is less widely available and usually imported to cater for niche upmarket consumers.

The FBS highlighted an over-abundance of and sustained increase in the supply of sugar and sweeteners over the past three decades (Changes in Trends of Energy and Nutrient Supply (FBS Review)). While the recommended upper daily limit for sugar is no more than 9 or 6 teaspoons a day, men and women respectively, the amounts available in the 1980s were equivalent to 21 teaspoons per person per day. The availability of sugar and sweeteners has continued to increase over the decades, hand in hand with the increase in prevalence of NCD and obesity.

Changes in lifestyle and behaviour

In keeping with Popkin’s findings (2015), underlying the afore discussed transition in Malaysia are the growth of the modern retail culture, a change in technology affecting physical activity and inactivity, access to mass media, urbanisation and penetration of modern food systems into all societies. The huge demographic change in Malaysia, from a nation that was largely rural (72%) in the 1960’s to a complete reversal of this situation by 2014, brought with it concomitant changes in lifestyle, behaviour and eating habit. It is difficult to disaggregate the individual factors from each other as one change has knock on effects on other factors. Together they fall under the banner of urbanisation. They have a significant impact on the eating behaviour and health outcomes of the population.

Sedentary urban living

Over three quarters of Malaysians now live in urban or peri-urban areas. They are linked by fast highways, by high speed internet and have access to technologies that are designed to make their lives more comfortable and convenient. Less energy is expended both at work and in traveling to work; people have sedentary occupations and tend to walk less as car ownership continues to rise. Even if one’s energy intake stays the same over the years, the gradual metabolic ageing causing reduction in basal energy requirement and reduction in energy expenditure due to sedentary lifestyle can bring about energy surplus that leads to a gradual, but persistent, weight gain over a considerable period of time.

Eating out

Changing lifestyles, mainly due to work commitment, have fuelled the increase in numbers eating out and the need for convenience foods. According to the Malaysian Food Barometer, more than 64% of Malaysians eat at least one meal per day outside of home; of the remaining 36% who eat at home, 12.5% have at least one meal that comes from outside [48]. Traditionally, foods were home cooked local dishes prepared by mothers. Due to an increasing number of “dual-income” families, eating out becomes increasingly prevalent in Malaysia. It is also not surprising that the review has found that about one-third of the population consume a fourth heavy meal late at night. In fact, around-the-clock dining has become so inherent with Malaysian culture that the government had to retreat a proposal to ban eateries from operating 24 h after facing community backlash [17].

The abundance of eateries in Malaysia makes eating out an easy option. Consumers do have the choice to select home-cooked fare such as the “nasi kandar” or “nasi campur” stalls that offers an abundance of local dishes – vegetables, fish, chicken, and curries of various kinds – served with limitless steamed rice. These eateries do provide healthy and less healthy options. It is left to the consumer to make choices and to select the appropriate amount to consume. In addition to the “healthy” choices, an abundance of small hawker stalls offer a range of food choices for a very reasonable price. In general, these foods tend to be fried, high in salt, sugar and devoid of nutrients. The availability of “ready meals” in convenience stores has mushroomed over the past 5 years. These ready meals do provide a safety net for those who do not have access to food storage or preparation facilities, but can be viewed as one of the contributory factors to lifestyle and dietary change and associated health outcomes.

Trendy food culture

The establishment of shopping malls in all towns has contributed to the globalisation of food products and culture that is further promoted and instilled in the local communities by their increasing presence across all towns in Malaysia, big and small. Outlets serving trending food is fast becoming a quintessential component of the evolving urban food culture. The long queue in front of these outlets cannot be missed. The latest trend in Asia, and in Malaysia, is the consumption of “bubble tea”, a high calorie sweetened tea-flavoured beverage with chewy tapioca balls. Coffee culture is also on the increase in Malaysia. The trending coffee shops are the well-known global brands, reinforced by independent local businesses that serve large volumes of sweetened, milk based beverages and cakes and pastries alongside. Kiosk chains market juice and smoothie drinks as healthy and offering a range of purported benefits such as “immune-boosting” and “cleansing”. All are sold in large volumes and, as with the bubble tea and coffee, some of these products are more akin to a meal than a beverage in terms of the total calorie count. For instance, a search on the webpage of one of the well-known retailers found that one of their popular products marketed as a protein drink provides 588.5 cal. A single serving of a “bubble tea” contains 299 cal and 38 g of sugar [37].

The internet era

The majority of Malaysians (75% in 2015) now have access to the internet. Whilst this service has numerous positive attributes –access to information being one of these – it also has negative attributes with respect to food access and availability. Improved internet access enables the online ordering of food (24 h a day), which can be home delivered. This further reduces the necessity to expend energy while searching for the next meal or snack. While there is a lack of official statistics from the Government, it has been reported elsewhere that 80% of the population is active social media user spending about 2.8 h per day on average just on social media [36]. The Instagram age of sharing trending foods with friends means that eating out is rapidly evolving to become more of a social pastime and hobby. It gives individuals kudos and bragging rights over their friends and peers. Eating out, especially at the latest trending place, is aspirational and seen as a form of success.

Government policies

The epidemiological transition in Malaysia is reflected in the parallels between evolving economies and a growing burden of NCD. Being aware of this situation, the government has implemented since 1996 national plans of actions in an attempt to curb it.

Nutrition action plans and policies to improve health

Since the early 1990s, Government efforts have focused on the coordination of nutrition intervention programmes in the country between various agencies [52]. The first blueprint was the National Plan of Action for Nutrition in Malaysia (NPANM I) (1996 to 2000). This plan was primarily targeted at undernutrition. Meanwhile, the problem with overweight was recognised for the first time and strategies to control unhealthy weight gain in the population were outlined in NPANM I. Unfortunately, not only did the strategies fail to have any impact, the prevalence of overweight and obesity rose by 60 and 177% respectively during the period of NPANM I implementation. At the same time, the incidences of diet-related NCD continued to rise at an alarming rate. It was not until the following NPANM II (2006–2015) and NPANM III (2016–2025) that the needs to prevent and control diet-related NCD were recognised. According to the latest NHMS, strategies to reduce diet-related NCD are underwhelming in effect as the prevalence of NCD has continued to rise over the years, with some figures surpassing the global average.

It is important to understand why these national plans of action were ineffective. Perhaps one of the contributing factors is that the strategies to promote healthy eating and active living over the years used a downstream marketing approach. The fact that the upstream factor of an abundance of cheap, readily available calories can cause problems were overlooked in all these policies. Policymakers expected a trickle down approach, of advertisements and handouts that implored people to eat less and do more exercise, to be whole heartedly adopted by the general population. While at the same time, the population was embracing the rapid development that urbanisation and globalisation brought with it. Requesting people to change or moderate their behaviour while living in a state of abundance, is difficult to achieve. Behavioural interventions have been deemed an ineffective means to prevent obesity in both adults and children mainly due to strong influences beyond individual control [11]. However, to succeed, this method requires more stringent measures to enable people to make healthy choices.

Subsidies and taxes

Whilst the MoH devised policies aimed at improving health outcomes, other sectors of the Government offered a range of subsidies and incentives to ensure ‘cheap food for all’. Annual Government spending on subsidising basic necessities is at least RM2 billion (USD 450 million) [35]. This allocation includes agricultural subsidies, especially rice production incentives, while part of the allocation is also spent on consumer subsidies. The four subsidised consumer items are sugar, flour, rice and cooking oil, all of which are energy dense, nutrient poor foods. This subsidy could partially explain the increasing per capita supply and surplus of such products. The abundance of excess calories has been exacerbated by the introduction of policies to subsidise these nutrient-poor, energy dense food items. Continued subsidy to increase access to and availability of these foods is paradoxical.

Ways forward

The kind of food that is most available, affordable and convenient is a major determinant of people’s diets [14]. According to this review, most of the Malaysian population failed to consume adequate amounts of fruit and vegetable (Changes in Trends of Energy and Nutrient Supply (FBS Review)). This is not surprising since the local supply has never been enough to support the recommended intake of at least 5 servings per person per day. The Malaysian fruit and vegetable industry is generally neglected. The emphasis of agricultural development has been on rice and the commodity crops of oil palm, rubber, cocoa and recently durian [8, 9]. To increase accessibility, policymakers need to offer at least as much research and financial support to local fruits and vegetable farmers. Subsidies strike the best balance between effectiveness in changing behaviours and long-term monetary benefits to society [15]. Instead of subsidising the aforementioned energy dense foods, fruits and vegetables should be subsidised as an incentive to encourage healthier eating habits. Reduced fruit and vegetable consumption is often linked to poor health and increased risk of NCD. The protective effects of fruits and vegetables in the diet may be due to their high content of micronutrients and fibre, acting through mechanisms such as lowering blood pressure [1, 50, 59], improving lipoprotein profile [19] and increasing insulin sensitivity [5, 58].

In tandem with subsidies for fruits and vegetables, fiscal disincentives can be useful for creating consumer demand for nutritious foods [14]. By exerting pressure on the food industry to improve food environments, food taxes such as the sugar tax can be effective at changing people’s diet. From July 2019, the Ministry of Finance (MoF) introduced a sugar tax levy akin to Mexico’s on the manufacturer of canned/bottled sugar-sweetened beverages, i.e. non-alcoholic beverages containing added sugars of more than 5 g per 100 ml drink and fruit or vegetable juice drink containing added sugars of more than 12 g per 100 ml drink. The sugar tax is very much in its infancy and it is impossible to tell whether it is likely to succeed in Malaysia in the absence of longitudinal epidemiological data. At a glance, the directive as it stands is unlikely to succeed, mainly because it is failing to address the real sugar problem – the consumption of sugar from sources other than canned/bottled drinks. Table sugar and non-dairy sweetener, as implied in the findings of MANS 2003 and 2014 conducted by the MoH, are not included in the proposed sugar tax. The most frequently consumed beverages are those prepared at home or at eateries, with added table sugar and/or non-dairy sweetener. A survey by Ahmad in 2015 reported that about 98.6% adults consumed on average two glasses of these beverages per day [3].

The rapid change in Malaysia’s food environment on top of the persistent overabundance of energy supply in the country has tipped the scales in favour of NCD proliferation. Policymakers have mostly overlooked the upstream links between poor diet and policy determinants of food supply from farm to shelves [56] and the importance of employing multicomponent, multidisciplinary and multifaceted approaches for obesity management [7]. As it has been in the past until now, the burden to reduce malnutrition and NCD lies mainly with the MoH. There is a need for setting an overarching vision and common goals for policymakers from different Ministries to meet for achieving the vision with a supportive policy ecosystem to facilitate that. In addition to the MoH, other Ministries with relevant roles to play include the Ministries of Agriculture, Domestic Trade and Consumer Affairs, International Trade and Industry, Education, Finance and Woman and Family. Coherence between different ministerial policies to promote healthy food environments should be ensured and progress towards achieving the goals should be measurable. A good case in point is the MoF and its sugar tax. How will the effectiveness of the sugar tax be measured? If the Key Performance Indicators for the MoF is only of balanced budget and fiscal sustainability, where does its accountability for obesity sit? Would the sugar tax be more robust had the MoF worked closer with other Ministries?

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