Asia-Pacific Journal of Public Health 1990-Vol .
4 No 1
Nutritional Problems of Malaysian
Children and Approaches Taken to
Overcome Them
JT Arokiasamy, MB, BS, MPH, S M
Department of Social and Preventive Medicine
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia
Abstract
Nutritional status of children is an important
factor in child survival, especially in devel-
oping countries. It is therefore important that
nutritional problems are addressed and
overcome. This paper reviews the many
studies conducted in Malaysia on nutritional
problems among children. It also documents
the approaches, including intersectoral
approaches, that have been taken to over-
come these problems. Possible actions that
have to be taken in the future to further
improve the nutritional status of Malaysian
children are discussed.
Key Words: child health research; intersec-
toral approach; nutrition of children.
The survival, as well as satisfactory growth of
children, is dependent on their nutritional status. This
is particularly true in developing countries such as
Malaysia where infection among children makes them
vulnerable to nutritional problems. Since independ-
ence in 1957, Malaysia’s health programmes have
given priority to improving the health of children.
The five year development plans implemented by the
government give priority to intersectoral approaches
to overcome the socioeconomic problems of the
country. As a result, several health problems of the
country have benefited from this intersectoral ap-
proach. This paper focuses on nutritional problems
among Malaysian children, first reviewing the many
studies conducted in the country on nutritional
problems among children and subsequently the
approaches that have been used in the country to
overcome these problems. The paper documents the
use of the intersectoral approach to overcome
nutritional problems.
Background
Malaysia is a tropical country which is composed
of three parts, namely, a part-on the Malay Penin-
sula known as Peninsular Malaysia and two eastern
parts on the island of Borneo known as Sarawak and
Sabah. Peninsular Malaysia is located south of
Thailand and north of Singapore. The multiracial
population of Malaysia in 1986 was estimated at 16.1
million persons. The population has been growing
at a rate of about 2.4 to 2.6 percent annually since
1980. About half the current population is under
the age of fourteen years. The birth rate in Malaysia
is still high, though it has declined from 46.2 per
lo00 population in 1957 to 31.3 per loo0 in 1985.
The Infant Mortality Rate has decreased from 183
per lo00 live births in 1921 to 75 per loo0 in 1957
and down to its present rate of 16 per loo0 in 1986.
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Asia-Pacific Journal of Public Health 1990-VoI 4 No 1
The Toddler Mortality Rate declined from 84 per lo00
toddlers in 1937 to 1.4 per lo00 in 1986.'
A Review of Nutritional Studies on Malaysian
Children
Child health research in Malaysia has been docu-
mented as early as 1900. In particular, several studies
on children have been carried out by the Institute
for Medical Research and local universities. Since
nutrition of children is important for their growth,
development and survival, it has been an important
focus of many studies.
Studies on Birtltweigltt
Birthweight is an indirect indicator of the general
health and level of socioeconomic development of
a country. It could also reflect the gap between the
privileged and the less privileged sectors of the
community.
Both Thompson2 and Chong et aL3, based on
their studies on birthweight conducted at the Ma-
ternity Hospital, Kuala Lumpur from 1953 to 1957
-and during 1973, 1975 and 1977, respectively,
reported that Chinese infants were found to be heavier
than Malay and Indian infants. Indians were found
to have a higher incidence of low birthweight or
small for gestational age infants (14.5%) compared
to Chinese (5.6%) and Malays (7.6%). A comparison
of these two studies revealed that both Malay and
Indian' infants showed birthweight increments pos-
sibly as a result of improved prenatal care and
improving socioeconomic status over the decades.
A review of vital statistics information3 confirmed
this trend as revealed by the I986 national data when
low birthweight incidence (less than 2.5 kg) was only
8.8 percent compared to 10.4 percent in 1981.
Nutrition in Preschool Children
Studies conducted prior to 1960 have shown that the
more extreme forms of malnutrition were prevalent
during this period. Kwashiorkor was first described
by Cicely Williams in 1949 when two such cases
were identified in Trengganu. Subsequently, similar
cases were described in Penang, Per& and Negri
Sembilan.4. Field in her report also recorded a high
incidence of severe Vitamin A deficiency in infants
fed with pomdge and sweetened condensed milk.5
Beri beri was also found in three infants, all of whom
were approximately three months of age. A survey
conducted in Perak in 1975 revealed that 19 percent
66
of Malay toddlers surveyed had kwashiorkor, and 44
percent showed signs of protein deficiency. Almost
all (95.5%) of them had vitamin A deficiency, while
14 percent had xerosis conjunctiva.
Studies conducted after 1960 have shown that
moderate to severe malnutrition still exists, particu-
larly in deep inland rural districts, certain rural estates
and urban slums. Table 1 summarises the findings
of several surveys undertaken during this period.
The predominant deficiencies found by these surveys
were those due principally to an inadequate intake
of calories, protein, vitamin A and iron, often
superimposed by the prevalence of chronic parasitic
infections like malaria and helminths. Income, food
consumption and customs were contributory factors
related to the nutritional problems that were iden-
tified.
Up till the mid 1970s, most nutritional surveys
focused on Malay preschool children, presumably
because a greater proportion of the rural population
was composed of Malays. However in 1976, a survey
on the nutritional status of Indian children was
undertaken in a rural estate in Selangor by Kandiah
and Lim.6 Twenty percent of the Indian children
were significantly malnourished. This figure, as can
be seen from Table 1, was higher than that found
among Malays in Kuala Langat (lo%), similar to the
findings among Malay preschool children in Kuala
Trengganu (23%) but comparatively better than for
Malay preschool children surveyed in Ulu Trengganu
(32%). Over forty percent (41.1%) of the Indian
children were found to be anaemic while 35 percent
had vitamin A deficiency. The latter percentage was
higher than that found among Malay children (15.7%)
in the same age group in 1970 in the same state.
It also was found that 12.3 percent of the Indian
children had vitamin B deficiency, while 7.7 percent
had manifestations of vitamin D deficiency.
In Sarawak, a nutritional survey of Iban chil-
dren revealed that there was widespread malnutrition
in the interior areas with 86.1 percent of the children
being affected with significant malnutrition.' Almost
30 percent were anaemic, 20.5 percent had vitamin
A deficiencies, while vitamin B deficiencies were
found in over 13 percent of them. In a survey of
Penan children in Sarawak it was found that only
14 percent of them could be classified as normal
according to the criteria of Waterlow's classification,
while 39 percent were nutritional dwarfs, 11 percent
were acutely malnourished and 36 percent were both
stunted and wasted!
In general it could be stated that for Peninsular
Malaysia, while malnutrition continues to exist, both
 Asia-Pacific Journal of Public Health 1990-Vol 4 No 1

Table 1.
Community Surveys on Malnutrition in Toddlers, Preschool and School Children (1957-1984)

Year Age Group Population Surveyed Number Malnutrition (96)

1957 0-4 Malays in Lambor and 200 19%-kwashiorkor

(Thornson) Layang Layang in Parak &%-signs of protein deficient diet

1961 1 mth- Children attending maternal 14,604 Weight curve drawn shows that
(Thornson) 5 yrs and child health clinic in all weights fall below English
Perak range. Boys heavier than girls.
Chinese>Malays>Indi.
1968 1-5 yrs Malay children in Ulu 207 48%-significantly malnourished
(IMR) Trangganu

1968 0-7 yrs Malay children of soldiers 660 10%-significantly malnourished

(Dugdale) in Malaysian army in
Kuala Lumpur
1969 0-5 yrs Malay children in Teluk 475 10%-significantly malnourished’
(IMR) Datok in Kuala Langat ( ~ 7 0 %of Harvard standard)
Districts in Selangor
1970 0-7 yrs Malay children in Mukim 425 OS%-marasmus (2 cases)
(IMR) Ulu Bernam in Ulu 25%-mild to moderate
Selangor District in malnutrition (boys)
Selangor 8%-nutritional dwarfs (boys)
38%-mild to moderate mal-
nutrition (girls)
3.9%-nutritional dwarfs (girls)
1971 0-4 yrs Paediatric inpatients in 147 13%-severe protein calorie
(Chan) University Hospital malnutrition2(40% of
expected weight for age)
65%-underweight
1972 1-5 yrs Malay preschool children 285 23%-significantly
(IMR) in Kuala Trengganu malnourished

1975 0-7 yrs Malay preschool children 209 32%-significantly malnourished

(Chong and Lim) in Ulu Trangganu (<70%of Harvard standard)

1976 0-5 yrs Indian children in rubber 41 2.5% (1 case)-marasmus3

(Kandiah) estate in Salangor 20%-significantly malnourished
(<70% of Harirard standard)
1977 0-9 yrs Iban children in 502 86.1%-significantly malnourished
(Anderson) Sarawak 9.6%-severe malnutrition
76.5%-moderate malnutrition
68.1%-stunted
1979-83. 0-6 yrs Malay preschool children 635 3.O%-severe chronic malnntriti011~
(MR) and Kelantan 5.O%-acute malnutrition
43.09b-stunted
37.O%-underweight
1982-84 0-12 yrs Iban children in 79 11.O%-acute malnunitionf
(Chen) Upper Baran Sarawak 36.0%-numtiod dwarfs
7.6%-rnoderate to sever0 wasdn&
75.01-st~nted
1. Criteria as defined by Jelliffe (1966).
2. Criteria of international working party in Jamaica 60-80% of expected weight for age-underwelghc <6o%-seVere
calorie malnutition.
3 Criteria of Wellcome Trust working party classification ( ~ 7 0 %of Harvard standard). The b a r d standard WBS based
on 50th percentile of Harvard or Boston distribution plotted for the tables given by Nelson et al.
4. Criteria as recommended by WHO/WPRO (1979).
5. Criteria as defined by Waterlow (1972).

Source: Wong and ArokiasamyI6

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Asia-Pacific Journal of Public Health 1990-Vol 4 No 1

Table 2. Nutritional Studies in Schools

Author (Year) Chen (1972)9
Age group 6-9.9 years
Ethnicity Malay, Indiaa and Chinese
Number 2,340
Locality Urban schools in Petaling Jaya and Kuala Lumpur

Percent with Malnutrition*

Group Underweight Stunting Wasting
Overall 27 25 9
Indian 41 30 16
Malay 35 38 7
Chinese 14 13 8
* Underweight - 4 0 % of weight for age
Stunting - 4 0 % of height for age
Wasting - <80% of weight for height
(Methods of measurement according to Jelliffe)

Author (year) Rampal (1976)'O

Age group 7-12 years
Ethnicity Malay, Indian and Chinese
Number 5,360 (3,107 rural, 2,253 urban)
Locality Urban and rural schools in Klang and Kuala Lumpur

Percent with Malnutrition*

Group Underweight Stunting
Indian 36.7 1.5
Urban Malay 47.2 2.5
Chinese 30.9 0.7

Indian 75.1 12.3

Rural Malay 67.0 10.9
Chinese 62.8 5.4

* Underweight - 60-80% of weight for age

Marasmus - 4 0 % of weight for age with no edema
stunting - <85% of height for age
Wasting - <80% of weight for height
(Methods of measurement according to Jelliffe)
Source: Wong and Arokiasarnyl6

its seventy and prevalence have been declining.
However the situation is quite different in Sarawak
where malnutrition still remains a serious problem.
Nutrition in School Children
A review of the literature revealed that, although
several nutritional studies have been undertaken
among preschool children, few have been conducted
among school children. Table 2 summarises the
68
findings of two studies conducted among school
children. While the study conducted by Chen9
focused on urban children, that by Rampal'" was
camed out on both urban and rural children. Chen
in her study found that a quarter of the school children
were underweight and stunted. However, wasting
was seen in only 9 percent of the children. In the
same study, more of the Indians (16%) were wasted
compared to less than 10 percent among the Malays
and Chinese.

In his study, Rampal found that Malay urban
school children were more underweight than Indian
and Chinese children. This result differed from that
reported by Chen who found that Indian school
children were more Underweight than the others. This
discrepancy may be due to sampling differences since
the findings of Chen were in fact more similar to
that for rural children in Rampal’s study. In both
studies, Chinese were nutritionally better off than the
other ethnic groups. Rampal also showed that being
underweight, wasting and stunting were more preva-
lent in rural children than urban children, particularly
among rural Indians. The poorer nutritional status
of rural Indian children was also observed by
Chong et al. in a study conducted in Kuala Langat
in 1972.” In this study it was found that 75.1 percent
of the school children were underweight and 18
percent had marasmus.
Feeding Practices
It is known that poor infant and toddler feeding
practices are important factors in the occurrence of
malnutrition. In Malaysia, studies have shown that
there is a discernible vaned pattern in the feeding
practices of children amongst different ethnic groups
which could contribute to the difference in preva-
lence of malnutrition amongst the three main ethnic
groups, namely, Malay, Chinese and Indian. Studies
have shown that breastfeeding is most common among
Malays (78% to 98%), followed by Indians (55%)
and Chinese (35%).12-l 3 There is also evidence
to suggest that the practice of breastfeeding has de-
clined in urban areas for all the ethnic groups,
particularly amongst Chinese but less markedly among
Malays.’4 While several of the studies have shown
no relationship between breastfeeding status and
factors such as age, parity and income of the mother,
Wong noted that among urban Chinese, breastfeed-
ing incidence declined with educational status.I4
About a fifth of the urban mothers studied by Wong
were not aware of the advantages of breastfeeding
and had misconceptions about it.
Weaning practices also varied among the dif-
ferent ethnic groups. It has been reported that only
a third of the infants of urban mothers receive meat,
fish or eggs by the age of six months. The weaning
diet of about one-third of the children, especially
among Indians and lower income groups, was also
found to be unsatisfactory and would fail to meet
the physiological requirements for rapid growth of
infants. Food taboos, especially among those in rural
areas, continue to be a common problem. Surveys
Asia-Pacific Journal of Public Health 1990-Vol 4 No 1
on child nutrition in the 1950s and 1970s reported
that eggs, fish and papaya were seldom given
to toddlers since they were believed to result in
worms.12
Approaches in Malaysia to Overcome Nutritional
Problems
Safeguarding the health and nutrition of Malaysian
children and thereby promoting child survival have
been largely the responsibility of the Ministry of
Health through the Rural Health Services. More spe-
cifically this has been the responsibility of the
Maternal and Child Health service (MCH) which is
a major and priority service of the Ministry of Health.
In Malaysia more than 80 percent of MCH services
are provided through government facilities. In
addition, in urban areas, the private sector and local
authorities supplement the efforts of the Ministry of
Health in providing certain aspects of MCH services.
A Primary Health Care survey conducted during the
period 1978-1980 to identify areas underserved and
unserved by static health facilities formed the basis
for the siting of health facilities and provision of
mobile health teams to improve the accessibility and
coverage of basic health services in line with the
primary health care approach. At about the same
time in 1979/1980, an internal review of the existing
MCH services was undertaken to identify service
weaknesses and to develop strategies to overcome
them. Changes were made in relation to programme
delivery with a shift in emphasis from a clinic based
to a more community based approach. Specific
examples of this change included the implementation
of the “Strategy for Nutrition Education-Community
Approach” and conduct of community sessions for
nutritional ~urveillance.’~
Promotion of breastfeeding has been a major
aspect of MCH services in attempting to overcome
nutritional problems. Pregnant mothers are advised
on breastfeeding, and this is reinforced during
postnatal home nursing visits by health staff and
during child health sessions. Breastfeeding promo-
tion was intensified from 1976 when, together with
the National Council of Women’s Organisations, the
Ministry of Health launched a national campaign on
the Promotion of Breastfeeding. In 1979, the Ministry
of Health in conjunction with the milk industry
developed a “Code of Ethics for Promotion and
Marketing of Infant Formula Products.” This code,
further amended and reviewed in 1985, prevents the
distribution of samples as well as advertisements in
the mass media. More recently in 1986 and 1987,
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Asia-Pacific Journal of Public Health 1990-Vol 4 No 1
workshops were held with interagency and volun-
tary organisation participation in which guidelines on
breastfeeding for mothers and various agencies were
produced.
Promotion of the nutrition of children has been
part of the government’s development plans since the
early 1970s with the implementation of the Applied
Food and Nutrition Program (AFNP). This pro-
gramme is described in greater detail below as an
illustration of an integrated multisectoral programme
involving various agencies and the community.
Growth monitoring of children under seven years
through the use of Growth Curves has been imple-
mented over the last ten years. Children whose weight
gain is below the desired weight for age are managed
accordingly by nutritional advice, supplementary
feeding, referral to hospital or other agencies, and
are subsequently followed up at home. In 1982, a
nutrition surveillance system was implemented where
more priority is given to the management and followup
of children identified as being underno~rished.~~
Intersectoral Approaches to Nutrition Problems
of Children
There are many factors beyond health fac-
tors that affect the health of children. This has to
be recognised if child survival is to be promoted and
has been recognised by the Malaysian government.
The Ministry of Health has practised the principle
of intersectoral participation since the late 1960s in
its efforts to implement programmes for the promo-
tion of child survival. This is particularly so with
regard to overcoming nutritional problems among
children. Thus in promoting breastfeeding the
Ministry of Health works with the Ministry of
Education, Ministry of Information, National Coun-
cil of Women’s Organisations and other agencies.
In working with the Prime Minister’s Department,
Ministry of Education, Department of Statistics,
Ministry of Agriculture, Ministry of Information, etc.,
the Ministry of Health also provides leadership in
nutritional surveillance and the management of
malnourished children.
The Applied Food and Nutrition Programme
(AFNP) in Malaysia is probably a classic example
of intersectoral participation that is often cited. This
programme was planned from inception to be intersec-
toral and to require community participation with the
objective of improving the nutritional status of
children, especially in rural areas. Implemented in
1969 as a pilot project, the programme involves
I agencies such as the Ministries of Agriculture,
70
Education, Information, Welfare, National and Rural
Development (Community Development), Youth and
Sports, Economic and Planning Unit and Imple-
mentation and Coordination Unit of the Prime Min-
ister’s Department, and the Ministry of Health which
provides technical leadership. In addition, agencies
such as the Farmers’ Association, Federal Agricul-
tural Marketing Authority, and voluntary bodies are
also involved in the programme. It is coordinated
by the Prime Minister’s Department at the national
level, by the State Development Officer at the state
level, by the District Officer at the district level, and
by the Village Headman at the village level. The
three pronged strategy of this programme is to increase
income and local production of nutritious food,
promote nutrition education and home economics, and
improve health and sanitation. Based on the success
of the pilot project, the AFNP was expanded to 38
other distri~ts.’~
While the Ministry of Health provides leader-
ship in implementing many of the intersectoral
programmes that were discussed, the other approach
practised is the collaboration of the Ministry of Health
in other health related programmes in which other
ministries assume the lead role. One such programme
of relevance to the nutrition of children is the Ministry
of Education’s Supplementary School . Feeding
programme.
Discussion and Recommendations
It is encouraging to note that the prevalence of low
birthweight has been declining especially for Malays
and Indians. While this trend could largely be due
to improved prenatal care over the decades, improve-
ments in socioeconomic status as a result of the
government’s five year development plans since
independence in 1957 would also have played a major
role. The further impact of the country’s socioeco-
nomic policies and of the strengthening of the Ministry
of Health’s MCH services on the prevalence of low
birthweight can be expected to be seen in the coming
decades. It would be worthwhile to undertake further
studies on the trends in birthweight changes for the
different ethnic groups of the country.
Early marriage, food taboos, underemployment,
poor communication and lack of child health services
have been suggested as contributory factors to the
malnutrition prevalent among Malay children found
in studies conducted prior to 1960.16 The decline
in severity and prevalence of malnutrition over the
subsequent years is probably a reflection of some
of these factors being overcome. It would be

important for future studies to identify those current
factors that are likely to be responsible for the
continuing malnutrition, even though milder than in
the past. This in turn will enable the Ministry of
Health to focus on these factors and to strengthen
its efforts in overcoming malnutrition among chil-
dren. The findings will also enable newer and more
sensitive indicators to be identified and used in the
nutritional surveillance efforts of the Ministry of
Health. The review of literature also noted a relative
lack of nutritional studies among Indian children who
appear to be less better off than their counterparts
in the other ethnic groups. The factors responsible
for the poorer nutritional status of Indian children
need to be urgently identified in order for a more
comprehensive program to be implemented to improve
the nutritional status of Malaysian children.
Finally, the efforts of the Ministry of Health
have made a definite impact on the nutritional status
of children as well as on child survival as evidenced
by the declining mortality rates among children
described earlier. Most health problems, including
nutritional problems, tend to be multifactorial in origin
and consequently an intersectoral approach to
overcoming them is not only necessary but prudent.
Policies on agriculture, food, nutrition, industrial
development and education need to be coordinated
to promote improved nutrition and child survival.
In this endeavour, mobilising universities, nongovem-
mental organisations, voluntary bodies and the private
sector would be important. Malaysia has been
fortunate that the intersectoral approach has been used
to overcome several of her problems. This approach
must therefore be enhanced and augmented so that
the health of children of the future will further improve
and be better than at present.
References
1. Malaysia, Vital Statistics, Peninsular Malaysia, (1957-
1986). Dept. of Statistics, Kuala Lumpur.
2. Thompson FA: The weight of preschool children in the
Asia-Pacific Journal of Public Health 1990-Vol 4 No 1
Federation of Malaya. Med J Malaya 1961; 15(13):160-
165.
3. Chong YH, Hussein H: Recent birth weight distribution
and trends in Kuala Lumpur. Med J Malaysia 1982; 37
(1):40-45.
4. Thompson FA: Child nutrition: a survey in the Parit
District of Perak, Federation of Malaya, 1952-58. Bull
lnst Med Res Malaya 1960; (new series), no. 10.
5. Field CE: Nutritional problems in the Federation. Med
J Malaya 1955; 9(3):179-194.
6. Kandiah N, Lirn JB: Nutritional status in a rural estate
community. Med J Malaysia 1977; 31 (4):270-276.
7. Anderson AJU: Nutrition of lban children of the Sut
and Mujong Rivers. J Trop Pediat 1981; 27:26-35.
8. Chen PCY: Child nutrition among the Penans of the
Upper Baram, Sarawak. Med J Malaysia 1984; 39
(4):264-268.
9. Chen ST: Comparative growth of Malay, Chinese school
children in Malaysia. SE Asian J Trop Med and Pub
Hlth 1972; 71443-451.
10. Rampal L: Nutrition status of primary school children:
a comparative rural and urban study. Med J Malaysia
1977; 32(1):6-16.
11. Chong YH, McKay DA, Lim RKH: Some results of recent
nutrition surveys in West Malaysia. Bull Pub/ Hlfh SOC
1972; 6:55.
12. Chen PCY: Child health in Malaysia: 1870-1985. Med
J Malaysia 1985; 40(3):165-I76.
13. Chong YH: Editorial: Nutritional scene in Malaysia. Med
J Malaysia 1986; 41(1):1-3.
14. Chong ML: A comparative study of breastfeeding in
the two main ethnic groups in Ulu Langat and Gombak
Districts in Selangor. Theses for MPH, University of
Malaya, 1982.
15. Karim R: The Ministry of Health’s approach in promot-
ing child survival in Malaysia. In Proceedings, Inter-
national Workshop on Innovative, lntersectoral Lead-
ership for Child Survival and Health for All. Department
of Social and Preventive Medicine, University of Malaya,
1988.
16. Wong ML, Arokiasamy JT: Review of studies on child
health in Malaysia. Department of Social and Pre-
ventive Medicine, University of Malaya, 1988.
71