Introduction
Despite the change in leadership, urgency remains to reform our national healthcare system. The work of the Health White Paper should be continued with even greater momentum.
As proposed by the former health minister Khairy Jamaluddin, this paradigm shift will position primary healthcare as the system's first line of health resilience, focusing on keeping people healthy, rather than just treating them when they fall sick.
In order to achieve health and wellness for all, nutrition, a long-neglected healthcare component, should be given greater emphasis. While the ambition to tackle malnutrition is strong, on-the-ground actions have been inadequate possibly due to the lack of political commitment and effective integration of nutrition into national policies.
Good nutrition for effective prevention
Nutrition is a core component of primary healthcare, preventing and promoting health through healthy eating. In fact, it is a significant determinant of various health issues across generations. It concerns not only the quantity and quality of the food we eat, but also eating patterns and lifestyle factors affecting our health and nutrition.
Optimal nutrition can be achieved through consuming a healthy, balanced diet that meets the body’s energy and nutrient requirements. According to World Health Organization (WHO), a healthy diet for adults generally includes fruit, vegetables, legumes, nuts and whole grains with a reduced intake of fat, salt and added sugar. For Malaysians, the Malaysian Dietary Guidelines serve as the primary guide to making healthy food and lifestyle choices.
Malaysian nutrition worrying
Malaysia’s health report card is far from satisfactory. Half of Malaysian adults and around 30% of children aged five to 17 are overweight or obese. Three of ten women of reproductive age (15 to 49 years old) suffer from anaemia, which is commonly caused by the lack of iron, a mineral naturally present in food. Stunting remains a public health concern, affecting one in five children under five.
In spite of the rising disease burden, healthy behaviours among Malaysians are lacking, possibly due to the lack of health awareness and knowledge and a supportive environment. One in four Malaysian adults is not physically active enough, while 95% do not eat enough fruits and vegetables.
Although national dietary guidelines are in place, Malaysians’ compliance with dietary guidelines appears to be inadequate. Previous studies have reported that Malaysian children and adolescents did not meet the dietary and physical activity recommendations. The gap between policy and behavioural science should be addressed to accomplish the desired outcomes intended by nutrition policies.
Poor nutrition causes preventable diseases
Many of the health issues can be attributed to modifiable and preventable food behaviour. Unhealthy diets and lifestyles do not just increase the risk of many diseases but can affect the quality of life, even mental health, negatively.
Most public health nutrition interventions are cost-effective considering their immediate, long-term and intergenerational impacts. For example, initiatives to improve the nutrition of women of reproductive age also improve their children's health.
Nutrition, a complex public health concern
Poor nutrition is not a stand-alone issue. Factors like age, gender, culture, education, income, and cooking knowledge and skills also determine food intake. What and how people eat are also influenced by personal preferences, family influences, food environments, social and cultural norms, and advertising.
For instance, a 2019 KRI report showed differences in the health behaviours of various households by income. Adults from the higher income quintiles were more likely to have enough fruit and water intake, whereas those from the lower income quintiles were more likely to smoke and binge drink i.e. drink excessive alcohol.
Hence, there is no one-size-fits-all approach to nutrition. Socioeconomic, environmental, and system-level factors need to be considered when designing and implementing nutrition interventions and policies.
Nutrition not adequately addressed
According to the Malaysia Health Accounts Health Expenditure Report 1997 to 2019, primary healthcare, which comprises first-contact health services provided in the community, constitutes about one-fifth of total health spending. Only 6.8% of total health spending was on public services, including health promotion and prevention, with most spent on curative services (67.7%).
Despite being effective, nutrition has been underutilized in health promotion and prevention. Existing nutrition-specific strategies that address the direct causes of malnutrition include micronutrient supplementation, breastfeeding promotion and nutrition education. They have been useful in directly improving the nutrition of targeted groups.
For example, Baby-Friendly Hospital and Clinic Initiatives are some of the key strategies that have significantly contributed to the reduced rate of child mortality by promoting breastfeeding knowledge and skills among expecting mothers at the community level. School Feeding Programme or Rancangan Makanan Tambahan (RMT) is another form of nutrition intervention to reduce malnutrition among school children from low-income families, who are more prone to hunger.
On the other hand, nutrition-sensitive strategies that target the underlying causes of malnutrition through policies in healthcare, education, city planning, agriculture and trade, social protection, and labour are underutilised. Combining both nutrition-specific and nutrition-sensitive strategies is critical to accelerate progress towards health and nutrition goals.
Growing complexity of the nutrition landscape
Where processed food is readily available and affordable, healthy eating is no longer an individual choice but is also strongly influenced by the food environment.
Rising food inflation typically means higher prices of nutritious food like fruits and vegetables. This has been a growing barrier to healthy eating, especially for those less well off. Marketing of unhealthy food and drinks, especially via unregulated digital media, can easily influence food choices, especially of children and adolescents.
Toxic food production due to excessive use of antibiotics and pesticides, water pollution and heavy metal contamination are making our food less safe to eat. Climate change is also causing food such as rice, corn and wheat less nutritious and raising concerns over the sustainability of food system in delivering nutritious food for both the present and future generations.
This means nutrition policies and strategies need to evolve to better respond to these complex challenges.
Food environment must support healthy choices
Malaysians need an environment more conducive to healthy food choices. Policies and guidelines can promote healthy food environments, e.g., in settings such as school canteens, health facilities and workplaces. These should be strongly enforced and extended pragmatically to improve people’s health.
While we may not be short of good nutrition policies, the bigger challenges lie in the uptake, implementation and compliance. Hence, it is equally imperative to ensure these policies are supported and friendly to be implemented by the stakeholders. Regular evaluation is recommended to study the effectiveness of such policies and to identify the enablers and barriers to effective implementation. Establishing a common understanding with the beneficiaries and stakeholders through communication and education is also crucial to encourage participation and adherence.
Conclusion
We may not need to reinvent the wheel; The Malaysian Dietary Guidelines and Healthier Choice Logo are among the existing nutrition initiatives. These can be more effective in improving health when supported by an enabling environment. The National Plan of Action for Nutrition of Malaysia (NPANM) III 2016-2025 and the National Nutrition Policy of Malaysia 2.0 can help better integrate nutrition into national policies and plans.
Nutrition is not just a healthcare issue. Food is the basis of nutrition, meaning nutrition is also intertwined with agriculture and the food system. Integrating nutrition, health, food and agriculture in policies can kill two birds with one stone, creating a greater impact on people and the planet.
Moving forward, we must ensure nutrition is central to health policy discussions. Mainstreaming nutrition and scaling up nutrition efforts will help enhance universal health coverage, making health a reality for all Malaysians.
