Public health alarm on habitual late diners

(Note: The original article title is installed back in this post... Editor's version is 'Late Night Supper? Think again')

AT the end of 2017, the government announced that it was considering banning eateries operating after midnight, as one of the 13 measures to promote healthier living among Malaysians as well as fight the growing threat of non-communicable diseases (NCDs).

Following this, many groups, especially those that habitually practiced night-eating, expressed disapproval over the government’s proposal. Some called it a ‘big brother’ move by the state, and felt it infringed their rights and freedoms.

Others argued that it would cramp the Malaysian lifestyle of meeting up at such eateries to ‘hang out’ all night long. Interestingly, the Malaysian Indian Muslim Congress (Kimma) president Syed Ibrahim Kader reportedly said that mamak eateries and 24-hour restaurants can prevent acts of khalwat. Yet others voiced concern that the proposal would deny the convenience of affordable and accessible food to late night shift workers.

I might be sympathetic with the late night workers, but there are still ways to go around the issue. For example, exceptions could be made for eateries operating at highway rest stops exception (though there might not be many food operators here that are willing to open 24 hours) to cater for long distance drivers.

These are diners who seek food, not for socialising, but to fulfill their basic sustenance needs. In that way, rest stop’ restaurants are markedly different from eateries located in the communities that cater more for habitual late diners. Eventually, these late night workers might even get into the habit of preparing or packing the food for themselves.

However, none of these disgruntled parties would deny that overeating and consumption of excessive calories and carbs late in the evening or at night has negative health consequences. Night eating syndrome (NES) is a recognised eating disorder, characterised by the consumption of at least 25% of food intake after dinner or the incidence of at least has two episodes of nocturnal eating per week. Studies from Europe and the United States found strong associations between severe obesity and NES.

Another 2016 study performed on a sample of 1,738 Korean adolescents revealed that 21% were night eaters who had greater tendencies to skip breakfast, and derived a higher energy intake from snacks, with a greater proportion of energy from fat. Night eaters also had lower Dietary Diversity Scores than non-night eaters. Alarmingly, adolescents were 4.4 times more likely to be night eaters when both parents were night eaters.

I am less confident that Malaysian situation would be any better, especially when the current proportion of obese Malaysians (17.7%) is 3 times higher than South Korea’s (5.3%). Malaysians are generally spoilt for choice when it comes to after midnight eateries, whereas this is far less common in South Korea and many other countries.

Furthermore, most eateries that operate after midnight tend to serve food that is laden with high calories and fat, with limited healthy options. Eating such food at late night would certainly cause health issues in the long run.

In 2015, NCDs were responsible for 1.2 million admissions to hospitals and 38,500 deaths nationwide. In the last two decades, the prevalence of diabetes, as well as hypertension and hypercholesterolemia, has increased among the Malaysian population. On that point, I agree with Dr Marimuthu Nadason, President of Federation of Malaysian Consumer Associations (Fomca), who stated that “If the government do(es) not take action now, it will be a burden in the future as the younger generation will keep falling sick and this could affect the country’s productivity.”

As part of the strategy to tackle NCDs, it is right that the government should curb ‘after-midnight’ operating hours of eateries. Doing so may help discourage the culture of late night dining and reduce the risk to public health caused by such habits.

It is true that, such a ban does not completely prevent night-eating behaviour, as one could still stock and feast on unhealthy snacks at home, or visit convenience stores, food trucks or even “Ramly Burger” food stalls to purchase food in the dead of night. Unless the government imposes similar restrictions on the operating hours of food stalls and food trucks, rooting out midnight snacking habits effectively would require further efforts to educate and inform Malaysians about healthy eating habits. Official policies can only do so much in this regard. Concerted effort and cooperation are needed from local communities and within the home.  

SM Mohamed Idris, President of Consumer Association of Penang (CAP), put it rightly that many people “do not know the right time to eat”. More often than not, people who gather in the mamak restaurants past midnight are not really hungry for food. They come in groups and tend to stay for long hours chit-chatting and ordering round after round of food. The government’s proposal is thus meant to be a nudge towards reducing this culture, rather than a blanket prohibition on the individual act of night eating.

One policy alone would not solve the entire obesity and NCDs problem. Nevertheless, limiting the operating hours of eateries would send out the right message that such late night dietary habits should not be condoned.

For example, the government does not ban smoking entirely, but the policy of placing anti-smoking restrictions in more public areas would alert smokers to the fact that they should consider the harmful effects of smoking imposed not only to themselves but also to others. If we just leave it to the market to solve public health issues, interest-bound parties and lobbyists would certainly favour the status-quo (in this case, more food sales), and leave more individuals vulnerable to harm.

The purpose of public policy is to shape desirable collective social outcomes. There are times when a government sees fit and reasonable to intervene. This is the time.

I believe that the government is acting with the best health knowledge, and the right public intentions to safeguard public interest, in proposing regulations aimed at reducing harm caused to the society.

Published at The Malaysian Insight, Voices, Jan 28, 2018.

Responses to a journalist's questions on stunting kids in Malaysia

The editor asked me questions at the very end of last year, and I could not make it to respond to all 5 questions from him before he went on publishing the article this morning. The questions he put to me, are not easy though. I tried to do it with my best knowledge and accuracy as a health policy researcher.

***
Question 1. The NHMS 2016 says national prevalence of stunting for kids below 5 years old is some 20%. In 2015, it was 17.7%. Why the increase? Supposedly we are slamming on the macroeconomic indicators and we've tackled poverty to 0.4% of the population?

Response:
Let’s start with the dry part (introduction) first: The NHMS 2016 methodology has stated how they define stunting according to the WHO Growth Standard 2006: Height-for-age (HAZ) smaller than 2SD (standard deviation). The reference/definition for ‘stunting’ is therefore statistical, not based on medical evidence. This is very crucial for your understanding.

If the sample given fell perfectly in the normal distribution pattern (in this case, it is not), there will always be at least 5% will be smaller than 2 SD just by statistics. For any measurement against standard deviation, the mean/average point is the significant. For example, in a poor country such as North Korea or some African countries, it could be the mean point individuals are also stunted, therefore by applying WHO Growth Standard 2006 might be misleading.

In 2016, the NHMS findings indicated the stunting children (younger than 5 years old) is 20.7%, while it was 17.7% in the preceding year, thus a 3% increase within a year. Notwithstanding the difference could be just fall within 5% standard error of survey (note that this is typically stated when media/pollsters performing polling during general election/ campaign).

Let’s just discuss theoretically by putting aside all the points raised above.

20.7% of stunting children at nationwide in 2016, it is still much higher than normal. Besides, percentage of children who are underweight and wasting are 13.7% and 11.5% respectively. This indicates rather significantly that some children suffer from malnutrition, despite Malaysia is right now at the upper-middle income nation category (and sooner graduating to high income nation).

Children are stunting and wasting for many reasons. Financial difficulty to obtain/purchase nutritious/healthy food could be one factor. In fact, in the NHMS 2016 Table 5.2.2.3, it shows that children living in the family with monthly household income less than RM1000 suffer the most from stunting (29.8%), as compared to wealthier family (more than RM5000, 17.4%). Other low household income brackets (less than RM3000) also have more than 20% stunting kids.

However, household income has been steadily increased and since the introduction of minimum wage, the financial situation for many families should be improving. In 2016, household with monthly income less than RM2000 is 8.8% while less than RM960 (poverty line in Peninsular Malaysia) is only 0.4%. So, even if you take out the proportion of children living in these financially poor households (assuming that they would be all stunting or wasting—actually not, just about 20-30%), there are still many more children outside these households to make up the difference. Thus, we can safely assume that there must be more than just economic reasons.

Since these kids are so young (smaller than 5 years old) to decide food for themselves (and before school age), therefore it must be almost totally the responsibility of parents to make sure their kids are on good health. It has something to do with the parents’ knowledge of nutrition and well-being, family lifestyle as well as parent's culinary skills.

I disagree that nutritious food are expensive. Plenty of affordable vegetables, beans, eggs and meat are in the Pasar (Marketplace) and grocery shops throughout the country, especially affordable for those families with household monthly income greater than RM2000. But that would take one’s effort to cook the food they bought.

Increasingly more people in our society, especially the younger generations, do not practice cooking at home, thus they are totally dependent on the food provision outside. In this case, if they do not equip with knowledge to purchase outside food with balanced diet and nutrition values, then the health of their children (and themselves!) would be affected. Eat junk and fast food very often in lieu of healthy nutritious food, can result in stunting kids (and they are not necessary underweight though). Parents' attention to children’s development and health growth is paramount to ensure stunting and wasting do not happen to their children.

In the NHMS 2016 report, if you flip to page 173 on Table 5.3.2.9 (Prevalence of minimum meal frequency, minimum dietary diversity, minimum acceptable diversity among children aged 6-23 months by socio-demographic characteristics) you would find out partially why there is a case for stunting or wasting kids in Malaysia. Only 80.8% of children population fulfilled the minimum meal frequency, 66.4% have obtained minimum dietary diversity (at least 4 food groups per day), 53.1% received minimum acceptable food diversity (combine minimum meal frequency and dietary diversity). If you look at the survey statistics by household income at the bottom, you would be surprised to actually found survey respondents with lower household income (RM5000), consistently. Some degree of parental negligence must be happening in the wealthier families too, at least to the children below 2 years old (as evidenced in this survey).

***

Question 2. The bumiputera are the majority. Of course the NHMS divides this into Other Bumis and Malays. Yet even on its own, these groups make the top 3. What's going on here? Aren't they the target of affirmative action policies? Also what about the Bumi Empowerment Agenda? Or even BR1M? A case of the Orang Asli being left out?

Response:
Economic status of bumiputera households might still be a factor which makes some differences.

If we refer to the Household Income and Basic Amenities 2016 survey, generally Bumiputera households have bigger average household size (4.3) compared to Chinese (3.5) and Indian (4.0). In terms of families with household monthly income less than RM2000, 10% of Bumiputera households (and 16% of ‘others’) fall into this category, while only 5.9% Chinese and 6.6% Indians. That means, poor Bumiputera households in general has more mouths to feed. In addition, the fact is that young families (which is usually sexually reproducing kids) tend to make less monthly income than households with older age breadwinner, the financial situation of these family might be more stressful.

However, as mentioned earlier, it might not entirely has something to do with financial resources, as affirmative action policies and Bumi Empowerment Agenda and even BR1M have not taught the parents how to deal with children nutrition, and I have previously argued the case that nutritious food might not be expensive.

Orang Asal should fall under the category of ‘other Bumiputera’.

***

Question 3. Interestingly in NHMS, Putrajaya ranks no.4 in terms of location. Any explanation why?

Response:
From the NHMS 2016 Table 5.3.2.9 on the children minimum meal frequency and dietary diversity, children in Putrajaya actually did not do too badly, thus it is puzzling why Putrajaya performed badly in terms of stunting children. Granted the target group of the survey (for that table) is kids only up till 2 years old, probably those 2-5 years old children in Putrajaya did poorly on dietary intake and lifestyle due to urban planning of Putrajaya might not be encouraging healthy children development. Could civil servants be lacking time to cook? Or is there lack of healthy food outlets in Putrajaya?

(the less ‘sexy’ answer could be… Putrajaya’s respondent sample size is small, thus big error margin is reported)

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Question 4. How does this increase inequality and in the long-term affect economic performance?

Response:
Stunting kids could have some irreversible health impact to their physical well-being in their later adult life. This could have considerable impact to their education learning ability and work productivity. For the government, this will be a laden cost to public healthcare, as these individuals would be more likely to have health complications and seeking medical attentions. Thus, in the long run, these would negatively affect our national economic performance. In addition, when these stunted kids grow up, they might already be disadvantageous to compete with similar age peers. In this way, inequality might persist (if the stunted kids come from poor family).

***

Question 5. What current policies need to be reviewed and what needs to be implemented quickly? And should we fail to deal with this properly, what are the long-term effects?

Response:
Primary care have to be strengthened, better via community-level family doctor system. Should certain high risk kids are monitored, then the danger of stunting or wasting could be averted via proper health screening and dietary advice through the community nurses or/and doctor.

Education or awareness on nutritious/healthy food need to be raised and put in practice. Probably younger generations should learn COMPULSORY cooking skills as part of their Kemahiran Hidup syllabus.

Nutrition/dietary knowledge and advice should be given to pregnant mothers too during ante-natal care medical check up. Better, if these first-time mothers could be arranged an ante-natal class to learn all the necessary information to prevent stunting or wasting child development problem.

As partially mentioned above in (4), if Ministry of Health and the larger society fail to deal with this issue, MOH has to fork out bigger budget (that they DON’T readily have) to treat more patients in years to come, and the affected families or individuals would have to commit more time in seeking medical care. It is a LOSE-LOSE situation for everyone.

Review of 2017 - Part III (Myself)

Last March I sprained my ankle badly during a badminton training session. It was a terrible sport accident. Unfortunately until today I have not gained back my full fitness for intense sport (like Badminton). It is partly due to not undergoing physiotherapy to regain fitness (after the initial 2 months of TCM treatments). In fact, this issue bothers me, I might still seek to solve it this year, because I cannot imagine I am out of badminton forever.

I managed to control my weight for the first time since my years in Germany– not only I did not gain weight but lose 2-3kg compared to the previous year. I cooked rather often, and spent time doing house chores (as usual) as part of responsibility. I regret that I did not cycle as often as I imagined to be, most of the times due to my busy work schedule. So, to ‘earn’ back the value of my bike, it is going to be this year! I had good time with my hiking kaki, hope to keep up with at least a hike once a month. Oh ya, last year I did not even go into a cinema once (performing arts theatre is excluded)!

To my own dismay, I did not read as much as I would like to have (mostly restricted to the reading time when I was in the LRT train), therefore my books keep accumulating. I also have horror at the number of unselected and unprocessed photos I took using my DSLR during many trips last year, wish I could have some personal time to do this. But sadly, I always lack time.

‘Priority’ is like a spell always sticks to me, compelling me to make certain decisions on how to distribute my time. I am already a different man with more responsibilities and commitments, gone are those days when I could simply go out anytime at night or weekends to meet friends or get involved in (social activist) activities and meetings. I cannot complain.

Therefore, I hope that my friends already rather understand. There are times when I need to take longer time to respond to WA or FB message or email, please bear with me. At home, I do have different priorities.

At this age, I treasure those ‘old-time’ friendships even more. I would try to meet and catch up with them as often as possible. I do wish all my friends lots of happiness this year, and may they have best of luck in the goals they want to achieve.

Mine is simple, just improvement in all the aforementioned points, hehe.

P/s: oh yes, these days I've got some interest in Korean language, might just casually learn it ;-)

Review of 2017 - Part II (Family)

On family, looking back at 2017, I owe heartfelt gratitude to my dear wife Xiao Hui. Due to her decision to move in with me to Penang (from Singapore) in 2016, and moved again to Subang Jaya by the end of 2016, we were in a more stable situation in 2017. Tirelessly, Xiao Hui took good care of Yee Chern at home when I went to work, watching our boy growing up fast. We are in good agreement on how to raise a child, and we have been very patient and loving with Yee Chern.

Yee Chern is now 19 months old. His intelligence and learning ability simply keep amazing us as parents. He seems to understand quite a great deal of words and phrases, learned to execute our instructions perfectly and even picked up our conversation sometimes (therefore xh and I have to be careful when talking about him). We are more delighted that he picked up reading habit from the resources and environment we built for him. We regularly bought him good books and read together with him. We bought and install a kid’s bookshelf in the living room, put all his books there so that he could access to those anytime he wants. Now he can pick any book, flip and read by himself. At the recent Big Bad Wolf book sale, we managed to visit the venue 2 times scanning through the children book sections carefully, filtered and acquired 40 very interesting and inspiring books for him (spent about RM400, super worth it).

Yee Chern was definitely not early in some of the milestones of child development. He could only walk independently when he just crossed into his 18 months old. Both of us were thrilled when he finally discovered his own ability (Xiao Hui screamed out loud in the video recording at that moment, just to show me who was at work). Actually he could have walked by himself a month or two earlier but he took more conservative and careful approach not letting go his grip on our hand (or even finger/s). Therefore when he first walked, he did with good balance and barely fell down. Now he is still considered slow in speech (according to MOH guideline), and is arranged a session with a MOH specialist. Actually he is found rather often talking to himself in baby babble. We can somehow imagine that once he could talk, he could be rather talkative.

Last year 2017, as a family, we had been travelling to many places, including Jogjakarta (Indonesia), east-coast United States, and Seoul (South Korea). Xiao Hui and Yee Chern had also followed me to Penang and Johor a few times for work trips. Yee Chern had to endure/adapt to changes in eating-sleeping schedule, sometimes it was difficult for him (and his mum). His behaviour and preference changes on dietary type and timing, and his bed/nap timing, are sometimes hard to predict. There were meltdowns at times, luckily most of the times those happened at home. He usually behaves rather well in the presence of guests, friends or family (thus they often only see the cute and mild side of him). To my pleasure of unique achievement, last year finally I could put him to sleep alone without mum’s presence for 3 times (although it would still be 10,000x his preference to have mum instead).

After Yee Chern turned 1 year old, Xiao Hui has been on the hunt for a job. We are mulling to send him to a daycare centre should one day Xiao Hui secures a job. Until the end of 2017, XH had no such luck. We hope that 2018 could be the year of breakthrough for Xiao Hui and our family. (If you wanted to ask about the second addition to the family, we couldn’t tell you about any plan yet).

In 2017, it is heart-warming to see Yee Chern becomes more charming to both sides of our family members as well as our friends with higher level of self-awareness, responses and interactions. Particularly he has improved relationship with his cousins Jayden, Jazzra, Brayden and Leann; they happily accepted him and played more with him.

We are delighted to see the return of Soo Leng from the US, and look forward to see bro How and her in our neighbourhood soon this year 

Review of 2017 - Part I

First week of the new year 2018 comes to an end soon, and only until now I find good time to summarise my year 2017.

2017 was quite a productive but very busy-action-packed year for myself. Looking back now, I feel contented and delighted at what I had achieved. Moving back from Penang to the Klang Valley might be the turning point of career development as a health policy researcher, turns out to be one of crucial life decisions that I’ve got it right. (However, given that the top management of my institute had changed rather significantly months later, who knows it could also go well for me if I had stayed? But it doesn’t matter now… I am happy for my research colleagues in Penang too)

In terms of work output, since I am part of the KL office team, I can’t believe myself that I had :
- attended 32 events (including workshops, conferences, forums and talks);
- contributed 7 The Malaysia Insight (TMI) articles, 5 Oriental Daily articles, 1 Contemporary Review article;
- published 1 research report on the Housemanship issue in Malaysia;
- co-author & research on the Market review of the Malaysia’s pharmaceutical sector;
- helped organise (with major intellectual inputs) the inaugural Penang Medical Expo and Conference 2017;
- made appearance on 3 presentations in public (one in Penang, one in Seoul, South Korea, and another one recorded live in the press conference for the launch of my Housemanship issue report), and quite a number of presentations in close-door workshops and meetings.

2018 would be equally if not more challenging for myself. I still have 3 outstanding major research projects to complete/clear (all almost there) and a few new ones about to start. It was obvious to me that the decision at that time to relocate back to KL would help me concentrating on policy research on health(care), and it did work out very well. I do have my general manager YB Dr Ong Kian Ming to thank, for the trust and confidence he has in my works. I am glad that he sees values in health policy research, at the same time gives me freedom to explore the topics beyond health.

I would like to thank my dear beloved colleagues in KL and Penang. Esther, she is the dai ga jie in the KL office, deserves her credits for her incredibly organised administrative work. I am happy that she built up her researcher profile too, and has improved tremendously in her skills and knowledge (and most importantly, her confidence and motivation). Su Lin is our office unofficial MO1 (Media Officer 1), for her excellent English proficiency and brilliant copyediting works (service only available for us, ok?!). Her recently upgraded car (we dubbed it as the “PI-van”) is always very useful and meaningful to us. We often love to make her our leader so that we could ‘follow’ her car (to lunch place, function, or to LRT station).

I also enjoyed working briefly with Dr Lyana Khairuddin as she worked as our visiting fellow, surely we had good time together (besides some intensive discussion and arguments). Of course, I didn't forget my wonderful colleagues + friends in Penang, too many names I cannot spell out one-by-one (scare whoever got left out perasan), thank you for keeping the friendship (and comradeship) as well as keeping in touch mostly via Whatsapp , emails and sometimes in person. I feel hard to see Evelyn and Kok Hin leaving to further their study at overseas, I do wish them well and happy for them (the former will return soon). Ya, over the ‘summer’ period we have a bunch of very good and bright interns who are studying in the UK and Canada, I enjoyed their company too.

馬哈迪不宜成為希盟的首相候選人

針對我個人聯署的<联合声明：马来西亚拒绝贪腐与独裁领袖>文告聲明裡的一些內容，我有共鳴。

我至今仍不讚成馬哈迪為希聯的首相候選人，對此我感到失望，雖然不至於我不投選心儀的候選人和比較認同的政黨。基本上，我仍同意馬哈迪和土團黨應加入希聯來擴大票源（而不是統領希聯的去向），只要階段性的制度改革議程沒被妥協太多。

我至今仍費解的是，為何馬哈迪非得要是首相候選人才能幫希聯吸票呢？如果馬哈迪的肖像真的那麼受歡迎（尤其是在半城鄉和鄉區），沒人規定要馬哈迪是首相人選才可以放上去海報宣傳的啊？如果一個首相候選人的新臉孔是馬哈迪支持的，難道不能取信選民嗎？我認為馬哈迪為首相候選人為希聯的競選運動和宣傳帶來不必要的麻煩，會減低道德公信力和減低對國陣的批判力度，畢竟馬哈迪有太多歷史包袱（雖然一些可被視為‘政績資產’）。

是的，選民可以表達對馬哈迪為首相候選人的不滿，甚至批評他和希聯。但選民不應因馬哈迪因素而‘教訓’或放棄投選有表現有素質的在野黨議員。先不談執政，至少要保存三分之一的在野黨議席。關於這個首相候選人的決定，選民不會也不能忘記。

我本身不支持廢票或不投票運動（尤其是不加區別地‘懲罰’希聯里的每一個候選人，這個很詬病），但我也明白在一些情況下有人不要出來投票或投廢票（這個反對不來…所以算是做到‘懲罰’某些口碑不好的政治人物）