Monday, January 08, 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?
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, 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 (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?

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?

From the NHMS 2016 Table 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)
Question 4. How does this increase inequality and in the long-term affect economic performance?
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?

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.

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