Which of the following is a true statement about the nutrition transition?

Background

The epidemiological transition, in particular the rapid shift in morbidity and mortality patterns towards much higher rates of non-communicable disease [NCD], has dominated the health profile of populations in higher income countries for the last half-century or more. Concurrent shifts in diet, activity levels and body composition also appear to be accelerating in many regions of the world []. Malaysia typifies a rapidly developing country that has undergone major demographic and socioeconomic changes since attaining independence in 1957. Transformation of the Malaysian economy from primary and secondary sector to tertiary sector has brought about rapid industrialisation and change of job patterns. Globalisation causes changes in the existing structure that bring the domestic economy closer to the international economy, mainly by improving absorption of labour, incomes and overall prosperity []. One of the expected impacts on dietary patterns relates to the globalisation of the food industry. As a result of direct foreign investment in food processing and retailing, and via global food advertising and local promotion, consumption patterns shift away from traditional local staples towards highly processed, often imported, food [].

In recent decades, a rapid process of change in dietary trends coupled with a worsening obesity crisis has been observed in many developing countries []. Popkin [] refers to these changes as “nutrition transitions”. In general, the transitions refer to the change from a traditional to a more ‘westernised’ or global diet and lifestyle, and from a largely agrarian based economy to an industrialised one. The changes are sequential and are distinguished by three distinctive phases – famine reduction, degenerative disease and behavioural change. This nutrition transition is preceded by changes in demographics, from populations with high rates of fertility and low life expectancy to lower fertility rates and longer life expectancy; and epidemiological transitions, from high rates of infectious disease, poor sanitation, periodic famine and malnutrition to a state where chronic disease and over-consumption prevail [].

The nutrition transition is not new to Malaysia. Noor [] reports on changes in eating habits and associated health outcomes since before the turn of the twenty-first century. Policymakers first recognised that the population was becoming overweight in the 1990s. To address this issue, strategies were outlined in the National Plan of Action for Nutrition in Malaysia [NPANM I] [1996 to 2000]. The subsequent NPANM II [2006–2015] and NPANM III [2016–2025] recognised the needs to prevent and control diet-related NCD. As Malaysia being dubbed the fattest in Asia for the first time in 2014 [] and continue to hold the record ever since, the strategies compel for a deeper look. To enable the development and implementation of effective policies for improved health outcomes, it is essential to understand the key drivers behind the nutrition transition in the country, and to assess which stage of the transition the nation is currently in. To achieve this, it is crucial to examine the nutrition transition in tandem with relevant policies that impact on food supply, diet and behaviour.

This paper focuses on the nutrition transition that has taken place in Malaysia over the last 30–40 years and highlights some important distinguishing features that have shaped the trend. We have chosen to adopt a quasi-historical approach to show how changes in food supply and dietary trends interact with the progression of NCD in roughly chronological order, using nationally representative data from multiple sources. To understand the demographic and epidemiological transitions, data are taken from the Department of Statistics, Malaysia [DoSM]. Changes in food availability and dietary trends, are evaluated from the analysis of food balance sheets. Health data has been taken from the Malaysian Adult Nutrition Surveys [MANS] and the National Health and Morbidity Survey [NHMS]. These interactions are used to gauge the effectiveness of the various national plans of action for nutrition in Malaysia [NPANM] in addressing the prevalence of non-communicable diseases [NCD].

To the best of the authors’ knowledge, this paper is the first one in Malaysia to appraise the change over time in Malaysian food and nutrition situation with policy implications.

Methods

To evaluate the multidimensional phenomenon of the nutrition transition in Malaysia, literature searches were conducted from May to June 2017 and data were synthesised from multiple sources as detailed below.

Demographic and socio-economic data

National demographics and socio-economic data were obtained from official spreadsheets and reports uploaded by the Department of Statistics, Malaysia [DoSM] on its open data portal []. These data included: [i] population growth rate, [ii] fertility rate, [iii] death rate and causes of death, [iv] under five mortality rate, [v] infant mortality rate, [vi] average life expectancy, [vii] old age dependency ratio, [viii] GDP index, [ix] household income, [x] broadband penetration rate, and [xi] vehicle ownership rate.

Food and health data

To evaluate the Malaysian nutrition transition, data were gathered from three nationally representative sources, namely the Food Balance Sheets [FBS], Malaysian Adult Nutrition Survey [MANS] and National Health and Morbidity Survey [NHMS].

Food balance sheets [FBS] – 1980 to 2013

Food balance sheets [FBS] downloaded from FAOSTAT were used to assess food availability [in terms of kCal/capita/day] over the 34-year period from 1980 to 2013 []. To evaluate the trend in food supply over the past three decades, the years were clustered into subgroups with a range of 5 years for each group [i.e. 1980–1984, 1985–1989, 1990–1994, 1995–1999, 2000–2004, 2005–2009 and 2010–2013]. The total energy available [kCal/capita/day] for the Malaysian population was estimated as the sum of energy supplied by animal and vegetable sources. The FAO definition of vegetable products includes the following: cereals, starchy roots, sugar crops, pulses, tree nuts, vegetable oil, vegetables, stimulants, spices, sugar and sweeteners, oil crops, fruits, alcoholic and miscellaneous; meanwhile, animal products consist of the following: meat, animal fats, eggs, milk [excluding butter], fish and seafood, aquatic product and offal [].

Prior to 2003, when Malaysia carried out the first Malaysian Adult Nutrition Survey [MANS], FBS analysis was the most widely used approach to estimating food availability. Its biggest advantage is that the data is readily accessible and available online. FBS may be beneficial in showing the basic trends of food supply, but is not useful to assess the actual dietary intake of a population. FBS overestimated food consumption and nutrient intake compared to individual dietary surveys because FBS items were calculated excluding reuse and stock variation [national account budgets]; they represented the total food items available per capita, but obviously not what was necessarily consumed. Despite the inherent inaccuracies of this method, food supply pattern is an important indicator of food consumption. An overabundance of food supply alone has been identified as a key cause of the obesity epidemic [].

Malaysian Adult Nutrition Survey [MANS] - 2003 and 2014

In Malaysia, nationwide dietary intake data was collected for the first time in MANS 2003 and then subsequently in 2014. MANS was a nationwide cross-sectional study conducted on more than 7000 subjects. Multistage stratified sampling design was used to select a representative sample of the Malaysian adult population, aged 18 to 59 years old. Data on food consumption were derived from a Food Frequency Questionnaire [FFQ] that contains commonly consumed foods and beverages, and a 2 day 24-h diet recall. Primary data analysis reports for MANS 2003 and 2014 published by the Institute of Public Health were obtained from its official website [,,,,, ,,]. Information about food consumption pattern was extracted for comparison with the FBS data. Information about the prevalence of each weight status categories were then extracted and tabulated for period-to-period comparison.

Reliable nationally representative individual dietary surveys are crucial to better understand the relationship between food consumption patterns and the emergence of diet-related diseases. However, comparison of nutrient intakes is not possible because both the MANS showed that adult energy intakes were so low that they failed to meet at least 80% of the Malaysian RNI. With lower reported energy intake, the intake of many micro-nutrients was expected to decrease. It was pointed out in the report that there was a high percentage of under reporting during dietary recall, limitation in food composition database and human error during data management and analysis. After careful consideration of the high prevalence of underreporting, we have decided to report the trends of change in food consumption pattern between the two MANS surveys rather than the absolute value of change.

National Health and Morbidity Survey [NHMS] I [1986] to V [2015]

The National Health and Morbidity Survey [NHMS] is a nationally representative survey of the Malaysian population, from new-borns to the elderly. It was initiated in 1986 as a platform for monitoring the health of the Malaysian population. The interval of NHMS has been reduced from every 10 years to a 4 yearly cycle, with annual data collection since 2011. Since 2011, the main focus of the NHMS has been health care demands, non-communicable diseases and risk factors for NCD. Primary data analysis reports for NHMS III [2006], NHMS IV [2011] and NHMS V [2015] were downloaded from the Institute of Public Health [, , ]. The primary data analysis reports for NHMS I [1986] and II [1996] were not publicly available; hence, references were made to a PowerPoint presentation by Mr. A.J. Ahmad, Director of the Division of Health Promotion of the Ministry of Health [MoH] Malaysia, at a health promotion conference in 2011 []. Information about the prevalence of each weight status categories and NCD were then extracted and tabulated for period-to-period comparison.

Empirical findings

Transitioning demographic [DoSM]

The official statistics for the 34 year period indicate a downward trend in population growth rate coupled with an increase in life expectancy. During the 1991–2000 period, the rate of population growth was on average 3% per annum, decreasing to 1.8% during 2000–2010. Demographic forecasts expect this trend to continue with an estimated decrease in growth rate to 0.8% by 2040, an average decrease of population growth rate by 0.05% per year. This decline in population growth rate is a reflection of reduced fertility rate [from 6.19 births per woman in 1960 to 2.0 in 2015]. Concurrently, Malaysia experienced a decline in annual death rate [from 8.17 per 1000 people in 1966 to 4.98 per 1000 people in 2015] and an increase in life expectancy. In 2016, average life expectancy was 77.2 years and 72.6 years for women and men respectively compared to 65.5 and 61.6 respectively for both genders in 1970. As a consequence, the Malaysia population is ageing. An increase in the old age dependency ratio, almost a three-fold increase from 7.4 [2010] to 21.7 [2040], is expected.

Malaysia is undergoing an epidemiological transition with causes of mortality shifting from communicable to NCD. Comparison of national statistics has shown that most deaths in Malaysia are now from NCD, with diseases of the circulatory system the most common cause of death. Nonetheless, the comprehensiveness of mortality data may be compromised since not all coders use International Classification of Diseases [ICD] codes [].

Rapid economic growth and transition [DoSM]

Remarkable changes have occurred in the Malaysian economy and the structure of its workforce over the past 30–40 years. GDP per capita increased dramatically since the 1970s, achieving an average GDP growth rate of 6.8% per annum during the 1970–2015 periods [Fig. ]. With this rapid improvement in income, an increase in living standards is expected. A dramatic shift in urbanisation and modernisation of the population also occurred during this period. In 1960, approximately 27% of the Malaysian population was urban and 73% rural, a situation which totally reversed by 2015 [75% urban]. Malaysia is transitioning from a largely agrarian economy to a service-oriented economy with tertiary sector accounting for 53.5% of GDP in 2014. While the economy has shifted from its initial dependence on an energy intensive workforce, during the 1987–2014 period, the rural primary-product sectors of agriculture, forestry and fisheries still accounted for 20% and manufacturing 23% of GDP in 2014.

Fig. 1

Malaysia GDP from 1960 to 2016 [Data adapted from DoSM []]

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In tandem with GDP growth, the Malaysian population experienced a rapid growth in household income. The annual growth of mean household income was about 11% in the 1990s and 9% annually since the 2000s up to 2014. During this period, the population became increasingly modernised and digitalised. Broadband penetration rate rose from 1.0% in 2004 to 72.2% in 2015. Vehicle ownership across all types also increased, with the percentage of Malaysian households owning cars as high as 83.9% in 2014. Increasing urbanisation has seen growing preference among Malaysians to spend their leisure time in shopping malls for food, social activities and entertainment. This habit has fuelled the mushrooming of shopping malls from just about 100 malls in the late 1980s to some 360 malls in 2015 [], and close to 700 malls by the end of 2019 [].

Changes in trends of energy and nutrient supply [FBS review]

Energy supply

Over the 34 year period in review [1980–2013], the total energy supply [kCal/capita/day] for the Malaysian population was consistently in excess of average daily requirements. Based on the average daily requirements of 1500kCal and 2000kCal for women and men respectively [], there was an excess of 75–93% available for women and 30–45% for men. The total energy per capita supply was stable over time with just a slight increase of about 5% over the last three decades [Table ]. However, there were rather significant signs of shifting trends in different food groups, in particular in the proportions of calories supplied by wheat, rice, sugar and sweeteners, poultry, fish and seafood, milk and eggs. While period-to-period variability [possibly due to external factors e.g. geopolitics and economic issue or seasonality] is observed, the long term trend is upward for energy supplied by wheat, sugar and sweeteners, poultry, fish and seafood and eggs and downward for rice and milk. The amount of energy per capita supplied by rice fell by 23.7% while that from wheat rose by 56.5% [Table ]. Available calories from sugar and sweetener increased by 23.9% over the past three decades [Table ], from 21 to 26.1 tsp. per capita per day. Calories from animal products too increased [poultry by 230.7%; fish and seafood by 38.7%; egg by 55.7%]. The only exception was milk, which decreased by 30% [Table ].

Table 1 Daily per capita dietary energy supply [kCal] by products over the 34-year period [Source: Adapted from []]

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Fruits and vegetable supply

Across the years in review, there is an observed decline in the reported supply of fruit and a twofold increase in vegetable supply [Table ]. When combined as the total fruit and vegetable supply, the per capita serving size increased from 2.7 to 3.9 servings per day, assuming 80 g of fruit and vegetables per serving. It is worth noting that the FBS does not capture fruit and vegetables that are home produced, hence, it is possible that there is an underrepresentation of total fruit and vegetable supply, especially when the country was less urbanised in the 1980’s. As the country becomes more urbanised, it is no longer viable for urban dwellers to plant fruit trees and vegetables for subsistence use. As such, the observed decline in fruit supply could be steeper, and the increment of vegetables less pronounced than that observed in the FBS review.

Protein supply

Overall, per capita protein supply increased by 33.8% [Table ] during the 1980–2013 period. Initially, vegetable-sourced protein outweighed animal protein [32.2 v’s 27.8 kg/capita/day]. But by 1990 the per capita supply of animal-based protein had overtaken vegetable protein. The supply of animal-based protein continued to increase at a faster rate than vegetable-sourced protein. Over the review period, the total protein available from animal products increased by 59.1% [Fig. ] while vegetable protein increased by 11.9% [Table ]. Rice has been the predominant staple food of Malaysians and was the leading source of protein in the diet until the mid-1990s [Fig. ]. Fish succeeded rice and emerged as the top protein source since then. The trends in availability indicate that poultry supply is increasing at a rapid rate and is projected to overtake rice very soon [Fig. ]. Besides rice, the supply of wheat, an alternative source of vegetable protein, has been gradually increasing over the past three decades [Fig. ]. While fish remain the biggest contributor of animal protein supply, the importance of poultry has increased over the years [Fig. ]. Poultry emerged as the second largest animal protein contributor in 2010–2013, with a two-fold increase from 13.4% in 1980–1984 to 29.0% in 2010–2013. At the same time, the availability of protein from dairy sources declined from 18.8 to 9.9%. Red meat, as a less popular source of animal protein, has seen fairly small marginal increases [Fig. ]. At the bottom of the list are beans, pulses and leguminous vegetables, whose protein contributions are insignificant during the period under review [Fig. ].

Table 2 Daily per capita supply of protein and fat from animal and vegetal sources over the 34-year period [Source: Adapted from []]

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Fig. 2

Daily supply of protein [g/capita/day] from animal and vegetal sources over the 34-year period [Source: Adapted from []]

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Fat supply

The total fat supply has been stable over time, with only a minor increase in per capita availability [from 84.9 to 88.8 g per capita per day]. Of the total fat available, in the 1980’s, around 70% was of vegetable origin [58.5 g/capita/day] and the remainder [26.3 g/capita/day] from animal sourced foods. By 2014, the balance had shifted slightly towards a higher percentage of animal sourced fat [37%], but with the majority [63%] being sourced from vegetable products [Table ].

Food habit pattern [MANS 2003 and 2014]

Both surveys show that the most widely consumed foods [by frequency of daily consumption] are white rice and table sugar. Between MANS 2003 and 2014, there is a decreasing trend in prevalence of consumption of rice and table sugar, which is offset by an increase in bread, wheat- and rice- based noodles, and sweetened “condensed milk”. The reduction in prevalence and frequency of daily consumption of rice was more prominent in the urban than rural populations. There is an increase in the frequency and prevalence of consumption of chicken and eggs in 2014 compared to 2003 and especially so in the urban population. While fish remains the most widely consumed animal protein, its frequency of daily consumption has decreased. Both surveys found that vegetables are more frequently and widely consumed than fruits although the frequency of daily consumption for both vegetables [