MDG For Children and Adolescents 2023

MOH/K/BPM/20.
23(HB)
Ministry of Health Malaysia
GUIDELINES FOR
!"#$%&'()*)
+%,$'-!'(.-
National Coordinating Committee on Food and Nutrition (NCCFN)

2023
MALAYSIAN
DIETARY GUIDELINES FOR
CHILDREN AND ADOLESCENTS
2023

2023
Malaysian Dietary Guidelines for Children and Adolescents 2023
ISBN : 978-967-26507-8-2
First Published in 2013

Second Published in 2023
Copyright © 2023 National Coordinating Committee on Food

and Nutrition
Ministry of Health Malaysia, 2023
All rights reserved. No part of this publication may be

produced, stored in a retrieval system, or transmitted in any
form or by any means electronic, mechanical, photocopying,
recording and/or otherwise, without prior written permission
from the publisher. Applications for such permission should be
addressed to the Chairperson, National Coordinating
Committee on food and Nutrition (NCCFN).
Published by,
Technical Working Group on Nutrition Guidelines
for National Coordinating Committee on Food and Nutrition
c/o
Nutrition Division
Level 1, Block E3, Parcel E
Federal Government Administration Centre
62590 Putrajaya, Malaysia
ii
MALAYSIAN
DIETARY GUIDELINES FOR
CHILDREN AND ADOLESCENTS
2023

2023
Liﬆ of Contents
Message by Minister of Health Malaysia viii
Foreword by Director-General of Health Malaysia ix
Preface by Deputy Director-General of Health (Public Health) Malaysia x
Preface by Chairman of Technical Working Group on Nutritional Guidelines xi
Acknowledgement xii
Technical Working Group on Nutritional Guidelines xiii
List of Authors xiv
Editorial Board xxii
Coordination and Documentation xxiii
List of Tables, Figures, Appendices xxiv
Executive Summary xxx
iv
Key Message 1 : Practise exclusive breastfeeding from birth until six months and 1
continue to breastfeed until two years
Key Message 2 : Give appropriate complementary foods to children between the 23

age of 6 months to 2 years
Key Message 3 : Eat a variety of foods within your recommended intake 49
Key Message 4 : Attain healthy weight for optimum growth 83
Key Message 5 : Be physically active everyday 125
Key Message 6 : Eat adequate vegetables and fruits everyday 161
Key Message 7 : Eat an adequate amount of rice, other cereals, whole grain 193
cereal-based products and tubers
Key Message 8 : Consume recommended amount of protein rich foods such as 215
fish, eggs, lean meat and poultry, nuts and legumes
Key Message 9 : Consume milk and milk products daily 233
Key Message 10 : Choose different types of fats and oils in appropriate amount 255
Key Message 11 : Limit intake of salt and sauces in daily meals 279
Key Message 12 : Consume foods and beverages low in sugar 301
Key Message 13 : Drink plenty of water daily 329
Key Message 14 : Consume safe foods and beverages 345
Key Message 15 : Educate children and adolescents on the use of nutrition 367
information on food labels
Food Group Discussion (FGD) on Malaysian Dietary Guidelines for Children and 395
Adolescents (2023) on 16 - 17 March 2022
Consensus Meeting on Malaysian Malaysian Dietary Guidelines for Children and 401
Adolescents (2023) on 13 - 15 July 2022
v
List of Key Messages

Key Message 1 : Practise exclusive breastfeeding from birth until six months and continue to
breastfeed until two years
Key Message 2 : Give appropriate complementary foods to children between the age of 6
months to 2 years
Key Message 3 : Eat a variety of foods within your recommended intake
Key Message 4 : Attain healthy weight for optimum growth
Key Message 5 : Be physically active everyday
Key Message 6 : Eat adequate vegetables and fruits everyday
Key Message 7 : Eat an adequate amount of rice, other cereals, whole grain cereal-based
products and tubers.
Key Message 8 : Consume recommended amount of protein rich foods such as fish, eggs,
lean meat and poultry, nuts and legumes
Key Message 9 : Consume milk and milk products daily
Key Message 10 : Choose different types of fats and oils in appropriate amounts
Key Message 11 : Limit intake of salt and sauces in daily meals
Key Message 12 : Consume foods and beverages low in sugar
Key Message 13 : Drink plenty of water daily
Key Message 14 : Consume safe foods and beverages
Key Message 15 : Educate children and adolescents on the use of nutrition information on food
labels
vi
Messages
Message by
Minister
T
he double burden of malnutrition (DBM) among
children and adolescents is on the rise in
Malaysia. Early food intake and preferences
influence later food choices. Poor dietary practices
have increased the risk of morbidity and mortality in
later life. Therefore, it is pivotal to inculcate healthy
eating practices from the young age to reduce the
prevalence of DBM and non-communicable diseases
(NCDs) in the population. The second edition of
Malaysian Dietary Guidelines for Children and
Adolescents (MDG C&A) is reviewed to further update
and strengthen information on child and feeding care
practices to assist health professionals, educators,
parents and caretakers.
This guideline is not solely for the health sector. Thus,

the undertaking and supports from parents and all
relevant stakeholders involved in child care are
fundamental in assisting behavioral and environment
change towards supporting healthy eating. I fervently
hope this guideline will be fully utilised as a source of
reference for optimal nutrition of children and
adolescents.
On behalf of the Ministry of Health, I would like to

express my utmost gratitude to the Technical Working
Group for Nutritional Guidelines, for their success in
publishing the latest edition of the Malaysian Dietary
Guidelines for Children and Adolescents (MDG C&A),
2023. I would also like to thank all the relevant
stakeholders for their valuable input and support since
the development of the guidelines. I am confident that
this document will serve its purpose well.
YB DR. ZALIHA MUSTAFA

MINISTER
MINISTRY OF HEALTH MALAYSIA
viii
Foreword by
Director-General of Health
T
he Malaysian Dietary Guidelines for Children and
Adolescents (MDG C&A), was first published in
2013. The review of the MDG C&A is one of the
significant strategies in the National Plan of Action for
Nutrition of Malaysia (NPANM) III, 2016-2025: Facilitating
Strategies: Providing Standard Nutrition Guidelines for
Various Targeted Groups, aims to educate the public with
updated information to stay healthy across the lifespan.
Specific dietary guidelines for each stage of life is necessary
taking into consideration the different nutritional needs,
feeding care, and ways to achieve them.
The revision of the MDG C&A (2013) is indeed timely in

view of our government’s effort to ensure all health
professionals and related parties have adequate access to
robust, practical, updated, and accurate information on child
nutrition. The publication of the guidelines will give a clear
and practical healthy eating recommendation through Key
Messages (KM), Key Recommendations (KR), and How to
Achieve (HTA) them.
I hope this MDG C&A (2023) will be a useful reference for

healthy eating messages. Therefore, I would like to express
my gratitude to those who have contributed to the revision
of this guideline, directly or indirectly. It is hoped that this
guideline would be extensively communicated, and used by
health professionals and relevant stakeholders, including
policy makers, academics, teachers, private sectors, and
general public.
DATUK DR. MUHAMMAD RADZI BIN ABU HASSAN

DIRECTOR-GENERAL OF HEALTH
ix
Preface by
Deputy Director-General of
Health (Public Health)
A
dequate nutrient intake and healthy behaviour during
childhood and adolescence are critical for growth and
overall well-being. Eating habits can have long-term
health and social consequences. However, due to the
pressures of modern lifestyles, many parents are struggling to
instil healthy eating habits for their children. Malnutrition
among children can have a wide range of negative
consequences, including increased morbidity and mortality.
In Malaysia, various programmes have been implemented

which are targeted to children and adolescents to prevent and
control the proliferation of nutrition-related health problems.
These programmes include breastfeeding advocacy and
healthy eating promotion in child care centres, schools, and
community. To support the programmes, updated and
established references based on latest scientific evidence on
nutrition are crucial. Therefore one of the facilitating strategies
in the National Plan of Action for Nutrition of Malaysia
(NPANM) III, 2016 – 2025 is to publish comprehensive
guidelines to help empower health professionals and related
parties in delivering nutrition messages and education to the
target population.
It is hoped that this guideline will be used by the relevant

stakeholders at all levels which aim at achieving optimal
nutrition well-being for children and adolescents. I am also
pleased that the review of this document has been
successfully completed from the commendable efforts of the
experts from various ministries, universities and all the
relevant agencies. I would like to congratulate the Technical
Working Group of Nutritional Guidelines under the purview of
the National Coordinating Committee for Food and Nutrition
(NCCFN) Ministry of Health Malaysia for their success in
publishing this guideline.
DATUK DR. NORHAYATI BINTI RUSLI

DEPUTY DIRECTOR-GENERAL OF HEALTH
(PUBLIC HEALTH)
x
Preface by
Chairman
Technical Working Group on
Nutritional Guidelines
C
hildhood and adolescence are both critical periods
during which rapid cognitive development and physical
growth occurs. During childhood, nutritional demands
increase, and adequate energy intake along with the
consumption of nutrient-dense foods are essential. While
undernutrition, largely under the age of 5 years is still prevalent,
we face a bigger challenge in that the prevalence of overweight
and obesity among children and adolescents is on the rise over
the last few decades. Hence, emphasizing the importance of
healthy dietary practices with the aid of dietary guidelines could
help improve the nutritional status and support optimal growth
and health of children and adolescents. There are many
interrelated factors that affect dietary intake including social,
psychological, environmental, cultural and economic influences.
The importance of the social relationships and teaching
standard along with the degree of various stakeholders and
child involvement can enrich the experience and environment
that a child is subjected to. The potential for informal
stakeholder perceptions to influence program delivery are key
features in this updated MDG C&A (2023) where parents,
teachers, health professionals and caregivers are actively
involved in disseminating nutritional information to meet the
key recommendations goals. The Malaysian Dietary Guidelines
for Healthy Children and Adolescents (2023) comprise of 15 Key
Messages and 67 key recommendations for healthy children and
adolescents from birth to 18 years of age.
This guideline is primarily intended for health professionals and the key recommendations has been
updated with some 756 HTAs (How to Achieve) that could be used by adolescents, parents, caregivers
and teachers in various settings. The Technical Working Group are hopeful that this guideline will be
widely used as a reference and we look forward for feedback from stakeholders and end users to help
us update and improve future edition of this guidelines. I would like to thank the writers, members of
the Technical Working Group, members of the Focus Discussion Group, the Editorial team, the
Consensus Workshop participants and in particular the TWG Secretariat for successfully revising and
updating MDG C&A (2023).
EMERITUS PROFESSOR DR. MOHD ISMAIL NOOR

FASC, FIUNS, FCFAM
CHAIRMAN
MALAYSIAN DIETARY GUIDELINES FOR CHILDREN AND ADOLESCENTS
TECHNICAL WORKING GROUP ON NUTRITIONAL GUIDELINES
NATIONAL COORDINATING COMMITTEE ON FOOD AND NUTRITION (NCCFN)
xi
Acknowledgement
from the various Departments and Institutes, the Ministry of Health Malaysia.
Academicians from local universities, nutritionists, dietitians, representatives
Individuals from related professional bodies, representatives from the food
manufacturing and trading industry, and consumer bodies are all
acknowledged by the Technical Working Group on Nutritional Guidelines. Their invaluable contributions
and dedication to complete this document successfully are sincerely appreciated.
A word of gratitude is also conveyed to the:
● Director, Disease Control Division, MOH

● Director, Health Education Division, MOH
● Director, Food Safety and Quality Division, MOH
● Director, State Department of Health (all over Malaysia), MOH
● Director, National Institutes of Health, MOH
● Director, Health Behavioural Research, MOH
● Dean, Faculty of Health Sciences, Universiti Kebangsaan Malaysia
● Dean, Faculty of Education, Universiti Kebangsaan Malaysia
● Dean, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia
● Dean, School of Health Sciences, Universiti Sains Malaysia
● Dean, Faculty of Health Sciences, Universiti Teknologi MARA
● Dean, Faculty of Applied Sciences, Universiti Teknologi MARA
● Dean, Faculty of Health Sciences, Universiti Sultan Zainal Abidin
● Dean, Faculty of Hospitality, Tourism and Wellness, Universiti Malaysia Kelantan
● Dean, Faculty of Medicine, Universiti Malaya
● Dean, Faculty of Food Science and Nutrition, Universiti Malaysia Sabah
● Dean, Faculty Medicine and Health Sciences, Universiti Malaysia Sarawak
● Dean, Kulliyyah of Allied-Health Sciences, International Islamic University Malaysia
● Dean, Faculty of Human Development, Universiti Pendidikan Sultan Idris
● Dean, Faculty of Applied Sciences, UCSI University
● Dean, School of Health Sciences, International Medical University
● Dean, School of Bioscience, Taylor's University
for their generous support and cooperation.
xii
Technical Working Group on Nutritional Guidelines

Chairman Emeritus Prof. Dr. Mohd Ismail Noor
Universiti Kebangsaan Malaysia
Vice Chairman Ms. Rusidah Selamat

Nutrition Division
Secretary Ms. Rozalina Ismail

Nutrition Division
Team members
Ms. Khairul Zarina Mohd Yusop Assoc. Prof. Dr. Mahenderan Appukutty
Nutrition Division Faculty of Sports Science & Recreation
Ministry of Health Malaysia (MOH) Universiti Teknologi MARA (UiTM)
Dr. Mohd Haniff Jailani Dr. Yasmin Ooi Beng Houi

Disease Control Division Faculty of Food Science and Nutrition
Ministry of Health Malaysia (MOH) Universiti Malaysia Sabah (UMS)
Ms. Nur Hidayatun Fadillah Mohd Noor Dr. Marhazlina Mohamad

Health Education Division School of Nutrition and Dietetic
Ministry of Health Malaysia (MOH) University Sultan Zainal Abidin (UNISZA)
Ms. Nur Liyana Mohd Nizar Prof. Dr. Winnie Chee Siew Swee
Food Quality and Safety Division School of Health Sciences
Ministry of Health Malaysia (MOH) International Medical University (IMU)
Prof. Dr. Poh Bee Koon Assoc. Prof. Dr. Satvinder Kaur
Faculty of Health Sciences Faculty of Applied Sciences
Universiti Kebangsaan Malaysia (UKM) UCSI University, Kuala Lumpur
Prof. Dr. Chan Yoke Mun Emerita Prof. Dr. Norimah A Karim
Faculty of Medicine and Health Sciences Universiti Kebangsaan Malaysia (UKM)
Universiti Putra Malaysia (UPM)
Dr. Tee E. Siong
Dr. Siti Raihanah Shafie Nutrition Society of Malaysia (NSM)
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia (UPM)
xiii
List of Authors
Practise exclusive breastfeeding from birth until six months
Key Message 1
and continue to breastfeed until two years
1. Assoc. Prof. Dr. Zaharah Sulaiman (Lead Author)

Universiti Sains Malaysia
2. Ms. Wan Fazlily Wan Mahmod

Nutrition Division, Ministry of Health Malaysia
3. Dr. Ning Desiyanti Soehartojo

Malaysian Breastfeeding Peer Counselor Association
4. Dr. Nurul Husna Mohd Shukri

Universiti Putra Malaysia
5. Dr. Norsyamlina Che Abdul Rahim

Universiti Malaysia Kelantan
6. Ms. Rashadiba Ibrahim@Rahman

Give appropriate complementary foods to children between the

Key Message 2
1. Prof. Dr. Zalilah Mohd Shariff (Lead Author)

2. Ms. Irma Hanim Abdullah

3. Assoc. Prof. Dr. Aryati Ahmad

Universiti Sultan Zainal Abidin
4. Ms. Nor Ratna Mustaffa

Jabatan Kesihatan Negeri Terengganu
5. Ms. Nur Shafawati Mohd Ghazali

6. Ms. Roslinda@Zakiah Kangan

xiv
Key Message 3 Eat a variety of foods within your recommended intake
1. Prof. Dr. Norimah A Karim (Lead Author)

2. Ms. Nor Hanisah Zaini

3. Ms. Rusidah Selamat

4. Ms. Khairul Zarina Mohd Yusop

5. Assoc. Prof. Dr. Gan Wan Ying

6. Dr. Sameeha Mohd Jamil

7. Dr. Nor Azwani Mohd Shukri

International Islamic University Malaysia
8. Ms. Wan Suria Yusoff @ Wan Yusoff

Pejabat Kesihatan Daerah Bentong, Pahang
Key Message 4 Attain healthy weight for optimum growth
1. Prof. Dr. Poh Bee Koon (Lead Author)

2. Emeritus Prof. Dr. Mohd Ismail Noor

3. Assoc. Prof. Dr. Ng Ruey Terng

Universiti Malaya
4. Dr. Denise Koh Choon Lian

5. Dr. Nurzalinda Zalbahar@Zabaha

6. Ms. Teh Wai Siew

7. Ms. Nur Azlina Abdul Aziz

xv
Key Message 5 Be physically active everyday
1. Assoc. Prof. Dr. Hazizi Abu Saad (Lead Author)

2. Ms. Noor Junainah Masjuni

Klinik Kesihatan Lanchang, Temerloh Pahang
3. Dr. Lee Yi Yi
International Medical University
4. Mr. Wan Mohd Hakim Wan Ismail

Health Education Division, Ministry of Health Malaysia
5. Assoc. Prof. Dr. Sharifah Wajihah Wafa Syed Saadun Tarek Wafa
Key Message 6 Eat adequate vegetables and fruits everyday
1. Dr. Yasmin Ooi Beng Houi (Lead Author)

Universiti Malaysia Sabah
2. Ms. Ain Hanani Budiono

3. Ms. Ainan Nasrina Ismail

4. Ms. Catherine Mering

Pejabat Kesihatan Bahagian Miri, Sarawak
5. Dr. Megan Chong Hueh Zan

International Medical University
6. Ms. Sarina Sariman

Management and Science University
xvi
Eat an adequate amount of rice, other cereals, whole grain

Key Message 7
cereal-based products and tubers
1. Assoc. Prof. Dr. Nik Shanita Safii (Lead Author)

2. Ms. Nuurdiana Mohd Rafien

3. Assoc. Prof. Dr. Wan Azdie Mohd Abu Bakar

4. Ms. Maizatul Azlina Chee Din

Disease Control Division, Ministry of Health Malaysia
5. Dr. Nurfarhana Diana Mohd Nor

Universiti Pendidikan Sultan Idris
6. Mr. Mohd Faez Bachok

Klinik Kesihatan Padang Piol Jerantut, Pahang
Consume recommended amount of protein rich foods such as

Key Message 8
1. Assoc. Prof. Dr. Satvinder Kaur (Lead Author)

UCSI University
2. Ms. Norfaiezah Ahmad

3. Assoc. Prof. Dr. Foo Leng Huat

Universiti Sains Malaysia
4. Assoc. Prof. Dr. Wee Bee Suan

5. Ms. Suriati Zakaria

Klinik Kesihatan Paya Besar, Kuantan, Pahang
xvii
Key Message 9 Consume milk and milk products daily
1. Assoc. Prof. Dr. Chin Yit Siew (Lead Author)

2. Ms. Siti Nur Hidayah Adznam

3. Ms. Gui Shirley

4. Prof. Dr. Barakatun Nisak Mohd Yusof

5. Asst. Prof. Dr. Serene Tung En Hui

UCSI University
6. Dr. Law Leh Shii

Universiti Malaysia Sarawak
Key Message 10 Choose different types of fats and oils in appropriate amounts
1. Assoc. Prof. Dr. Mohd Razif Shahril (Lead Author)

2. Mr. Shahir Shamshuddin

Pejabat Kesihatan Daerah Batu Pahat, Johor
3. Assoc. Prof. Dr. Zulfitri ‘Azuan Mat Daud

4. Dr. Khor Ban Hock

5. Prof. Dr. Tilakavati Karupaiah

Taylors University
xviii
Key Message 11 Limit intake of salt and sauces in daily meals
1. Assoc. Prof. Dr. Wong Jyh Eiin (Lead Author)

2. Ms. Munirah Nasir

3. Prof. Dr. Suzana Mohd Shahar

4. Ms. Rozalina Ismail

5. Dr. Siti Raihanah Shafie

6. Ms. Siti Farrah Zaidah Mohd Yazid

Disease Control Division, Ministry of Health Malaysia
Key Message 12 Consume foods and beverages low in sugar
1. Dr. Hanapi Mat Jusoh (Lead Author)

2. Dr. Nur Dayana Shaari

3. Prof. Dr. Ruzita Abd Talib

4. Dr. Norliyana Aris

5. Assoc. Prof. Dr. Sabariah Buhari

Universiti Teknologi MARA
6. Dr. Nurul Hayati Anwar

Pejabat Kesihatan Pergigian Daerah Kuala Terengganu
7. Ms. Norwati Sakiram

Pejabat Kesihatan Daerah Tampin, Negeri Sembilan
xix
Key Message 13 Drink plenty of water daily
1. Prof. Dr. Loh Su Peng (Lead Author)

2. Ms. Nor Hasyimah Khalid

3. Ms. Noor Faezah Abdul Jalil

4. Dr. Nor Baizura Md Yusop

5. Ms. Nur Wahidda Azmi

Pejabat Kesihatan Daerah Pendang, Kedah
Key Message 14 Consume safe foods and beverages
1. Assoc. Prof. Dr. Hasnah Haron (Lead Author)

2. Ms. Nor Nabihah Ab Rahman

Food Safety and Quality Division, Ministry of Health Malaysia
3. Ms. Shazlina Mohd Zaini

4. Dr. Fadhilah Jailani

5. Dr. Nurul Huda Razalli

6. Ms. Siti Fatimah Mohd Tarmizi

Pak Tam Katering Sdn. Bhd
xx
Educate children and adolescents on the use of nutrition

Key Message 15
information on food labels
1. Dr. Emmy Hainida Khairul Ikram (Lead Author)

2. Ms. Siti Dinie Syazwani Azlam

3. Ms. Norlaily Mohd Nasir

Health Education Division, Ministry of Health Malaysia
4. Ms. Rabia’atuladabiah Hashim

5. Ms. Noryanti Rahmat

6. Dr. Ng See Hoe

Taylors University
xxi
Editorial Board
Emeritus Prof. Dr. Mohd Ismail Noor Assoc. Prof. Dr. Chin Yit Siew
(Chief Editor) Universiti Putra Malaysia (UPM)
Universiti Kebangsaan Malaysia (UKM) Serdang, Selangor
Kuala Lumpur
Assoc. Prof. Dr. Mohd Razif Shahril
Assoc. Prof. Dr. Zaharah Sulaiman Universiti Kebangsaan Malaysia (UKM)
Universiti Sains Malaysia (USM) Kuala Lumpur
Kubang Kerian, Kelantan
Assoc. Prof. Dr. Wong Jyh Eiin
Prof. Dr. Zalilah Mohd Shariff Universiti Kebangsaan Malaysia (UKM)
Universiti Putra Malaysia (UPM) Kuala Lumpur
Serdang, Selangor
Dr. Hanapi Mat Jusoh
Prof. Dr. Poh Bee Koon International Islamic University Malaysia
Universiti Kebangsaan Malaysia (UKM) Kuantan, Pahang
Kuala Lumpur
Prof. Dr. Loh Su Peng
Assoc. Prof. Dr. Hazizi Abu Saad Universiti Putra Malaysia (UPM)
Universiti Putra Malaysia (UPM) Serdang, Selangor
Serdang, Selangor
Assoc. Prof. Dr. Hasnah Haron
Dr. Yasmin Ooi Beng Houi Universiti Kebangsaan Malaysia (UKM)
Universiti Malaysia Sabah (UMS) Kuala Lumpur
Kota Kinabalu, Sabah
Dr. Emmy Hainida Khairul Ikram
Assoc. Prof. Dr. Nik Shanita Safii Universiti Teknologi MARA (UiTM)
Universiti Kebangsaan Malaysia (UKM) Puncak Alam, Selangor
Kuala Lumpur
Assoc. Prof. Dr. Satvinder Kaur

UCSI University
Kuala Lumpur
xxii
Coordination and Documentation

of the Malaysian Dietary Guidelines (MDG) for Children and
The documentation Adolescents 2023 was coordinated by the Technical Working
Group (TWG) on Nutritional Guidelines, which is under the
purview of the National Coordinating Committee on Food and
Nutrition (NCCFN), Ministry of Health Malaysia. The Nutrition Division, Ministry of Health Malaysia served
as the secretariat for the Malaysian Dietary Guidelines for Children and Adolescents.
Secretariats:
Emeritus Prof. Dr. Mohd Ismail Noor

Chairman
Technical Working Group for Nutritional Guidelines
National Coordinating Committee on Food and Nutrition
Ms. Rusidah Selamat

Vice Chairman
Nutrition Division, MOH
Ms. Rozalina Ismail

Secretary
Ms. Khairul Zarina Mohd Yusop

Principal Assistant Director
Ms. Nur Irsalina Mohamed Zaki

Research Officer MySTEP
Ms. Siti Fatimah Mohd Tarmizi

Research Officer MySTEP
(until Feb 2022)
xxiii
List of Tables, Figures and Appendices
Key Message 1 Appendix 1.1 Breastfeeding with correct technique 21
Key Message 2 Table 2.1 Daily energy requirement for infants and children 27
from 6 months – 2 years
Table 2.2 Fluid requirement for young children by age 32
Table 2.3 Feeding frequency according to age 35
Key Message 3 Figure 3.1 Malaysian Healthy Plate 2016 51
Table 3.1 Recommended caloric intake of children and 61

adolescents by age and sex according to
Recommended Nutrient Intakes for Malaysian
(2017)
Table 3.2 Recommended food portions per day according 62

to age groups (age 6 months to 3 years)
Table 3.3 Recommended number of servings of food groups 64

by age (4 to <18 years) and energy requirement
Per day (kcal)
Table 3.4 Examples of menu for children aged 6 – 12 months 65
Table 3.5 The total daily energy requirement from 76

complementary foods
Table 3.6 Examples of vegetables equivalent to one serving 76

size
Table 3.7 Examples of fruits equivalent to one serving size 77
Table 3.8 Examples of rice, other cereals, wholegrain 78

cereal-based products and tubers equivalent to
one serving size
xxiv
Table 3.9 Examples of legumes, nut and seeds equivalent to 79

one serving size
Table 3.10 Examples of fish and seafood equivalent to 80

one serving size
Table 3.11 Examples of poultry, meat and egg equivalent to 80

one serving size
Table 3.12 Example of milk and milk products equivalent to 81

one serving size
Figure 3.2 Standard household measurements used in this 81

dietary guideline
Key Message 4 Table 4.1 Stages of childhood 85
Table 4.2 Interpretation of Z-scores for BMI-for-age 88
Table 4.3 Interpretation of Z-Scores for height-for-age 88
Table 4.4 Basal Metabolic Rate (BMR) formulas used in 89

calculating Total Energy Expenditure (TEE)
Table 4.5 Trend in nutritional status of children below 94

5 years in Malaysia
Table 4.6 Trend in nutritional status of adolescents aged 94

10 – 17 years old in Malaysia
Appendix 4.1 BMI-for-age growth chart from birth to 2 years old 115
(boys)
Appendix 4.2 BMI-for-age growth chart from 2 to 5 years old (boys) 115
Appendix 4.3 BMI-for-age growth chart from birth to 2 years old 116
(girls)
Appendix 4.4 BMI-for-age growth chart from 2 to 5 years old (girls) 116
Appendix 4.5 BMI-for-age Z-score table and interpretation for 117

5 to 19 years old (boys)
Appendix 4.6 BMI-for-age Z-score table and interpretation for 118

5 to 19 years old (girls)
Appendix 4.7 Height-for-age growth chart from birth to 2 years 119

old (boys)
Appendix 4.8 Height-for-age growth chart from 2 to 5 years old 119

(boys)
Appendix 4.9 Height-for-age growth chart from birth to 2 years old 120
(girls)
xxv
Appendix 4.10 Height-for-age growth chart from 2 to 5 years old 120

(girls)
Appendix 4.11 Height-for-age Z-score table and interpretation 121

from 5 to 19 years old (boys)
Appendix 4.12 Height-for-age Z-score table and interpretation from 121

5 to 19 years old (girls)
Appendix 4.13 Weight-for-age growth chart from birth to 2 years old 122
(boys)
Appendix 4.14 Weight-for-age growth chart from 2 to 5 years old 122

(boys)
Appendix 4.15 Weight-for-age growth chart from birth to 123

2 years old (girls)
Appendix 4.16 Weight-for-age growth chart from 2 to 5 123

years old (girls)
Appendix 4.17 Head circumference-for-age growth chart from 124

birth to 3 years old (boys)
Appendix 4.18 Head circumference-for-age growth chart from 124

birth to 3 years old (girls)
Key Message 5 Figure 5.1 Physical activity pyramid for children and 139
adolescent adapted from NCCFN (2013)
Table 5.1 Sleep behaviour recommendation in 24-hour by 145

age for infants, children and adolescents
Appendix 5.1 Examples of moderate and vigorous activities defined 155

by level of intensity
Appendix 5.2 Examples of muscle strengthening and bone 156

strengthening activities defined by level of intensity
Appendix 5.3 Examples of structured and unstructured physical 156

activities
Table 5.2 Examples of physical activity for children and 157

adolescent per day
xxvi
Key Message 6 Figure 6.1 Traditional vegetables 177
Key Message 8 Table 8.1 Recommended intake for protein: 226

RNI Malaysia (2017)
Table 8.2 Example of common foods (per serving) in 227

household measurement for intake of protein
per day
Table 8.3 Examples of fish and seafood equivalent to one 229

serving
Table 8.4 Examples of poultry, meat and egg equivalent to 229

one serving
Table 8.5 Examples of legumes equivalent to one serving 229
Table 8.6 Examples of nuts and seeds equivalent to one 229

serving
Key Message 9 Table 9.1 Milk supplies essential micronutrients and 236
contributes to healthy diets
Table 9.2 Differences between lactose intolerance and 238

Cow's Milk Protein Allergy
Appendix 9.1 Nutrient composition of cow’s and goat’s milk 253

(per 100g of milk)
Key Message 10 Appendix 10.1 Fatty acids composition of selected dietary 274
fats and oils
Appendix 10.2 Malaysian foods with significant content of 275

dietary fats (g/100g)
Appendix 10.3 Marine omega-3 fatty acids content in 277

Malaysian fishes
Appendix 10.4 Alternatives for fried foods 278
Key Message 11 Table 11.1 Sodium requirement (AI mg/ day) for all age groups 283
Table 11.2 Sources and content of sodium in selected foods 295
Key Message 12 Figure 12.1 Classification of sugars 303
Figure 12.2 Classification of sweeteners 304
Figure 12.3 Sugar (Raw Sugar Equivalent, RSE) 309

consumption per capita (kg)
xxvii
Figure 12.4 World Centrifugal Sugar: Human Domestic 309

Consumption (1,000 Metric Tons, Raw Value)
Table 12.1 Consumption of sugary confectionery and snacks 310

among Malaysian adolescents
Table 12.2 Consumption of beverages among Malaysian 311

adolescents
Table 12.3 Recommended free sugars imit 311
Figure 12.5 Distribution of free sugar ingredients, 312

sweeteners, a combination of both or neither in
prepackage foods and beverages.
Appendix 12.1 Total sugars content in selected local kuih 323
Appendix 12.2 Total sugars content in selected local cooked dishes 324
Appendix 12.3 Total sugars content in selected cereals based 324

products & tubers, legumes, nuts & seed and
other processed products
Appendix 12.4 Total sugars content in selected sugar & syrup 326
products and beverages
Appendix 12.5 Total sugars content in selected fruits 327
Key Message 13 Table 13.1 Calculation of water requirement for boys 336
according to Malaysian RNI
Table 13.2 Calculation of water requirement for girls 336

according to Malaysian RNI
Table 13.3 Recommended plain water intake of children 338

and adolescents by age (6 months to 18 years)
Key Message 14 Figure 14.1 Incidence rate for typhoid, cholera, hepatitis A 351
and dysentery in Malaysia (2009 - 2019)
Figure 14.2 Incidence and episodes of food poisoning in 353

Malaysia (2008 - 2018)
Appendix 14.1 Keep your hands clean 364
Appendix 14.2 Recycle symbols 365
Appendix 14.3 Plastic container safety symbols 366
xxviii
Key Message 15 Figure 15.1 Example of food label with all the common 371
nutrition information
Table 15.1 A sample of Nutrition Information Panel (NIP) 372

with only mandatory nutrients
Figure 15.2 Example of Quantitative Ingredient

Declaration (QUID) 375
Figure 15.3 A sample of energy icon 376
Figure 15.4 Healthier Choice Logo (HCL) logo 377
Figure 15.5 Examples of food marketing techniques 381
Appendix 15.1 Foods requiring mandatory nutrition labelling 392
Appendix 15.2 Component of Nutrition Information Panel (NIP) 394
xxix
Executive Summary
Malaysia is continuously facing a double burden of malnutrition
especially among children and adolescents. Adequate nutrients
intakes allow children and adolescents to achieve optimum growth
and cognitive function of their lives; to live, grow, develop
physically and mentally, learn as much as possible, play,
participate and interact with their surroundings.
xxx
In contrast, malnourished children will not be able

to do so. In fact, persistent childhood malnutrition
may result in detrimental health issues, including
non-communicable diseases (NCD), in later life. The
problems of undernutrition especially stunting and
wasting among children under five years old still
persist and need serious attention. The National
Health and Morbidity Survey (NHMS) series reported
the increasing trend of stunting from 17.5% in 2006
to 20.7% in 2016, 21.8% in 2019 and 21.2 % in 2022.
The prevalence of wasting has decreased from 13.2%
in 2006 to 11.5% in 2016 and to 9.7% in 2019, but
increased slightly to 11.0% in 2022. There was a
slight fluctuation in the prevalence of overweight
among this group from 5.8% in 2006 to 6.0 in 2016
and 5.2% in 2019. The cause of malnutrition,
although complex, can be attributed to low socio-
demographic status, poor infant and young child
feeding practices, as well as inappropriate child care
practices, food insecurity, and low nutrition literacy
among parents and children. Consuming a healthy
diet, appropriate feeding practices and active
lifestyles throughout the life-course helps to prevent
malnutrition in all its forms as well as a range of
NCDs and conditions.
xxxi
The Malaysian Dietary Guidelines for Children foods. There is an urgent need to develop and
and Adolescents (MDG C&A) is a government implement effective interventions to improve
endorsed document that provides specific diet quality from a young age in order to
recommendations for healthy eating practices significantly reduce the overall risk of chronic
targeted to children and adolescents. The MDG diseases. Knowledge is thus a key parameter
C&A is evaluated every ten years to ensure for changing attitudes and practices.
that the Malaysian had access to the most up-
to-date information on knowledge, attitude and The Malaysian Dietary Guidelines for Children
practices related to food and nutrition, focusing and Adolescents (MDG C&A) was first
on children and adolescents. The MDGs are published in 2013. The current document
intended to be used as guidance for end-users provides updates on breastfeeding and
(health professionals, and other related appropriate feeding practices, food intakes,
practitioners alike), and nutrition education dietary diversity, and physical activities of food
programmes to foster healthy eating habits and safety and quality, as well as educate this
lifestyles among target audiences. groups on reading nutrition information panel
(NIP).
Strategies to promote a healthy diet include the
development of food-based dietary guidelines The publication of the MDG C&A is under the
(FBDG). Dietary guidelines are a key coordination of the Technical Working Group
component of a coherent food policy and are (TWG) for Nutritional Guidelines. All the write-
the basis for the development of policies up are written and reviewed by experts in their
intended to shift consumption patterns into field from the academia, Ministry of Health
healthier and more environmentally Malaysia and related professional bodies.
sustainable directions. In addition, they are Scientific and clinical information were
meant to be used as a guide for consumers in translated into Key Messages (KM), Key
making food choices based on analyses of food Recommendations (KR) and How to Achieve
and nutrient intakes, food supply, prevalence (HTA) that are more practical and
and the significance of diet-related health and understandable by the end-user. The KM, KR
nutrition outcomes for public health, cultural and HTA were then vetted by public health
preferences, and other factors. professionals (end-users) to assess the
relevance and clarity through Focus Group
In general, dietary recommendations focus on Discussion (FGD) on 16-17 March 2022. The
a diet consisting mainly of vegetables and final draft together with the KM, KR and HTA
fruits,, whole grains, low-fat foods, legumes, will be presented in a 3-day Consensus
nuts and seeds, fish and lean meats. It is also Meeting on 13-15 July 2022. The meeting
advisable to consider the expansion of involved relevant stakeholders from various
transnational food and beverage corporations ministries, government agencies, academia,
in emerging economies, which is accelerating professional bodies, food industries, and
dietary change for children and adolescents by consumer associations for revision and
promoting the availability, affordability and approval.
appeal of high-calorie and ultra processed
xxxii
The revised MDG C&A (2023) features some of the following updates:
a) The MDG C&A uses the Recommended d) The 15 Key Messages in the MDG C&A
Nutrient Intakes for Malaysia (2017). The (2023) remain as for the 2013 version.
RNI (2017) recommends the However, content of each key message in
macronutrients contribution towards Total the MDG C&A (2023) have been revised
Energy Intakes (TEI) for Malaysian and updated with recent scientific
children and adolescents should be as evidence.
follows:
e) The Malaysian Dietary Guidelines for
• carbohydrates 50 - 65%; Children and Adolescents 2023 provide
• fat 30 - 40% for 6-11 months; 25 - 35% many options in their recommendations.
for 1 year olds and above The advice focuses on dietary patterns that
• protein 10 - 20% promote health and wellbeing. It offers
approximately 756 statements on “how to
b) Recommended number of serving size for achieve” to help users make informed
each food group is based on calorie choices toward healthier eating habits.
requirements (age and sex) as follows:
f) KM, KR and HTA were written according to
• 6 to 11 months : 570 - 720 kcal the role of who may be involved in the
• 1 to 3 years: 900 - 980 kcal nutrition education, such as parents,
• 4 to 6 years: 1210 - 1300 kcal caregiver, teachers, health professional
• 7 to 9 years: 1610 - 1750 kcal and adolescents themselves.
• 10 to 12 years: 1710 - 1930 kcal
• 13 to 15 years; 1810 - 2210 kcal; and
• 16 to 18 years; 1890 - 2340 kcal
c) The MDG C&A 2023 is based on foods that

are available, accessible and culturally
appropriate for the population's healthy
diets at all times and places. They ensure
healthy foods have variety and diversity for
all income groups.
xxxiii
Malaysian Dietary Guidelines for

Children and Adolescents (2023)
Key Messages (KM)
KM1 KM9
Practise exclusive breastfeeding from Consume milk and milk products daily.
birth until six months and continue
to breastfeed until two years.
KM2 KM10
Give appropriate complementary foods to Choose different types of fats and oils in
children between the age of 6 months to appropriate amounts.
2 years.
KM3 KM11
Eat a variety of foods within your Limit intake of salt and sauces in daily
recommended intake. meals.
KM4 KM12
Attain healthy weight for optimum growth. Consume foods and beverages low in
sugar.
KM5 KM13
Be physically active everyday. Drink plenty of water daily.
KM6 KM14
Eat adequate vegetables and fruits Consume safe foods and beverages.
everyday.
KM7 KM15
Eat adequate amount of rice, other Educate children and adolescents on the
cereals, whole grain cereal-based use of nutrition information on
products and tubers. food label.
KM8
Consume recommended amount of

protein rich foods such as fish, eggs, lean
meat and poultry, nuts and legumes.
xxxiv
Key Message 1
Practise exclusive breastfeeding from birth until six

months and continue to breastfeed until two years
KM1
Practice exclusive breastfeeding from birth until six months and continue to breastfeed until two years
Key Message 1
Practise exclusive breastfeeding from birth until six

months and continue to breastfeed until two years
Assoc. Prof. Dr. Zaharah Sulaiman, Dr. Ning Desiyanti Soehartojo, Dr. Nurul Husna Mohd Shukri,
Dr. Norsyamlina Che Abdul Rahim, Ms. Rashadiba Ibrahim @ Rahman and
Ms. Wan Fazlily Wan Mahmod
1.1 Terminology
Anticipatory guidance Baby Friendly Hospital Initiative

Guidance and information offered in Baby Friendly Hospital Initiative (BFHI) is a
anticipation of predictable challenges or global initiative of both the World Health
situations that may impact mothers’ Organisation (WHO) and United Nations
breastfeeding goals. Children's Fund (UNICEF) targeted to ensure
that every child gets the best start in life
Breastfeeding counselling through an environment that supports
Breastfeeding counselling provides breastfeeding. Baby Friendly Hospital is set
education, reassurance, skilled practical help, up to protect, promote and support
and problem solving, and anticipatory breastfeeding through creating a supportive
guidance in the antenatal, birth and environment for mothers to breastfeed their
postpartum periods through to the first two children with breast milk, providing a service
years of life. that helps mothers to breastfeed and carrying
out a policy that protects breastfeeding.
2
Baby Friendly Clinic Hand expression of breast milk

The Baby Friendly Clinic (Klinik Rakan Bayi) is one A technique of expressing breast milk out from the
of the Ministry of Health Malaysia's (MOH) efforts breast by hand.
to promote, protect, and support breastfeeding in
health facilities that provide health services to Pre-lacteal feeding
mothers and children throughout the country Giving any solid or liquid foods other than breast
(Health Clinics, Maternal and Child Health Clinics, milk during the first three days after birth.
and Rural Clinics). It is also a continuation of the
Implementation of Baby-Friendly Hospital Initiative Predominant breastfeeding
(BFHI). The Baby Friendly Clinic aims to provide The infant’s predominant source of nourishment is
services and environments that promote and breast milk. However, the infant may also have
support breastfeeding practices. This establishment received water and water-based drinks (sweetened
is one of the MOH’s strategies to encourage mothers and flavoured water, tea, infusion etc).
to exclusively breastfeed their babies from birth to
the first six months and continue until the baby is Responsive (on demand) breastfeeding
two years old. Breastfeeding a baby in response to signs of
readiness to feed, as frequently and for as long as
Breastfeeding initiation the baby wants, from one or both breasts at each
Refers to the introductory steps taken to support feed, without specific regulations. Responsive
and achieve the onset of lactation, including skin- breastfeeding may also be called ‘unrestricted’ or ‘on
to-skin contact, positioning and latch attempts, and demand’ feeding.
colostrum expression, either via hand or pump. Early
initiation of breastfeeding, within one hour of birth, Rooming-in KM1
protects the newborn from acquiring infection and Allow mothers and infants to remain together - 24
reduces newborn mortality. hours a day.
Skin-to-skin contact
Code of Ethics in marketing infant food and Care in which an infant is placed prone on the
related product mother’s abdomen or chest with no clothing
Code of Ethics is required to protect, support, and separating them.
promote breastfeeding practices through strict
control of the marketing of baby food products and The International Code of marketing of
breastfeeding equipment for mothers. Code of breast-milk substitutes and subsequent
Ethics is produced with the cooperation of dairy relevant WHA resolutions
industries operating in Malaysia. Its’ goal is to The Code is a set of recommendations to regulate
contribute to the promotion of safe and optimal the marketing of breast-milk substitutes, feeding
nutrition for infants by protecting and promoting bottles and teats. The Code aims to stop the
breastfeeding and ensuring the use of correct breast aggressive and inappropriate marketing of breast-
milk replacement products (if necessary) by milk substitutes (and protect mothers/caregivers of
providing adequate information using a controlled both breastfed and non-breastfed infants and young
marketing and distribution method. children from commercial influence on their infant
feeding choices). It is a minimum requirement to
Competency protect and promote appropriate infant and young
The ability to use a set of related knowledge and child feeding.
skills to successfully perform identified jobs, roles, or
responsibilities. Breastfeeding counselling Young child
competencies can be either basic or advanced Any person from the age twelve months up to the
competencies. age of three (3) years.
Exclusive breastfeeding
When an infant receives only breast milk and no
other liquids or solids, including water (with the
exception of prescribed vitamins, minerals or
medicines).
3
1.2 Introduction
Adequate nutrition is critical to child health and with continued breastfeeding until 24 months of age
development. It is well recognised that the period or older (WHO/UNICEF, 1989). Malaysia is
from birth to 2 years of age is a critical window for committed to promote, protect and support
the promotion of optimal growth, health, and breastfeeding practices by having the National
behavioural development (National Coordinating Breastfeeding Policy in place and other initiatives
Committee on Food and Nutrition - NCCFN, 2013). such as, Baby Friendly Hospital Initiative (BFHI),
Breastfeeding is a core part of “getting it right” in Baby Friendly Clinics, Milk Bank, Code of Ethics in
terms of nutrition in the first 1,000 days of life. Marketing Infant Food and Related Product
Therefore, supporting healthy eating for children (Nutrition Division, 2021). Mothers in general need
starting with breastfeeding is one of the main key support and practical help to establish
recommendations. Breast milk is the healthiest start breastfeeding.
for every infant’s optimal growth and development.
It is safe, readily available and contains anti-infective World Alliance for Breastfeeding Action (WABA)’s
and anti-inflammatory properties which helps Warm Chain of Support for Breastfeeding (Warm
protect against many common childhood illnesses Chain) campaign places the breastfeeding dyad at
and chronic diseases. Breast milk provides the the core and follows the first 1,000 days timeline. It
energy and nutrients requirements that the infant strives to link actors at different points to provide a
needs for the first six months of life, and it continues coordinated continuum of care. A Warm Chain
to provide up to half or more of a child’s nutritional across the continuum of care will provide consistent
needs during the second half of the first year, and up messages and good referral systems so that any
KM1 to one third during the second year of life. Breast family with a breastfeeding baby receives the
milk also improves the neurodevelopmental ongoing support they need in a timely fashion. Thus,
outcomes and reduces the risk of stunting, a public health approach to breastfeeding, where
overweight and obesity. Breastfeeding also provides husband or partner, family, employer, and healthcare
health and emotional benefit to the mother, with a providers, as well as government and other
broader impact on the family, economy and stakeholders, must work together to create a
environment. breastfeeding-friendly environment. This approach
represents the idea that breastfeeding is a shared
The World Health Organization (WHO) recommends responsibility and implementation must be done
that breastfeeding should be initiated within the first using evidence-based guidelines on what works
hour after birth and that infants should exclusively and how to support breastfeeding practices. These
breastfeed for the first six (6) months; will be further discussed across the key
complementary foods should then be introduced, recommendations.
4
1.3 Scientific Basis
1.3.1 Mother and father/ partner Mothers are encouraged to have a companion with
them during labour and delivery (if given permission
Antenatal preparation for breastfeeding by the hospital), who can stay until at least the first
Usually, by the third trimester, a woman has breastfeed. A companion can also help the mother
generally made her own decision on how she will and baby to find a comfortable breastfeeding
nourish her baby (breastfeeding or not) (Victora et position (WHO, 2020). Fathers and spouses have
al., 2016). This finding is also supported by Shukri et been identified as influential in maternal feeding and
al. (2021) which showed that the total Iowa Infant breastfeeding decisions (Rempel & Rempel, 2004;
Feeding Attitude Scale score (IIFAS) was Scott et al., 2006). If a mother feels that her partner’s
significantly associated with the confidence levels attitude toward breastfeeding is positive and
in achieving breastfeeding goals among Malaysian supportive, it is highly likely that she will continue
mothers (r=0.285, p<0.011). This indicates a positive breastfeeding (Samir et al., 2000; Pisacane et al.,
attitude towards breastfeeding was correlated with 2005). Unfortunately, if their partner has a negative
higher confidence level in achieving the attitude towards breastfeeding, the woman is more
breastfeeding goal during pregnancy. likely to decide to discontinue breastfeeding. The
partner’s attitude influences maternal perceptions
Mothers are encouraged to learn more about of breastfeeding (Pisacane et al., 2005).
breastfeeding by attending classes, reading, and
joining support groups. A study conducted by Maintaining breastfeeding
Mattar et al. (2007) proved that mothers who Parents and caregivers need to be enabled to access
received simple antenatal instruction with a short, appropriate help when they have concerns about KM1
single, individual counselling session combined with feeding. This may be particularly important in the
educational material were as twice as likely to first few weeks after birth when breastfeeding is
practice exclusive or predominant breastfeeding at being established, and during potential changes in
three and six months postpartum compared with their situation (such as the mother’s return to school
mothers who did not receive formal antenatal or work), when they may have concerns about
instruction. maintaining breastfeeding, according to their
individual circumstance. To ensure that
Mothers are advised to consult with a healthcare breastfeeding can be effectively practiced, mothers
professional about their plans to breastfeed and to need to acquire enough rest, good nutrition, and
choose facilities that encourage breastfeeding after adequate fluid to keep healthy. There is no evidence
childbirth. It is particularly suggested to give birth base to support any restriction of certain food during
at a Baby Friendly Hospital Initiative (BFHI), which breastfeeding (Karcz et al., 2020; Jeong et al., 2017;
has implemented practical steps to create the best Wood, 2016).
environment possible for breastfeeding support.
Children born in a baby-friendly health facility are Family members, particularly partners or fathers,
more likely to be breastfed for a longer time, play an essential role in caring for the infant and
particularly if the hospital shows high compliance ensuring that the mother gets enough rest.
with UNICEF guidelines (Lauwers & Swisher, 2011). Breastfeeding duration was associated with
paternal support and a positive attitude. A local
Initiate breastfeeding within one hour of study by Phua et al. (2020) indicated three
birth significant variables that impacted fathers'
World Health Organization (WHO) recommends that involvement in breastfeeding such as fathers'
early skin-to-skin contact between mothers and breastfeeding knowledge, fathers' attitudes
infants should be initiated as soon as possible after regarding breastfeeding practices, and mode of
birth regardless of the mode of delivery. The contact delivery. Consistently, another recent study in Kuala
should be uninterrupted for at least 60 minutes Selangor also found that fathers' breastfeeding
(WHO, 2018a). Baby's sucking reflex is active involvement is significantly influenced by their
immediately after birth and the infant is more alert breastfeeding knowledge and attitudes toward
between 30 to 60 minutes after birth. If the baby is breastfeeding practices (Mat Nawi & Abdul Hamid,
placed against his mother's breast in this period, the 2021). Therefore, it is essential to educate and
probability of exclusive breastfeeding might be increase breastfeeding knowledge among men in
increased. general, especially among fathers-to-be.
5
The nutritional composition of breast milk is thought infants’ cues for feeding if they are separated from
to be influenced by the mother's diet. The them. Nevertheless, breastfeeding at night is helpful
proportion of diet-related variability in human milk for keeping the milk supply higher (WHO, 2020).
is mostly unclear. The majority of previous research More prolactin is produced at night, therefore
that found a dietary influence on breast-milk breastfeeding at night is especially helpful for
composition did not assess diet directly, did not keeping up the milk supply. Prolactin seems to make
quantify its relationship with milk composition, or a mother feel relaxed and sleepy, subsequently she
both. The available information on breastmilk usually rests well even if she breastfeeds at night
composition is scarce and diversified. Most of the (WHO, 2009). To ensure adequate milk production
evidence currently used in clinical practice to make and flow for six months of exclusive breastfeeding,
recommendations is limited to studies that only a baby needs to feed as often and for as long as he
reported indirect associations (Bravi et al., 2016). On or she wants, both day and night (Kent et al., 2006).
the other hand, a systematic review has reported This is called demand feeding, unrestricted feeding,
that maternal psychological state could influence or baby-led feeding.
some components in breast milk such as milk fat
and bioactive factors (e.g., immune-components, Giving anything other than breast milk to newborns
hormones etc.) as well as milk yield (Mohd Shukri et in the first few days after birth disrupts the
al., 2018). A randomised trial in Klang-Valley, establishment of breast milk production. Newborns
Malaysia, has also reported the changes in milk who are fed other foods or fluids will suckle less
hormone, specifically reduction of milk cortisol vigorously at the breast and thus inefficiently
(could be part of stress indicator) and increase in stimulate milk production, creating a cycle of
milk intake were shown among mothers who were insufficient milk and supplementation that leads to
KM1 less stressed due to the practice of relaxation breastfeeding failure. Infants who are supplemented
therapy (Mohd Shukri et al., 2019). prior to facility discharge have been found to be
twice as likely to stop breastfeeding altogether in
Breastfeeding also involves in recognising and the first six weeks of life (DiGirolamo et al., 2008). In
responding to the infant's expression of hunger and addition, foods and liquids may contain harmful
feeding cues, as well as readiness to feed, which bacteria and carry a risk of disease. Supplementation
helps foster mother-infant bonding relationship. with artificial milk significantly alters the intestinal
Responsive feeding (also called on demand or baby microflora (Guaraldi & Salvatori, 2012).
led feeding) puts no restrictions on the frequency or
length of the infant’s feeds, and mothers are advised A study by Win et al. (2006) proved that mothers
to breastfeed whenever the infant is hungry or as who express breast milk were more likely to
often as the infant wants. Scheduled feeding, which breastfeed to six months ('any' breastfeeding).
prescribes a predetermined, and usually time- Breast milk expression enables a woman to be away
restricted, frequency and schedule of feeds is not from her child while continuing to breastfeeding. In
recommended. It is important that mothers know addition to allowing infants left behind by their
that crying is a late cue and that it is better to feed mothers to enjoy the full benefits of breast milk,
the baby earlier, since optimal positioning and breast milk expression is also of immense benefits
attachment are more difficult when an infant is in to mothers as it brings relief from the pressure that
distress (WHO, 2018a). Health professionals should the milk subjects the mammary glands, hence
educate mothers on responsive feeding and place a reduces the risk of breast engorgement, mastitis and
particular emphasis on first-time, older, and non- breast cancer (Kimani-Murage et al., 2011). Breast
exclusive breastfeeding mothers (Chen et al., 2020). milk expression is believed to be a feasible
intervention to ensure high level coverage of
McKenna et al. (1997) discovered that infants who exclusive breastfeeding (Attahiru et al., 2018). In
consistently slept together with the mother, addition, poor practice of breast milk expression has
breastfed approximately three times longer during been found to be rooted in several erroneous beliefs
the night than infants who routinely slept separated, (such as milk supply generally being insufficient for
resulting in a twofold increase in the number of babies) and lack of knowledge, especially on how to
breastfeeding sessions and 39% longer sessions. increase their milk production (Prabhu et al., 2016).
Consistently, in Malaysia, bedsharing has also In Malaysia, many antenatal programs now include
shown to be associated with exclusive information on breast milk expression and this could
breastfeeding among mothers in Klang (Tan, 2011). be expanded to ensure that all parents are given
In addition, rooming-in is necessary to enable information on the appropriate and safe use of
mothers to practise responsive feeding, as mothers expression and the storage of breast milk.
cannot learn to recognize and respond to their
6
1.3.2 Healthcare provider
All healthcare providers such as doctors, midwives, and preterm infants with weak or poor sucking
nurses, nutritionists, dietitians, and other allied skills. If the volume of mother’s own breast milk
healthcare personnel have a role to play in providing does not meet the infant's feeding requirement,
support and practical help to breastfeeding women. donor breast milk should be the first choice of
Timely and appropriate care for breastfeeding supplement, if available. Healthcare providers also
mothers can only be accomplished if healthcare need to provide anticipatory guidance to help
providers have evidence-based knowledge, parents anticipate and prepare for common
competence and skills in both lactation breastfeeding challenges they might encounter
management and communication required for (such as breast engorgement, sore nipples, milk
breastfeeding counselling (WHO, 2018b). supply issues) and how to manage them (WHO,
2018a; WHO & UNICEF, 2020).
Evidence has shown that providing antenatal and
postnatal breastfeeding counselling to mothers, and Ambivalent attitudes towards breastfeeding are also
other family members by skilled personnel can influenced by pervasive marketing and increasing
reduce the risk of not initiating breastfeeding within global sales of infant formula. The International
the first hour by 42%, increase exclusive Code of Marketing of Breastmilk Substitutes and its
breastfeeding by 48% and improve breastfeeding subsequent resolutions are fundamental to
practices (Kim et al., 2018; Navarro et al., 2021). protecting the public and healthcare staff from
inappropriate marketing by infant formula
Therefore, training healthcare professionals on companies. It is therefore critical that healthcare
properly guiding and informing mothers on staff who are in contact with breastfeeding mothers KM1
breastfeeding is also an important key component and babies, their families, and communities
in promoting and protecting breastfeeding practices understand the International Code of Marketing of
(Navarro et al., 2021). The training enables them to Breastmilk Substitutes and their role in its
develop effective counselling skills, build mother’s implementation. Without such knowledge,
confidence, give consistent messages, and healthcare staff are vulnerable to direct and indirect
implement policy standards to protect, promote and marketing (Gavine et al., 2016). Therefore, all
support breastfeeding (WHO, 2018b). When healthcare providers who provide maternal and
healthcare providers are confident in their own skills child health services must be trained not only in
and capacities to support breastfeeding mothers, breastfeeding counselling but also the Code and
they are more likely to positively promote conflicts of interest (Nutrition Division, 2021).
breastfeeding and offer support to mothers (Dykes,
2006; Almeida, 2015). As part of protecting, promoting, and supporting
breastfeeding, healthcare providers need to
All healthcare providers that come in contact with coordinate with community services that provide
mothers, infants and children should have basic breastfeeding/ infant feeding support, including
competencies in the following topics, but not limited clinical management and mother-to mother support.
to: counselling skills, importance of breastfeeding, This is in line with WABA’s Warm Chain of Support
risks of not breastfeeding, early initiation of for Breastfeeding (Warm Chain) campaign to ensure
breastfeeding, skin-to-skin contact, rooming in and that parents and their infants have access to
practical skills such as positioning and attachment, ongoing support and receive appropriate care
responsive (on demand) feeding, recognizing during the first 1000 days. Evidence indicates that
feeding cues and sustaining breastfeeding. They effectiveness of interventions promoting exclusive
should be able to teach mothers hand expression, breastfeeding up to six months after birth increases
handle expressed breast milk and cup feed. Mothers when a protocol is available for provider training,
should be coached on how to express breast milk as when healthcare professionals are involved, when
a means of establishing and maintaining their milk interventions are conducted from the pre to
supply in the event of their being separated postnatal period and when the hospital and
temporarily from their infants due to hospitalisation community are connected (WHO, 2018b; Kim et al.,
or returning to work; or in situations of small, sick 2018).
7
1.3.3 Family member and community especially crucial for new parents. This support
network has been shown to be effective in
Everyone, including family, friends, and society as a increasing exclusive breastfeeding duration and
whole, has a responsibility for protecting, promoting, rates, as well as reducing pre-lacteal feeding cases
and supporting breastfeeding. Studies have shown among newborn infants, especially in developing
that mothers who have a positive support network, countries (Shakya et al., 2017), including Malaysia
such as strong physical and emotional support from (Monoto et al., 2020). Interestingly, a Malaysian
their partner, family, and broader social network, study reported the use of breastfeeding videos as
were more likely to initiate breastfeeding and/or educational and training tools among breastfeeding
have longer exclusive breastfeeding duration (Bano- peer counsellors in helping mothers remotely
Pineroet et al., 2018). Therefore, educating and (Monoto et al., 2018). This is especially crucial when
promoting breastfeeding in the community is face-to-face support is difficult, such as during the
crucial, and this could also help to normalise travel restriction due to COVID-19 pandemic.
breastfeeding in the population.
Family and community support are also vital in
A systematic review has demonstrated that improving maternal mental health and well-being,
breastfeeding counselling and guidance delivered especially during the postpartum period. A recent
in a variety of contexts, integrating health systems, local study discovered that mothers who received
home and family, and the broader environment high family support, namely from their partners or
concurrently, have shown the greatest improvement family members, had fewer psychological distress
in breastfeeding initiation and exclusive symptoms, which could reduce breastfeeding
breastfeeding rates (Sinha et al., 2015). Within the problems and lengthen exclusive breastfeeding
KM1 support system, the husband or partner is duration (Dib et al., 2020). This suggests that
commonly the most influential support for mothers maternal social networks and coping behaviours
during the postpartum period, follow-up with family may have an indirect impact on lactation
and relatives such as grandmothers and siblings, as performance by improving the mother’s mental
shown in local studies including NHMS (IPH, 2016; health or emotional well-being.
Hamid et al., 2017; Phua et al., 2020; Shukri et al.,
2021). In addition, breastfeeding online support 1.3.4 Employer
groups and social media have become one of the
strongest platforms for mothers to seek help and Family-friendly policies that support breastfeeding
support remotely, especially during the COVID-19 are critical to maternal health and well-being, infant
pandemic, including in Malaysia during the health and development and gender equity in the
movement control order (Shukri et al., 2022). A workplace. Maternity leave policies have a positive
recent study has found that mutual relationships impact on breastfeeding initiation, exclusivity, and
between mothers or parents as members of a social breastfeeding duration (Navarro-Rosenblatt &
media community promote higher breastfeeding Garmendia, 2018) while returning to paid work too
success (Black et al., 2020). This indicates that online soon after the birth of a child may pose detrimental
platforms have been a good source of mother-to- effects (UNICEF, 2019). Most of the women often
mother support, empowerment, and knowledge- have to return to work after a short period of
sharing platforms. More study is needed, however, maternity leave and have minimal support to
to explore strategies to better assist breastfeeding continue breastfeeding at the workplace.
in the future, whether in person or online, during
pandemics or uncertain conditions. Mothers are always motivated to breastfeed their
child despite working conditions, or their socio-
Within the household, the partner and family demographic circumstances as long as the
members may be able to assist with infant care and workplace support is available to facilitate this
household chores, in addition to encouraging process (Rashid et al., 2018). A study in Taiwan
breastfeeding. This may be more advantageous for revealed that the rate of breastfeeding among
a woman if she has a family member who has employed mothers rapidly decreases after returning
previously breastfed her child. Within the to the workplace (Tsai, 2013). Thus, lack of a
community, breastfeeding support networks such supportive environment and facilities to breastfeed
as peer support and lactation counsellor groups can reduce the number of working mothers who
could provide technical aspects and practical tips breastfeed their child (Rashid et al., 2018). Therefore,
on breastfeeding, such as dealing with workplace support was significantly associated with
breastfeeding problems or challenges, which are breastfeeding support (Rashid et al., 2018).
8
Employers play a critical role in mothers’ success Mothers are acutely aware of and devoted to their
with breastfeeding when the women work full-time responsibilities when it comes to feeding their
(Tsai, 2013). Providing workplace lactation children, but the responsibilities of others must be
programming helps to maintain a stable workforce identified so that all mothers can obtain the
by reducing employee turnover. Lactation support information, help, and support they deserve when
for employees may save employers money in the they breastfeed their infants. Identifying the support
long-run (UNICEF, 2019). Some factors such as systems that are needed to help mothers meet their
higher education, lower workload, lactation room personal breastfeeding goals will allow them to stop
with independent space, taking advantage of breast feeling guilty and alone when problems with
pumping breaks and encouragement by colleagues breastfeeding arise. The role of fathers who support
and supervisors to use breast pumping breaks were breastfeeding includes providing support during
significant predictors of continuing to breastfeed for early initiation and advising mothers to breastfeed
more than six (6) months after returning to work immediately. They should also provide nutritious
(Tsai, 2013). If all these workplace support food for mothers to increase milk production and
mechanisms are in place, the productivity of the purchase breast-pumping equipment to stimulate
female worker will likely increase and mothers will first-time breastfeeding and become involved in
be less reluctant to come back to work sooner after doing household chores (Junarti et al., 2020).
maternity leave (Rashid et al., 2018).
Evidence suggests that inadequate hospital
Besides that, there is evidence showing a positive practices, and sociocultural and community factors
association of breastfeeding practice with self- have detrimental effects on timely initiation and
efficacy and workplace support (Rashid et al., 2018). exclusive breastfeeding (EBF); these include,
This positive association highlights that working providing infant formula to new mothers, separating KM1
mothers will continue to breastfeed their child if child and mother, not providing adequate
support from employers are provided which will in information and support to mothers regarding
turn increase their self-efficacy in carrying out this breastfeeding, and sociocultural beliefs, among
practice. Self-efficacy is an important predictor for other effects (Rollins et al., 2016; Al-Nuami et al.,
breastfeeding duration while the workplace may 2017). As a consequence, the availability of skilled
help bolster women’s self-efficacy by providing an peer counsellors in the community may be a helpful
environment that is supportive to breastfeeding approach for mothers to identify and overcome their
working mothers (Wallenborn et al., 2019). Hence, it challenges and barriers. Mothers require additional
is undeniable the effects of workplace support such counselling sessions in order to find approaches for
as letting mothers take short intervals to breast establishing and maintaining exclusive
pump or express breast milk, providing a clean place breastfeeding. Breastfeeding counselling should
with refrigerator for breast milk storage and also anticipate and address significant breastfeeding
having an onsite day care for babies in determining difficulties and conditions, as well as help mothers
good breastfeeding practice among working develop skills, competences, and confidence.
mothers (Rashid et al., 2018).
1.3.5 Challenges and overcome barriers
Breastfeeding self-efficacy is a mother's belief about

her ability and capacity to accomplish a task or to
deal with the challenges of breastfeeding (Nakada,
2008; Yamasaki et al., 2010; Abbass-Dick et al., 2015).
Mothers are likely to give up when faced with
challenges such as latching difficulties, fatigue, and
perceived insufficient milk production, (Mannion et
al., 2013). Indeed, the higher the maternal stress
level, the more likely she will stop providing breast
milk for her infant. Mothers should be conscious of
the challenges and barriers that might obstruct
breastfeeding and seek assistance so that
breastfeeding can be performed efficiently and
mothers can accomplish their breastfeeding goals
(Ismail et al., 2016).
9
1.4 Current Status
The WHO originally set a global target of 50% breastfeeding will be successful. Data showed our
exclusive breastfeeding prevalence by 2025. It was achievement in initiation was 65.3% within an hour,
recently updated to a prevalence of at least 70% by 24.3% within a day, and 6.9% a day after birth. The
2030. This means that each member country is remaining 3.6% of newborns, unfortunately, were
expected to reach a prevalence of exclusive never put to the breast. Early initiation within an
breastfeeding of at least 70% by the end of 2030. hour was more successfully practised among
This is aligned with the National Plan of Action for mothers from rural compared to urban; among other
Nutrition of Malaysia (NCCFN, 2016). The National Bumiputera compared to other ethnicities and those
Health and Morbidity Survey in 2016 is the latest who delivered their babies through vaginal delivery
national data that are available related to as compared to other assisted delivery or Caesarean
breastfeeding practise. Ever breastfed is defined as section (IPH, 2016).
those infants who have been put to the breast, even
if only once. The overall prevalence of ever- Women who initiated breastfeeding later than an
breastfeed was 98.1%, highest among Indians hour after delivery and those with more
compared to other ethnicities (IPH, 2016). breastfeeding difficulties were more likely to
discontinue exclusive breastfeeding. A longer
The most recent data on estimated exclusive prenatal intended duration and those who did not
breastfeeding in the first six months of life was express their breast milk were less likely to
40.3% (Nutrition Division & IPH, 2021). Married discontinue exclusive breastfeeding. Strengthening
status and housewives were more commonly able of Baby-Friendly Hospital Initiatives by encouraging
KM1 to breastfeed exclusively than single or working early initiation of breastfeeding and providing skill
women. It was interesting to note women from to handle breastfeeding difficulties are needed. A
lower social backgrounds including lower education correct breast milk expression technique and
and lowest household income are commonly able to storage might prevent women from discarding the
exclusively breastfeed their infants compared to expressed milk. All these strategies should be
women with higher education and higher household emphasised during antenatal classes to improve the
incomes categories. During the COVID-19 women’s intention and actual breastfeeding
pandemic, a local study reported 63% of mothers behaviour later (Ismail et al., 2013, Ismail et al., 2016).
breastfeed their infants up to six months during the Looking at the current achievement and the target
movement control order in 2020 (Shukri et al., 2022). set for 2030, there is a need to improve support and
Predominant breastfeeding among infants below six create a conducive environment that could promote
months was 70.1%. Reported highest in Malay, and protect breastfeeding practices. The role of four
among educated mothers and high household main stakeholders described in Key Message One;
income (IPH, 2016). the woman and her partner, family, employer, and
healthcare providers are exceptionally important.
The rate of breastfeeding success has been shown Their roles are discussed across the key
to be directly related to the time of early initiation. recommendations in ensuring the key message one
The earlier initiation takes place, the higher chance achievable.
10
1.5 Key Recommendations
Key Recommendation (KR) 1: Be mentally, emotionally and physically prepared for breastfeeding
starting from early pregnancy
How to Achieve (HTA)
Mother/ Father Family member Health Professional Employer
KR1: HTA1: KR1: HTA1: KR1: HTA1: KR1: HTA1:

Set personal Support the mother Attend breastfeeding Provide breastfeeding
breastfeeding goal. and father/ partner’s training to provide friendly workplace
decision to breastfeed skilled help. (maternity leave,
their child. breast milk
expression break and
other facility).
KR1: HTA2: - KR1: HTA2: KR1: HTA2:

Obtain breastfeeding Provide breastfeeding Encourage the
knowledge and skills counselling to all establishment of
by attending classes, pregnant women and breastfeeding peer
reading and joining mothers with young support group at KM1
support groups. children. workplace.
KR1: HTA3: - - -
Choose to give birth in
a hospital that supports
breastfeeding practices.
KR1: HTA4: - -
Ensure mother gets enough rest, good nutrition
and adequate fluid to keep healthy.
KR1: HTA5: - - -
Identify breastfeeding
support network and
reach out for help when
needed
11
Key Recommendation (KR) 2: Initiate breastfeeding within one hour of birth
Mother/ Father Health Professional
KR2: HTA1: KR2: HTA1:

Request to allow mother to hold baby skin to Allow, assist and encourage the mother to do
skin immediately after birth. skin-to-skin and initiate breastfeeding within one
hour after birth.
KR2: HTA2:
Initiate breastfeeding immediately within one hour after birth.
KR2: HTA3: -
Father/ partner assist and encourage mother to
do skin-to-skin.
Key Recommendation (KR) 3: Breastfeed frequently and on demand

KM1

Mother to stay near and Support and encourage Enable mothers and Provide supportive
be together with her mother to breastfeed on their infants to remain breastfeeding
infant/ infants day and demand. together and to practise workplace
night. rooming-in 24 hours in environment.
a day.

Recognise infant's Assist mothers to Discuss employee's
feeding cues. recognize and respond workload and
to their infant's cues consider flexible
for feeding. working hours.

Feed infants frequently Assist and encourage Consider exemption
and on demand during mother to breastfeed from field work if
day and night. on demand. necessary.
KR3: HTA4: - - -
Recognise the signs
infants is getting
enough milk.
12
Key Recommendation (KR) 4: Breastfeed with correct techniques
Mother/ Father Family member Health Professional
KR4: HTA1: KR4: HTA1: KR4: HTA1:

Learn the correct techniques to Experienced family member to Learn the correct breastfeeding
breastfeed. guide and assist mother to techniques.
breastfeed.

Ensure mother and baby are in Provide conducive and friendly Recognise when breastfeeding
comfortable position to environment for mother to is going well or having difficulty.
breastfeed. breastfeed.
KR4: HTA3: - KR4: HTA3:

Assist baby to latch correctly. Learn how to assist and
support mother and baby to
breastfeed.
KM1
Key Recommendation (KR) 5: Give only breast milk to infant below six months unless there are
medical reasons

Provide only breast Support mother and Support mother to Provide breastfeeding
milk to infants below father/ partner’s establish breastfeeding friendly workplace
six months either decision to provide and sustain breast milk (facility, maternity
through breastfeeding breast milk. supply by practising leave and
or expressed breast Key Recommendation breastfeeding break).
milk. 1 to 4.
KR5: HTA2: - KR5: HTA2: -

Establish breastfeeding Identify the possible
and sustain breast milk causes of milk
supply by practising insufficiency and
Key Recommendation manage appropriately.
1 to 4. Consider another
mother's breast milk
first before resorting to
formula milk in cases
of true breast milk
insufficiency.
KR5: HTA3: - - -
Continue to breastfeed
frequently, including at
night to sustain milk
production.
13
Key Recommendation (KR) 6: Continue to give breast milk up to 2 years old even when mother is
away from the baby (eg. hospitalisation, return to work, field work)

Express breast milk Help to feed and care Teach hand expression Provide maternity
when mother is away for the baby when and handling of leave.
from baby. mother is away. expressed breast milk.

Manage expressed Teach and practise Provide breastfeeding
breast milk according cup feeding. friendly workplace
to guidelines. (breastfeeding break
and facility).

Practise giving Teach and assist Provide flexible
expressed breast milk mother and father/ working hours.
using a cup. The use partner about hand
KM1 of milk bottles, nipples expression, handling
and empty nipples can of expressed breast
interfere with milk and cup feeding.
breastfeeding.
KR6: HTA4: - - -
Make arrangements to
have your baby near
your workplace, if
possible.
Key Recommendation (KR) 7: Be aware of the challenges and barriers in breastfeeding and ask
for/ offer help

Recognise challenges Experienced family Learn to recognise Allow mother time off/
and barriers that can member to guide and challenges and barriers unrecorded leave to
interfere with assist mother and that can interfere seek help/ medical
breastfeeding. father/ partner to with breastfeeding. treatment.
overcome challenges
and barriers.

Ask for help to Provide conducive and Provide appropriate Provide breastfeeding
overcome the friendly environment advice and treatment. friendly workplace
challenges and for mother to (maternity leave,
barriers. breastfeed. breastfeeding break
and facility).
14
Key Recommendation (KR) 7: Be aware of the challenges and barriers in breastfeeding and ask
for/ offer help (cont.)
- - KR7: HTA3: KR7: HTA3:

Refer mother to Consider flexible
breastfeeding peer working hours.
counsellor/ support
group.

Be aware of and Refer mother to
comply to the Code of breastfeeding support
Ethics for the group at work place if
Marketing of Infant available.
Foods and Related
Products.
KM1
15
1.5.1 Additional Recommendation
Breastfeeding in emergencies
Breastfeeding contributes to short and long term revised based on the latest evidence in December
health, good nutrition and food security in non- 2020, allowing skin-to-skin contact and
emergency and emergency situations. Emergencies breastfeeding. This, however, is determined on a
include natural disasters (such as floods or case-by-case basis, taking into account both the
earthquakes), civil unrest and war, famine or public mother's and the infant's health and healthcare
health emergencies (such as disease outbreak or resources. Regardless, this situation has also
pandemic). In Malaysia, floods are regular natural contributed to new experiences among mothers
disasters that happen almost every year during the during childbirth, which could have influenced the
monsoon season. Since January 2020, Malaysia has mothers' support system and maternity care at birth
been faced with COVID-19 pandemic. and postnatally. According to a study conducted
during the movement control order in Malaysia,
Research shows that during emergencies, infants these changes could have negatively influenced
and children are most vulnerable to malnutrition, mothers' postnatal experiences, emotional well-
illness and death. Access to food, shelter, safe water, being as well as breastfeeding practices (Shukri et
sanitation, medical care and access to other basic al., 2022).
necessities required to keep children safe and
nourished are commonly disrupted. When systems In addition, COVID-19 pandemic has impacted
are disrupted, breastfeeding continues to offer livelihood and maternal social support, which may
KM1 nutrition security, hydration, comfort, connection, have affected the overall mother’s mental health and
and protects babies from infectious disease (ENN, wellbeing, and this may eventually influence
2021). Therefore, strengthening systems and breastfeeding practice (Shukri et al., 2022). Therefore,
capacities for breastfeeding support is regular mental health screening is also

recommended because it is a crucial form of recommended in any emergency situations.
emergency preparedness. Putting policies, Symptomatic mothers may get early intervention,
programs and actions in place is also recommended which, in the absence of therapy, may increase the
to provide support for mothers to breastfeed even probability of breastfeeding discontinuation. In
when they are impacted by emergencies. addition, all stakeholders (such as the family,
community, government, etc.) should provide
In March 2020, Malaysia established a COVID-19 financial, social, and emotional support to ensure
management guideline for newborns in which that the mother and child are in the best possible
breastfeeding was not permitted unless the health throughout any disaster or emergency
mother's COVID-19 infection had been confirmed situation, including the recovery phase.
negative (WHO, 2020). The guideline was later
16
1.6 References
Abbass-Dick, J., Stern, S., Nelson, L., Watson, W. & Dennis, C-L. (2015). Coparenting Breastfeeding Support
and Exclusive Breastfeeding: A Randomized Controlled Trial. Pediatrics, 135(1),102-110.
https://doi.org/10.1542/peds.2014-1416.
Almeida, J. M. D., Luz, S. D. A. B., & Ued, F. D. V. (2015). Support of breastfeeding by health professionals:
integrative review of the literature. Rev Paul Pediatr. 33(3):356-63. doi: 10.1016/j.rpped.2014.10.002.
Attahiru, A. Awosan, Kehinde M Oche, Oche Umar, Kaoje Yusuf, Tahir &Ango, U.M.. (2018). Breastfeeding
Support and Determinants of Expressed Breast Milk Feeding Practice among Working Mothers in
Sokoto, Nigeria. International Journal of Contemporary Medical Research [IJCMR]. 5.
10.21276/ijcmr.2018.5.8.18.
Bano-Pinero, I., Martínez-Roche, M. E., Canteras-Jordana, M., Carrillo-García, C., & Orenes-Piñero, E. (2018).
Impact of support networks for breastfeeding: a multicentre study. Women and Birth, 31(4), e239-
e244.
Black, R., McLaughlin, M., & Giles, M. (2020). Women's experience of social media breastfeeding support
and its impact on extended breastfeeding success: A social cognitive perspective. Br J Health Psycho,
25(3), 754-771.
Bravi, F., Wiens. F., Decarli, A., Dal Pont, A., Agostoni, C., & Ferraroni, M. (2016). Impact of maternal nutrition KM1
on breast-milk composition: a systematic review. Am J Clin Nutr. 104(3):646-62. doi:
10.3945/ajcn.115.120881.
Chen, T. L., Chen, Y. Y., Lin, C. L., Peng, F. S., & Chien, L. Y. (2020). Responsive Feeding, Infant Growth, and
Postpartum Depressive Symptoms during 3 Months Postpartum. Nutrients, 12(6), 1766.
Dib, S., Fewtrell, M., Wells, J. C., & Shukri, N. H. M. (2020). The influence of hospital practices and family
support on breastfeeding duration, adverse events, and postnatal depression among first-time
mothers. Malaysian J Med Health Sci, 16(6), 90-98.
DiGirolamo, A.M., Grummer-Strawn, L.M., & Fein, S.B., (2008). Effect of maternity-care practices on
breastfeeding. Pediatrics. 122(Suppl.2):S43–9. doi:10.1542/peds.2008-1315e.
Dykes, F. (2006). The education of health practitioners supporting breastfeeding women: time for critical
reflection. Maternal & Child Nutrition, 2(4), 204-216.
Emergency Nutrition Network (2021). IFE Core Group. Operational Guidance: Breastfeeding Counselling
in Emergencies. https://www.ennonline.net/breastfeedingcounsellinginemergencies
Gavine, A., MacGillivray, S., Renfrew, M. J., Siebelt, L., Haggi, H., & McFadden, A. (2016). Education and
training of healthcare staff in the knowledge, attitudes and skills needed to work effectively with
breastfeeding women: a systematic review. Int Breastfeed J, 12(1), 1-10.
Hamid, S. B. A., Chih, H. J., & Binns, C. (2017). Predictors of Breastfeeding Intention in Malaysia.
Environment-Behaviour Proceedings Journal, 2(5), 161-167.
Institute for Public Health (2016). National Health and Morbidity Survey 2016 (NHMS 2016), vol. II, Kuala
Lumpur (2016) Maternal and Child Health Care.
Ismail, T. A. T., Muda, W. A. M. W., & Bakar, M. I. (2016). The extended Theory of Planned Behavior in
explaining exclusive breastfeeding intention and behavior among women in Kelantan, Malaysia.
Nutrition Research and Practice, 10(1), 49-55.
Jeong, G., Park, S. W., Lee, Y. K., Ko, S. Y., & Shin, S. M. (2017). Maternal food restrictions during breastfeeding.
Korean Journal of Pediatrics, 60(3), 70–76. https://doi.org/10.3345/kjp.2017.60.3.70
17
Junarti, D., Raharjo, B. B. & Rahayu, S. R. (2020). Role factors that affecting non-exclusive breastfeeding
(Qualitative Study at Pegandan Health Center). Public Health Perspective Journal, 5(2), 119–127.
Karcz, K., Lehman, I., & Królak-Olejnik, B. (2020). Foods to Avoid While Breastfeeding? Experiences and
Opinions of Polish Mothers and Healthcare Providers. Nutrients 12, 1644, 1-11.
https://doi.org/10.3390/nu12061644.
Kent J et al. (2006). Volume and frequency of breastfeeding and fat content of breastmilk throughout the
day. Pediatrics, 117(3): e387–392.
Kim, S. K., Park, S., Oh, J., Kim, J., & Ahn, S. (2018). Interventions promoting exclusive breastfeeding up to
six months after birth: A systematic review and meta-analysis of randomized controlled trials.
International Journal of Nursing Studies, 80, 94-105.
Kimani-Murage, E.W., Madise, N.J., Fotso, J.C., Kyobutungi, C., Mutua, M.K., Gitau, T.M., & Yatich, N. (2011).
Patterns and determinants of breastfeeding and complementary feeding practices in urban informal
settlements, Nairobi, Kenya. BMC Public Health; 11: 396.
Lauwers. J. & Swisher, A. (2011) Counselling the Nursing Mother: A Lactation Consultant Guide. 5th Edition,
Jones and Bartlett Learning, Burlington.
Mannion, C. A., Hobbs, A. J., McDonald, S. W. & Tough, S. C. (2013). Maternal perceptions of partner support
KM1 during breastfeeding. International Breastfeeding Journal, 8, 4, 1-7. https://doi.org/10.1186/1746-4358-8-4.
Mat Nawi, N. I., & Abdul Hamid, S. B. (2021). Determinants of fathers' involvement in breastfeeding practices
in Kuala Selangor. Malaysian Journal of Nutrition, 27(1).
Mattar, C.N., Chong, Y.S., Chan, Y.S., Chew, A, Tan, P, Chan, Y.H., & Rauff, M.H. (2007). Simple antenatal
preparation to improve breastfeeding practice: a randomized controlled trial. Obstet Gynecol.
109(1):73-80. doi:10.1097/01.AOG.0000249613.15466.26. PMID: 17197590.
McKenna, J.J., Mosko, S.S., & Richard, C.A. (1997). Bedsharing promotes breastfeeding. Pediatrics,
100(2):214-219. 32.
Mohd Shukri, N. H., Wells, J., Eaton, S., Mukhtar, F., Petelin, A., Jenko-Pražnikar, Z., & Fewtrell, M. (2019).
Randomized controlled trial investigating the effects of a breastfeeding relaxation intervention on
maternal psychological state, breast milk outcomes, and infant behaviour and growth. Am J Clin Nutr
110(1), 121-130.
Mohd Shukri, N. H., Wells, J. C., & Fewtrell, M. (2018). The effectiveness of interventions using relaxation
therapy to improve breastfeeding outcomes: A systematic review. Maternal & Child Nutrition, 14(2),
e12563.
Monoto, E. M. M., & Alwi, N. K. M. (2018). Breastfeeding videos as a new training tool for Malaysian
breastfeeding peer counsellor program in empowering breastfeeding communities. IIUM Medical
Journal Malaysia, 17(1): 59-63.
Monoto, E.M.M., Hamzah, Z., Mohamad Alwi, N., & Abdul Wahab, A. (2020). Breastfeeding peer counsellor
program in Malaysia: Impact on breastfeeding duration and exclusivity. Bali Medical Journal 9(3):
876-883.
Nakada, K. (2008). An Analysis of maternal self-efficacy and breastfeeding continuation. Journal of Japan
Academy of Midwifery, (22)2,208-221.
Navarro, I., Soriano, J.M. & Laredo, S. (2021). Applying systematic review search methods to the grey
literature: a review of education and training courses on breastfeeding support for health
professionals. Int Breastfeed J 16, 31-xx. https://doi.org/10.1186/s13006-021-00373-5
18
Navarro-Rosenblatt, D., & Garmendia, M. L. (2018). Maternity leave and its impact on breastfeeding: a review
of the literature. Breastfeeding Medicine, 13(9), 589-597.
NCCFN (2013). Malaysian Dietary Guidelines for Children and Adolescents 2013. National Coordinating
Committee on Food and Nutrition, Ministry of Health Malaysia, Putrajaya.
NCCFN Malaysia (2016). National plan of action for nutrition of Malaysia III 2016-2025. National
Coordinating Committee on Food and Nutrition, Ministry of Health Malaysia, Putrajaya.
Nutrition Division & Institute for Public Health (2021). Over or Under: Double Burden of Child Malnutrition
in Malaysia: A Landscape Analysis (Volume I). Ministry of Health Malaysia Putrajaya.
Nutrition Division (2021). Code of Ethics for Marketing Infant Food and Related Products. Ministry of Health
Malaysia, Putrajaya. https://nutrition.moh.gov.my/en/tata-etika-pemasaran-makanan-bayi-dan-
produk-berkaitan/
Pérez‐Escamilla, R., Martinez, J. L., & Segura‐Pérez, S. (2016). Impact of the Baby‐friendly Hospital Initiative
on breastfeeding and child health outcomes: a systematic review. Maternal & Child Nutrition, 12(3),
402-417.
Phua, H.W., Razak, N.A.A.A., & Shukri, N.H.M. (2020). Associations of father’s breastfeeding attitude and
support with the duration of exclusive breastfeeding among first-time mothers. Malaysian J Med
Health Sci, 16, 84-89. KM1
Pisacane, A., Continisio, G.I., Aldinucci, M., D’Amora, S. & Continisio, P. (2005). A controlled trial of the
father’s role in breastfeeding promotion. Pediatrics, 116(4), E494–E498.
Prabhu, P.M., Radhe, B.K., Naik, J.D., Brahmankar, T.R., Behere, V.S. (2016). Knowledge, attitude and practice
of expression of breast milk among mothers in Western Maharashtra. J Med Sci Clin Res 4: 8828-8834.
Rempel, L. A. & Rempel, J. K. (2004). Partner influence on health behavior decision making: Increasing
breastfeeding duration. Journal of Social and Personal Relationships,21(1),92–111.
Rashid, A. A., Shamsuddin, N. H., Ridhuan, R. D. A. R. M., Amalina, N., & Sallahuddin, N. K. D. (2018).
Breastfeeding practice, support, and self-efficacy among working mothers in a rural health clinic in
Selangor. Malays J Med Health Sci, 14(2), 39-49.
Rollins, N.C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C.K., Martines, J.C., Piwoz, E.G., Richter, L.M.,
Victora, C.G. and Group, T.L.B.S., (2016). Why invest, and what it will take to improve breastfeeding
practices?. The Lancet, 387(10017), pp.491-504.
Guaraldi, F. & Salvatori, G. (2012). Effect of breast and formula feeding on gut microbiota shaping in
newborns. Front Cell Infect Microbiol. 2:94. doi: 10.3389/fcimb.2012.00094. PMID: 23087909; PMCID:
PMC3472256.
Samir, A., Cheryl, M., Julie, W. & Phyllis, K. (2000). Major Factors Influencing Rates: Moher’s Perception of
Father’s Attitude and Milk Supply. Pediatrics, 106(5),1-5.
Scott, J. A., Binns, C. W., Graham, K. I. & Oddy, W. H. (2006). Temporal changes in the determinants of
breastfeeding initiation. Birth, 33(1),37–45.
Sinha, B., Chowdhury, R., Sankar, M. J., Martines, J., Taneja, S., Mazumder, S., & Bhandari, N. (2015).
Interventions to improve breastfeeding outcomes: A systematic review and meta‐analysis. Acta
paediatrica, 104, 114-134.
Shakya, P., Kunieda, M. K., Koyama, M., Rai, S. S., Miyaguchi, M., Dhakal, S., & Jimba, M. (2017). Effectiveness
of community-based peer support for mothers to improve their breastfeeding practices: A systematic
review and meta-analysis. PloS one, 12(5), e0177434.
19
Shukri, N. H. M., Wells, J., & Fewtrell, M. (2021). Differences in maternal characteristics and their associations
with breastfeeding attitudes among primiparous mothers. Midwifery, 95, 102931.
Shukri, N. H. M., Gan, W. Y., Zalbahar, N., Tusimin, M., & Nasri, N. M. (2022). COVID-19 Restrictions and
Maternal Experience and Infant Feeding. Nursing Research, 71(2), E10-E20.
Tan, K. L. (2011). Factors associated with exclusive breastfeeding among infants under six months of age
in peninsular Malaysia. Int Breastfeed J, 6(1), 1-7
Ismail, T. A. T., Muda, W. A. M. W., & Bakar, M. I. (2013). Factors predicting early discontinuation of exclusive
breastfeeding among women in Kelantan, Malaysia. Health and the Environment Journal, 4(1), 42-54.
Tsai, S.Y. (2013). Impact of a breastfeeding-friendly workplace on an employed mother's intention to

continue breastfeeding after returning to work. Breastfeed Med. 8(2):210-6. doi:
10.1089/bfm.2012.0119. Epub 2013 Feb 7. PMID: 23390987; PMCID: PMC3616406.
UNICEF (2019). Business and family-friendly policies: an evidence brief. United Nations Children’s Fund.
New York. https://www.unicef.org/media/95071/file/UNICEF-Breastfeeding-Family-
Friendly%20Policies-2019.pdf
Ventura, A. K. (2017). Associations between breastfeeding and maternal responsiveness: a systematic review
of the literature. Advances in Nutrition, 8(3), 495-510.
KM1
Victora, C.G., Bahl, R., Barros, A.J., França, G.V., Horton, S., Krasevec, J., Murch, S., Sankar, M.J., Walker, N.,
Rollins, N.C. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet,
387(10017), 491-504. doi:10.1016/s0140-6736(15)010442
Wallenborn, J. T., Perera, R. A., Wheeler, D. C., Lu, J., & Masho, S. W. (2019). Workplace support and
breastfeeding duration: The mediating effect of breastfeeding intention and self‐efficacy. Birth, 46(1),
121-128.
Win, N. N., Binns, C. W., Zhao, Y., Scott, J. A., & Oddy, W. H. (2006). Breastfeeding duration in mothers who
express breast milk: a cohort study. International Breastfeeding Journal, 1(1), 1-5.
Wood, N.K., Woods, N.F., Blackburn, S.T., & Sanders, E.A. (2016). Interventions that enhance breastfeeding
initiation, duration, and exclusivity: a systematic review. MCN Am J Matern Child Nurs; 41:299-307.
World Health Organization & United Nations Children's Fund ( UNICEF) ( 1989) . Protecting, promoting,
and supporting breast-feeding: the special role of maternity services / a joint WHO/UNICEF
statement. World Health Organization. https://apps.who.int/iris/handle/10665/39679
WHO/UNICEF (2009). Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care.
Section 3: breastfeeding promotion and support in a Baby-friendly hospital. A 20-hour course for
maternity staff. WHO, Geneva.
WHO (2018a). Implementation guidance: protecting, promoting and supporting breastfeeding in facilities
providing maternity and newborn services: the revised baby-friendly hospital initiative. World Health
Organization, Geneva.
WHO (2018b). Guideline: counselling of women to improve breastfeeding practices. World Health
WHO (2020). Baby-friendly hospital initiative training course for maternity staff: trainer's guide (session 6).
World Health Organization, Geneva
Yamasaki, M., Iriyama, S., Hamasaki, M. & Honda, Y. (2010). The relationships between Sense of Coherence,
breastfeeding self-efficacy and burden of breastfeeding among mothers with early confinement
periods. Health Science Research, 22(2),45-50.
20
Appendices
Appendix 1.1: Breastfeeding with correct technique
1. Make sure the mother is in a comfortable

position either sitting or lying down.
2 2. Make sure baby is well-positioned for

breastfeeding:
a. Baby’s head and body are in a straight KM1
line.
b. Baby is held close to the mother's
body.
c. Baby’s whole body and head is well
supported and facing the mother's
breast.
3
3. Make sure the baby is well latched on to the
breast. Signs of good attachment are:
a. Baby’s mouth is wide open.
b. Baby’s lower lip is turned outward.
c. Baby’s chin touches the mother's breast.
d. More areola, seen above the baby's
upper lips.
4
4. Observe baby’s suckling. Signs of baby’s
effective suckling:
a. Baby suckles slowly and deeply with
pauses in between.
b. Baby’s cheeks appear full and round
during suckling.
c. Mother can hear the baby swallowing.
d. Baby releases breast when finished.
21
KM1
22
Key Message 2
Give appropriate complementary foods to children

between the age of 6 months to 2 years
KM2
Give appropriate complementary foods to children between the age of 6 months to 2 years
Key Message 2
Give appropriate complementary foods to children

between the age of 6 months to 2 years
Prof. Dr. Zalilah Mohd Shariff, Assoc. Prof. Dr. Aryati Ahmad, Ms. Nor Ratna Mustaffa, Ms. Nur Shafawati Mohd Ghazali,
Ms. Roslinda@Zakiah Kangan and Ms. Irma Hanim Abdullah
2.1 Terminology
Animal source foods Dietary diversity

Food items from animal source such as meat, Number of food groups or foods which are
seafood, eggs, milk and dairy products. consumed over a specific period.
Bisphenol A (BPA) Finger foods

Chemical produced in large quantities for use Any food that is self-held and can be eaten
primarily in the production of polycarbonate plastics independently, such as soft biscuits, rusks and bite-
and epoxy resins. sized fruits.
Complementary foods Food texture

Solid, semi-solid and soft foods (both locally Qualities of a food that can be felt with the fingers,
prepared and commercially manufactured) provided tongue, palate, or teeth
to children between the ages of 6 and 23 months to
complement breastmilk. Fortified foods
Food that has extra nutrients added to it or has
nutrients added that are not normally there.
24
Infant formula Minimum meal frequency (MMF)

Any food described or sold as an alternative for A breastfed child aged 6-8 months and 9 months to
human milk for the feeding of infants. It is a product 2 years receiving minimum 2 meals and 3 meals
prepared from milk of cow or other animal or other daily respectively, while non-breastfed child aged 6-
edible includes ready-to-feed formula. 23 months receiving at least 4 meals daily.
Infant Nutritious snacks

A child not more than 12 months of age Any nutrient dense food eaten in small portions and
between main meals. It should not replace main
Micronutrient supplementation meals and is usually self-fed, convenient and easy
Administration of a single or multiple micronutrients to prepare, such as fresh fruits and mini sandwiches.
in the forms of drops, syrups, tablets, or capsules.
Responsive feeding
Minimum acceptable diet (MAD) An active and interactive process of feeding that
An indicator for evaluating child feeding practices pays attention to the young child while offering food,
that consists of a combination of minimum dietary observes for reactions and cues, and responds
diversity and minimum meal frequency. promptly and supportively to the child’s needs.
Minimum dietary diversity (MDD) Young child

A child receiving at least five out of eight food A child in the age group of 6 to 24 months.
groups which are breast milk, grains/roots/tubers,
legumes/nuts, milk/dairy products, flesh foods
(meat, fish, poultry, liver or other organs), eggs, KM2
vitamin A-rich fruits and vegetables, and other fruits
and vegetables.
2.2 Introduction
The first two years of life is a window of opportunity inappropriate complementary feeding practices,
for promoting optimal growth and development. with their associated adverse health consequences,
Early growth faltering is a consequence of remain a significant global public health problem.
interaction of many factors such as poverty, poor
sanitation and access to potable water, lack of Since the year 2000, the global prevalence of
access to health care services, poor maternal health undernutrition among children under five years of
and nutrition, low birth weight, suboptimal child age has gradually declined with the prevalence in
feeding practices, inadequate access to diverse 2020 for underweight, stunting and wasting were
foods and lack of responsive caregiving or 12.6%, 22.0% and 6.7%, respectively. On the other
psychosocial stimulation (Aneja et al., 2020). hand, the prevalence of overweight has slightly
Feeding practices in early life can have lifelong increased from 5.4% to 5.7% (World Bank, 2022). In
health implications as young children establish Malaysia, the National Health and Morbidity Survey
eating habits and food preferences during this (NHMS) 2022 reported that 15.3%, 21.2%, 11.0% and
period (Darling et al., 2020). Starting good nutrition
practices early in life can help young children
develop healthy dietary habits and patterns that can
track into later childhood and adult life (CDC, 2021).
The World Health Organization (WHO) defines

complementary feeding as the process of
introducing foods or liquids other than breastmilk to
meet the nutritional requirements of infants that are
no longer sufficient to be met by only breast milk
(WHO, 2019). The period of complementary feeding
typically covers the age of 6 months to 2 years and
is a transition from exclusive breastfeeding to
feeding family foods while continuing breastfeeding
until two years of age or beyond. It is a critical
period of rapid growth and development and
25
6.0% of children under five years were underweight, months) has been associated with nutrient
wasted and overweight, respectively (IPH, 2022). deficiencies and risk of growth faltering (WHO,
Malnutrition during this period can be prevented 2021a). During the period of introducing
through many strategies, including breastfeeding in complementary feeding, the young child is
the first 2 years of life and introducing nutritious, developmentally ready for other foods, shows
diverse and safe foods in early childhood. interest in foods other than milk and gradually
becomes accustomed to eating family foods
Around the age of 6 months, breast milk or infant (Abeshu et al., 2016). As complementary feeding is
formula alone is insufficient to meet the growing essential to provide the energy and nutrients
child’s requirements for energy and nutrients, required for continued growth and development of
particularly protein, iron, zinc and some fat-soluble the young child, recommended practices of
vitamins (A and D) (Abeshu et al., 2016). The timing complementary feeding should include the timely
of complementary feeding is critical as both too introduction of complementary foods at 6 months of
early and too late in introducing complementary age, sufficient meal frequency and portions sizes,
foods have been associated with adverse health and diversity of diet, appropriate food texture, safe food
nutritional outcomes (Hirvonen et al., 2021). For preparation, storage and hygiene behaviors, and
example, early introduction to complementary foods responsiveness to feeding cues (PAHO, 2003; WHO,
(<4 months) has been linked to child overweight 1998; WHO & UNICEF, 1998).
(Baidal et al., 2016), whereas late introduction (>6
KM2 2.3.1 Timing of complementary feeding
The first 1000 days of life includes breastfeeding and (ESPGHAN) Committee, and the European Food
complementary feeding practices that are important Safety Authority (EFSA) recommends that
for child growth and development. Good nutrition complementary feeding starts between the age of 4
during early childhood is also linked to reduced risks and 6 months (Dimaggio et al., 2017; Fewtrell et al.,
of double burden of malnutrition and non- 2017; EFSA, 2019). Although there are
communicable diseases in later life as well as inconsistencies in these guidelines, none has
improved cognitive outcomes (Campoy et al., 2018). recommended introducing complementary foods
To promote optimal complementary feeding before 4 months or delaying beyond 6 months of
practice, the World Health Organization has age.
provided guiding principles for complementary
feeding, appropriate for breastfed and non-breastfed The timing of complementary feeding coincides
infants for use in developing relevant young child with the child’s physiological maturation of
feeding recommendations (WHO, 2021a). Building gastrointestinal, renal and neurological systems as
on these guiding principles and current well as motor skills that usually occur around 4 – 6
complementary feeding practices in the Asia Pacific months of age (Fewtrell et al., 2017). However,
region, the Asia Pacific Academic Consortium for available evidence shows that introducing
Public Health (APACPH) provides recommendations complementary foods before 6 months confers no
for complementary feeding of infants in the Asia advantage on growth and acceptance of new foods,
Pacific region (Binns et al., 2020). reduces the amount of breast milk and increases the
risk of gastrointestinal and upper respiratory
The WHO recommends that complementary feeding infections and that there are unlikely to be any risks
should start at 6 months of age (WHO, 2019), based associated with initiating complementary feeding at
on an expert consultation (WHO, 2001) and a 6 months (SACN, 2018). Additionally, delaying the
systematic review of the optimal duration of introduction of complementary foods beyond 6
exclusive breastfeeding (Kramer & Kakuma, 2012). months, may lead to feeding difficulties and
While the WHO guideline has been adopted by micronutrient deficiencies that could potentially
many countries, the American Academy of affect cognitive and neurological development
Pediatrics (AAP), the European Society for Pediatric (SACN, 2018).
Gastroenterology, Hepatology and Nutrition
26
2.3.2 Energy and nutrients of complementary (WHO, 2021a; WHO, 2021b). In Malaysia, similar
foods energy requirement has been recommended for
healthy breast-fed and formula-fed infant due to
Complementary feeding recommendations and recent significant changes in the composition of
practices are based on the concept that breast milk infant formula whereby the protein to energy ratio
alone is no longer sufficient to meet the infant’s is closer to human milk (NCCFN, 2017). Therefore,
nutritional requirements. As an infant grows and energy needs from complementary foods are
develops, it experiences physiological shifts in estimated as shown in Table 2.1.
nutrient and energy requirements that can no longer
be supported by breast milk alone. Consequently, Several complementary feeding indicators have
other foods and liquid together with breastmilk been recommended to ensure that the diets of
become essential to support the active phase of infants and young children met the recommended
growth and development during the early life, energy and nutrient requirements during this period
provide adequate energy and nutrients, maintain a of rapid growth and development. Among others are
better balance with other nutrients and avoid excess minimum meal frequency (MMF), minimum dietary
and deficiency of nutrients (Binns et al., 2020). diversity (MMD) and minimum adequate diets
Although nutritional requirements vary throughout (MAD) (WHO, 2021c). Globally, only 52%, 29% and
the first 2 years of life and growth patterns are 18% of infants and young children met MMF, MDD
closely linked to the child’s dietary intake, the and MAD with no significant improvements in MMF
strategies to achieve adequate energy and nutrients (2010 – 51%) and MDD (2010 – 21%) over the past
through complementary foods will vary with the decade (UNICEF, 2021a). In addition, there are
environment e.g. food availability and culture. An disparities in the distribution of MMF and MDD
exploratory study in the United Kingdom reported across regions of the world as well as residence and KM2
that most Chinese immigrant infants were wealth of the populations. Young children in Eastern
introduced to solid foods earlier than the and Southern Africa, West and Central Africa, and
recommended age of 4 to 6 months, which is a South Asia have the lowest meal frequency, dietary
common practice in some parts of China. Compared diversity, and consumption of nutritious foods
to their White middle-class counterparts, the (fruits/vegetables, eggs/ fish/meat). By residence,
Chinese immigrant mothers also demonstrated a the percentages of children with MMF and MDD are
stronger belief that preventing access to unhealthy higher in urban (MMF – 57%; MDD – 39%) than rural
foods was a better strategy to prevent overweight (MMF – 48%; MDD – 23%) residence. Comparison of
which will generally improve the infant’s diet the poorest (MMF – 45%; MDD – 19%) and
(Zhang et al., 2020). wealthiest (MMF – 57%; MDD – 40%) wealth
quintile shows that not only wealth affects the diet
Generally, breast milk contributes approximately 50- quality of children, but also poor diets of young
60% of energy and nutrient requirements for 6 – 11 children are prevalent regardless of wealth (UNICEF,
month old infants and continues to provide 30-40% 2021a).
of their nutritional needs in the second year of life
Table 2.1 Daily energy requirement for infants and children from 6 months – 2 years
Daily energy Estimated energy for

Age (Months/ Years)
needs (kcal/day)1 complementary food (kcal/ day)2
6 to 8 months
Male 630 252 – 315
Female 570 228 – 285
9 to 11 months
Male 720 288 – 360
Female 660 264 – 330
1 to 2 years
Male 980 588 – 686
Female 900 540 – 630
1 RNI (NCCFN, 2017)
2 WHO (2021a); WHO (2021b)
27
Infants and young children require a variety of foods foods in the diet of infants and young children and
to ensure all nutrient needs are met. The newly that eliminating or reducing grain foods may lead to
revised MDD indicator has included breast milk as unintended nutrient and health consequences
the eighth food group and changed the criterion of (Papanikolaou & Fulgoni, 2019).
MDD from 4 out of 7 food groups to 5 out of 8 food
groups (WHO, 2021b; WHO, 2021c). Other than Adequate diets during complementary feeding
breast milk, food groups that should be included in periods should not only include variety and nutrient-
the diets of infants and young children are grains, dense foods, animal source foods, fruits and
roots, tubers and plantains; pulses (beans, peas, vegetables but also exclude sugars or salt and
lentils), nuts and seeds; dairy products (milk, infant without excess energy, saturated and trans fats
formula, yogurt, cheese); flesh food (meat, fish, (UNICEF, 2020). Foods or drinks with low nutritional
poultry, organ meats); eggs; vitamin A rich fruits and value (high fat, sugar and salt) should be avoided in
vegetables; and other fruits and vegetables. The the diets of young children as these foods and drinks
consumption of at least 5 food groups, including can contribute to excess energy, displace breastmilk
animal source foods, has been shown to be and decrease appetite for nutritious foods. Although
associated with reduced risk of stunting in young an adequate amount of fats is needed to support
children (Krasevec et al., 2017; Headey et al., 2018). growth and development of children, the quality of
fats in the diets of young children is important. While
In a systematic review and meta-analysis of long-chain polyunsaturated fatty acids promote
randomised controlled trials in low- and middle- cognitive and motor development, trans fats should
income countries, complementary feeding practices be avoided due to its association to inflammation
that include animal source foods, tend to improve during childhood and risk of chronic disease in
KM2 the physical growth (higher length-for-age and adulthood (Bournez et al., 2019; Caroli et al., 2022).
weight-for-age) of young children (Asare et al., Sweet taste experience in early childhood may
2022). For infants who are unable to consume animal trigger the preference for such flavor and establish
source foods in sufficient amounts, adequate quality lifelong taste preference for sugar which could
protein can be obtained by consuming fortified increase the risk of overweight and obesity as well
foods or a combination of grains and legumes that as non-communicable diseases (D’Auria et al., 2020).
should be included in the daily diet, preferably In line with salt reduction strategies by the World
within the same meal. De Jager et al., (2019) reported Health Organization, there is no recommendation on
that 60% of children in Northern Ghana consumed the amount of salt that should be added in foods
legumes with an average portion size of 20g per day prepared for infants and young children during the
(cooked), contributing more than 10% of their total period of complementary feeding (WHO, 2020).
protein, folate, iron, and niacin intakes. Consumption Added sugar and salt should be avoided in home or
of grains was also linked to greater daily intake of commercially prepared complementary foods as
several recommended food groups in both younger taste experience during early childhood could
and older infants as compared to non-consumption establish a lifetime preferences and habits (Binns et
of grains. This evidence substantiates the al., 2020)
importance of including whole and enriched grain
28
2.3.3 Food texture 2.3.4 Responsive feeding
Food texture plays an important role in food Responsive feeding is defined as feeding infants
acceptance by infants and young children, directly and assisting young children, appropriate
especially during the complementary feeding for their age and developmental needs, to ensure
period. Acceptance of food texture develops with that they consume adequate amounts of
age throughout the course of the complementary complementary food. It is a reciprocal process or a
feeding period and is related to the development of two-way relationship between caregiver and child
the child’s oral-motor skills (Carole et al., 2020). The where the child communicates hunger and satiety
development of these skills enables an effective cues and caregiver recognizes and responds
transition from milk feeding to eating family foods. appropriately to these cues (WHO, 2009; UNICEF,
The neuromuscular development of infants 2016). Responsive feeding is not only crucial in
indicates the minimum age at which they can ingest establishing and nurturing life-long healthy dietary
particular types of food (Motuma Abeshu et al., habits but also is protective of infant health,
2016). Pureed foods or semi-solid are needed at first, development, and well-being (UNICEF, 2017).
until the ability to munch (jaw movements) and Responsive feeding is also considered as a
chew (use of teeth) develop. Generally, healthy preventive strategy against child malnutrition, either
infants aged 6 to 8 months will gradually be able to undernutrition or overweight and obesity, and
tolerate pureed, mashed, and semi-solid foods. By therefore should be incorporated into dietary
the age of 8 months, most infants can hold and eat guidelines for infants and young children (Perez-
finger foods. At 9 to 11 months of age, infants begin Escamilla et al., 2019; Sall et al., 2020).
to develop chewing skills and can consume coarsely
chopped foods. At the age 1 year old, infants learn Non-Responsive Feeding (NRF) is characterized by KM2
to swallow with easy lip closure and begin to lack of active feeding or lack of interaction between
develop biting skills. Most young children at this age the caregiver and child. The different types of NRF
can eat the same types of food consumed by other include caregiver is uninvolved or ignoring the child
family members (UNICEF, 2021b). Evidence during mealtimes, caregiver is controlling and
suggests that most infants can consume solid pressuring the child to eat or finish the food or
consistency “family foods” by 1 year old, even if they caregiver is allowing the child to control mealtimes
are still given semi-solid foods (Abeshu et al., 2016; (Perez-Escamilla et al., 2017). While practicing
Front, 2016). As infants get older, the food texture responsive feeding is associated with ideal growth,
and methods of food preparation can be gradually optimal nutrient intake and long-term regulation of
changed to adapt to their development and abilities. weight, non- responsive feeding (NRF) practices are
For optimal growth and development, it is important associated with feeding problems (overeating, picky
to gradually increase the consistency of eating, failure to thrive, poor food preference) and the
complementary foods with age of the child even development of under- or overnutrition (Harbron et
though it could result in longer feeding time for the al., 2013).
caregivers (WHO, 2021a).
Appropriate feeding behaviours of caregivers should include (WHO/UNICEF, 1998):
1. Adaptation of the feeding method to the psychomotor abilities of the child (e.g. spoon handling ability,
ability to munch or chew, use of finger foods);
2. The active involvement of the feeder, including encouragement to eat, offering additional foods and
providing second helpings;
3. Responsivity of the feeder, including the affective relationship between child and feeder, timing of
feeding, and positive or aversive style of interaction;
4. The feeding situation, including the organisation, frequency and regularity of the feeding situation,
whether the child is supervised and protected while eating and by whom, distraction during eating
events, etc.
29
A systematic review on responsive feeding handwashing with soap alone can reduce diarrhoea
recommendations from high-income countries incidence by 30–47% (Ejemot-Nwadiaro et al., 2015).
(Perez-Escamilla et al., 2021) recommended
components of effective responsive feeding and There are four steps that should be followed when
responsive parenting interventions to improve preparing food for children under the age of five
feeding of infants and young children that include years, which is clean: wash hand, utensils and
introduction of complementary foods, hunger satiety surface often; separate: raw meat, poultry, seafood
cues, soothing, flavor preferences, food consistency, and eggs can spread illness-causing bacteria to
portion sizes, caregiver feeding styles, nurturing ready to eat foods; cook: food is safely cooked only
feeding environment, eat as a family, avoid when internal temperature is high enough to kill
distractions during feeding and daily routine or germs that can make young children sick; and chill:
structure. Interventions based on these refrigerate perishable food promptly which bacteria
comprehensive responsive feeding that cause food poisoning multiply quickest
recommendations have been shown to improve between 40oF and 140oF (CDC, 2022a). Aside from
feeding behaviors that lead children to develop food handling, feeding using contaminated bottles
healthier food preferences, increase intake of may be an important transmission pathway of
healthier foods, reduce intake of ultra-processed enteric pathogens during early life (Rothstein et al.,
foods and sugar-sweetened beverages and to have 2019). Plastic feeding bottles are widely used to feed
improved weight outcomes. infants when breastfeeding is not possible (Pant et
al., 2022). Gibson et al. (2017) reported that high
2.3.5 Safe preparation and storage of levels of faecal bacterial contamination have been
complementary foods found in the lacteal content of feeding bottles, as
KM2 well as on the bottles and nipples.
Children below the age of 5 years have a higher risk
of foodborne illness and related health problems Bisphenol A (BPA) is an endocrine disruptor that is
because their immune system is still developing, widely used in the manufacturing of plasticwares.
and they are more susceptible to infections as It is leached out from plastic wares upon exposure
compared to older children and adults (FDA, 2020). to high temperature, changed pH, or cleaning using
Foodborne illness (also called food poisoning) can harsh detergents (Pant et al., 2020). BPA exposure
be particularly dangerous for young children could increase the risk of cancer, impaired immune
because it often causes vomiting or diarrhoea or function, early puberty, obesity, diabetes, and
both. Since a child’s body is small, he or she can hyperactivity (UCSF, 2022). For infants and young
quickly lose a lot of body fluid and become children whose developing systems might be less
dehydrated (USDA, 2021). efficient to detoxify BPA (Judy, 2018), continuous
use of BPA-containing plastic feeding bottles could
Despite being preventable, foodborne diseases put them at risk of sustained exposure to toxic BPA.
remain a global health challenge. Food hygiene is Other toxic materials such as bisphenol F, bisphenol
defined as conditions and measures that are S, or phthalate can also leach out from BPA-free
required during production, processing, storage, plasticware. These materials act as endocrine-
distribution and preparation of food to ensure that disrupting chemicals and could also increase the
it is safe, wholesome and fit for human consumption risk of various health problems including endocrine
(WHO, 1984; Kamboj et al., 2020). Food can become disturbances (Jeon, 2022).
contaminated at any point during slaughtering or
harvesting, processing, storage, distribution, Although the use of BPA in feeding bottles has been
transportation, and preparation (Kamboj et al., 2020). banned by most countries including Malaysia in
Food hygiene is an essential part of food safety with 2012, many developing countries are still using it in
the latter encompassing all important practices, the manufacturing of plastic wares such as feeding
including the hygiene of food handling, that must be bottles, sipping cups, and infant formula packaging.
followed to manage risk and ensure food is fit for As BPA can be released from polycarbonate feeding
consumption. Poor food hygiene practices at home bottles or plastic wares into infant formula and baby
such as unhygienic food preparation and storage as foods, it is important to regulate its use in the
well as improper handling of kitchen utensils, are manufacturing of plasticwares. Furthermore,
among the major causes of diarrhoea transmission consumers must check the plastic type, toxicity
in young children (Chidziwisano et al., 2019). level, and most leached toxins when purchasing
Besides, studies have indicated the importance of plasticwares (Jeon, 2022).
handwashing in diarrheal disease reduction, with
30
There are foods and drinks that are not safe for child has regained any lost weight and is growing
young children to eat and are not as healthy as other well again.
foods. For example, milk and milk products provide
a wealth of nutritional benefits but raw milk and raw 2.3.7 Fortified foods and micronutrient
milk products, including unpasteurized milk, soft supplementation
cheese, ice cream, and yoghourt, can be
contaminated with harmful bacteria that can cause Energy- and nutrient-dense complementary foods
serious illness, hospitalisation, or death (CDC, should be introduced to children 6 months to 2 years
(2022b). Raw milk can carry dangerous bacteria of age due to their high energy and nutrient
such as Salmonella, E. coli, Listeria, Campylobacter, requirements. However, during this complementary
and others that cause foodborne illness, often called feeding period, it is a challenge for young children
“food poisoning.” These bacteria can adversely to achieve their nutrient requirements from locally
affect human health, particularly those with available foods that are typically unfortified (Dewey,
weakened immune systems (such as transplant et al., 2013). In many developing countries,
patients and individuals with HIV/AIDS, cancer, and particularly in low-income settings, diets are
diabetes), young children, older adults, and pregnant predominantly cereal-based, low in dietary diversity
women (FDA, 2018). Furthermore, eating food that and nutrient-density, and poor micronutrient
has botulinum toxin produced by the bacterium bioavailability. The small stomach capacity of young
Clostridium botulinum or related species, can cause children also limits the amount of food consumed.
food-borne botulism which is a serious and Together, these conditions put young children at-
potentially fatal disease but is relatively rare (WHO, risk of micronutrient deficiencies.
2018). While botulism often involves improperly
processed home canned foods, in infants under one Fortification of complementary foods and vitamin- KM2
year of age, it has been associated with the ingestion mineral (micronutrient) supplementation are
of C. botulinum spores from the environment or common strategies used to ensure young children
specific foods such as honey (DOH, 2011). As honey receive adequate amounts of micronutrients (WHO,
can contain this bacterium that causes infant 2003). Although fortification is recommended as a
botulism, avoiding feeding honey to infants 12 long-term strategy to increase intake of certain
months of age or less is the only known preventive micronutrients in the general population, the limited
measure of infant botulism. Honey, however, is safe amounts of micronutrients added to foods due to
for children older than 1 year of age (CDC, 2022c). safety regulations may contribute to young children
who consume small amounts of foods not being able
2.3.6 Feeding during and after illness to achieve micronutrient requirements. On the other
hand, supplementation is an effective short-term
During illness, a child may lose excess body fluids strategy to prevent and manage micronutrient
through increased body temperature, sweating, deficiencies in specific at-risk groups with its single
vomiting and diarrhoea, thus increasing fluid dose administration that could meet daily
requirement. To prevent dehydration, it is essential micronutrient requirements (Bailey et al., 2015).
to provide extra fluids in addition to water
consumed from the normal diet and to continue Evidence from low- and middle-income countries
frequent breastfeeding during illness. Dehydration showed that local complementary foods are
in children can lead to more serious conditions, commonly deficient in calcium, iron and zinc while
including death (Vega & Avva, 2021). energy, vitamin A, thiamine, riboflavin, niacin, folate
and vitamin C do not always meet daily
A child’s nutritional status can rapidly decline requirements of children. Even when the use of local
during illness especially if the additional nutrient foods is optimised (increasing frequency and
requirements associated with the illness are not quantity of nutrient-dense foods) or diets include
properly met and the nutrients are averted from fortified infant food products, iron and zinc remain
growth and development towards building the problematic and, in some context, calcium, folate,
immune response (Degefa et al., 2019). Even though thiamine, riboflavin and niacin are inadequate
appetite may be reduced during illness, continuous (Osendarp et al., 2016). The Feeding Infants and
breastfeeding and complementary food could Toddlers Study reported that infants fed
preserve nutrient consumption and improve commercially prepared baby foods (fruits,
recovery. After a recovery, the child should be vegetables and dinners) were more likely to
offered more food than usual to replenish the energy consume fruits and vegetables and had higher
and nutrient losses due to illness and to allow for intakes of vitamin A, vitamin C, vitamin E,
catch-up growth. Extra food is needed until the potassium, magnesium and fibre but lower in
31
sodium and vitamin D than non-consumers of these 2.3.8 Fluid requirement

products (Reidy et al., 2018). Micronutrient
supplementation includes the provision of a single A young child’s fluid requirement usually is fulfilled
micronutrient or multiple micronutrients in the form with breast milk for breastfed child, formula milk for
of capsules, tablets, drops, or syrup. Micronutrient the non-breastfed child and other fluids from
powder (MNP) is dry powder containing complementary foods and liquid intake, mainly
micronutrients that can be added to semi-solid and water. Maintaining adequate fluid intake and
solid foods at point-of-use, frequently when hydration status in a child is important for
preparing home-made meals (WHO, 2016). A physiological and behavioral reasons.
systematic review and meta-analysis of the effect of Physiologically, water supports many essential
micronutrient supplementation, including MNP, and functions including thermoregulation, waste
fortification on health and development outcomes elimination and numerous metabolic reactions. A
among young children (< 5 years-old) in low- and child with suboptimal fluid intake will be at risk of
middle-income countries showed that these potential adverse consequences mainly on kidney
strategies were effective in reducing the burden of and other metabolic processes (Kavouras, 2019) as
micronutrient deficiencies (Tam et al., 2020). A well as cognitive and mood impairments (Muñoz et
Cochrane Review of the effectiveness of MNP mixed al., 2015). It is also essential to establish a healthy
with complementary foods on health and nutrition drinking habit in infancy as it will lead to good
outcomes in children under 2 years of age reported dietary habits in later childhood and adulthood.
that MNP containing at least iron, zinc and vitamin During early childhood, the acquisition of drinking
A could reduce the risk of anaemia and iron habits is mainly driven by adults since children
deficiency (Suchdev et al., 2020). depend on their caregivers for the provision of food
KM2 and beverages (Bottin et al., 2019). Fluid requirement
among young children is shown in Table 2.2
Table 2.2: Fluid requirement among young children by age
Age Fluid requirement (mL/day)
6 – 12 months 800 – 1000

1 – 2 years 1000 – 1300
Source: EFSA (2009); IOM (2005); WHO (2003); WHO (2005)
32
2.4 Current Status
The National Health and Morbidity Survey (NHMS) Several studies have examined the adequacy of
2016 reported that the rate of ever-breastfeeding is energy and nutrient intakes of infants and young
almost universal (98.1%), while the rate of exclusive children. Khor & Lee et al. (2021) showed that while
breastfeeding below 6 months was only 47.1%. A complementary foods provided protein in excess of
clinic-based report in 2020 showed that 70.3% recommended intake (RNI), other nutrients (vitamin
infants were exclusively breastfed, and this figure A, vitamin C, thiamine, riboflavin, folate, calcium,
exceeded the target (70.0%) of National Plan of iron and zinc) were less than the RNIs. Also, the
Action for Nutrition of Malaysia III (2016-2025). The intake of essential fatty acids from complementary
State Health Department report in 2020 revealed foods did not achieve the Adequate Intake (AI).
that 99.0% infants received timely complementary SEANUTS Malaysia (Poh et al., 2013) reported that
feeding. Khor et al. (2016) and Bong et al. (2018) more rural infants (6-11 months) and toddlers (1-4
reported that high proportions of urban infants years) achieved the requirement for energy and RNI
(97.9%) and rural Penan infants (85.7%) had timely for micronutrients (vitamin A, vitamin C, vitamin D,
introduction of solid, semi-solid or soft foods. calcium and iron) compared to their urban
counterparts. Among urban toddlers (1-3 years), the
The NHMS 2016 reported that although 80.8% and proportions not achieving recommended intakes of
66.4% of children aged 6 to 23 months had MMF and energy and nutrients did not differ across socio-
MDD, respectively, only 53.1% of children achieved economic groups. However, 14-20% of these young
minimum acceptable diet (MAD) which is defined children did not achieve energy requirement, 29-
as receiving at least minimum dietary diversity and 38% for vitamin A, 5-13% for vitamin C, 19-49% for
minimum meal frequency for breast-fed children vitamin D, 21-31% for calcium, 7-19% for iron, 17- KM2
and receiving at least 2 milk feedings with minimum 28% for zinc and 12-28% for folate (Zalilah et al.,
dietary diversity and minimum meal frequency for 2015)
non-breastfed children. A study among urban 6-24
months children also found that while a high To empower current feeding practices, several
proportion (78.0%) of breastfed and non-breastfed activities related to infant and young child feeding
infants met MDD and MMF (breastfed – 69.3%; non- have been added to the National Plan of Action for
breastfed – 95.2%), MAD was achieved by only Nutrition of Malaysia III (2016-2025). Education on
39.5% and 50.6% of non-breastfed and breastfed the feeding practices of infants and young children
infants, respectively (Khor et al., 2016). Bong et al. has been integrated into public health programmes,
(2018) reported that 83.0%, 76.6% and 55.3% of rural including written materials, postnatal lectures,
Penan children achieved MMF, MDD and MAD, seminars and training courses for health
respectively. professionals, childcare center caregivers and
parents to help them have a better understanding of
infant and young child feeding and achieve the goal
of this key message.
Key Recommendation (KR) 1: Give appropriate complementary foods to children between the
Health Professional Parents/ Caregiver

Advise parents/ caregivers on the timing of Start with a few teaspoons of
complementary feeding and continuing complementary foods and gradually increase the
breastfeeding until the child is 2 years of age or amount and variety as child gets older.
beyond.
- KR1: HTA2:
Continue on-demand breastfeeding
until child is 2 years of age or beyond.
33
Key Recommendation (KR) 2: Feed child with enough food to meet energy needs.
Parents/ Caregiver
KR2: HTA1:
Give child a variety of cereals (e.g. porridge, rice, bread) and tubers (e.g. potatoes, sweet potatoes).
KR2: HTA2:
Introduce whole grain foods in child’s diet, at the beginning of 9 months.
KR2: HTA3:
For child 6 to 8 months, start with 2 – 3 tablespoons of food per feed, increasing gradually to ½ cup.
Give foods that are thick enough to stay in the spoon as it gives more energy.
KR2: HTA4:
For child 9 to 11 months, give ½ cup of food per feed.
KR2: HTA5:
For child 1 to 2 years, give ¾ to 1 cup of food per feed.
KM2
KR2: HTA6:
For non-breastfed child 6 months to 2 years, give up to 2 glasses (500ml) of milk per day in addition
to food.
KR2: HTA7:
Add about ½ teaspoon of oil, butter or margarine in each main meal every day (up to a maximum of
2 ½ teaspoons per day).
Key Recommendation (KR) 3: Increase the feeding frequency of complementary foods according
to age.

Advise parents/ caregivers on the frequency of For breastfed child, give complementary foods
meals that should be given to the child according (solid, semi-solid or soft). Refer to the table
to their age. below for frequencies of complementary foods
according to age (Refer Table 2.3).

Advie parents/ caregivers on the additional eals For non-breastfed child 6 to 24 months, increase
that should be given to the non-breastfed child the feeding 1 to 2 times per day from the
according to their age. recommended intake according to age.
34
Table 2.3: Feeding frequency according to age
Age Minimum Meal Frequency (times/ day)
6 – 8 months 2
9 – 11 months 3
1 – 2 years 3
Source: UNICEF, 2020
Note: Nutritious snacks may be offered 1 to 2 times per day, depending on child’s appetite.
Key Recommendation (KR) 4: Change food texture and preparation methods gradually according
to child’s requirements and abilities.

Identify the age and ability of the child and give Give blended, mashed, and soft foods to child at
appropriate advice according to their age group. the age of 6 to 8 months.
KM2
Advise parents/ caregivers on the types of food Give chopped foods to child at the age of 9 to 11
that should not be given to their child to prevent months. Healthy finger foods such as fruits can
choking. also be given.
- KR4: HTA3:
Give nutrient dense family foods to child at the
age of 1 year old.
- KR4: HTA4:
Avoid foods that are hard, uncooked, whole or in
certain shapes and sizes (e.g. tough meat, nuts
and seeds, uncut fruits, raw vegetables, chewing
gums, hard candy) and supervise child during
mealtimes to avoid choking.
35
Key Recommendation (KR) 5: Give a variety of food and gradually increase the quantity to
ensure that all nutrient needs are met.
Parents/ Caregiver
KR5: HTA1:
Give animal source foods such as meat, poultry, fish or eggs every day, as they are the main sources
of protein, iron and zinc.
KR5: HTA2:
For non-breastfed child:
a) Avoid giving full cream or fresh cow’s milk before the age of 1 year old.
b) Beyond 1 year old, give all types of milk (growing up milk, fresh milk, full cream milk) except low-
fat milk, skimmed milk, sweetened condensed milk or creamer. Soy milk should not replace dairy
milk unless advised by health professional.
c) Avoid adding sugar to milk and choose milk (fresh, pasteurized or UHT), with little or no added
sugar.
KR5: HTA3:
Give both cereals and legumes (e.g peas, beans, and lentils) in the same meal, if child is not
KM2 consuming adequate amounts of milk and animal source foods.
KR5: HTA4:
Give dark green leafy vegetables and yellow or orange-colored fruits and vegetables every day. Fresh
fruits can be served as healthier and nutrient-dense snacks.
KR5: HTA5:
Avoid giving fruit or vegetable juice to child less than 1 year old. For children above 1 year old, intake
of 100% juice should be limited to less than ½ cup (100 ml) per day.
KR5: HTA6:
Prepare complementary foods without adding salt or sugar.
KR5: HTA7:
Avoid giving processed foods that is high in fat, sugar, or salt content.
KR5: HTA8:
Avoid giving drinks of low nutrient value such as tea, coffee, sugar-sweetened beverages and
carbonated drinks.
Key Recommendation (KR) 6: Practice responsive feeding (give attention and response to child)
at each mealtime.
KR6: HTA1: K6: HTA1:

Explain the feeding practices and their effects on Feed infant directly and assist older child when
the child's food intake. he is able to feed himself.

Explain to the parents/ caregivers the specific Be aware of signs of hunger and satiety. Stop
techniques to encourage young children to eat. feeding when child is already full.
36
Key Recommendation (KR) 6: Practice responsive feeding (give attention and response to child)
at each mealtime. (cont.)

Identify if there are obstacles in the provision of Feed child slowly and patiently. Encourage but
food responsively to the child and refer to other do not force to eat.
health professionals if necessary.
- KR6: HTA4:
Minimize any distraction during mealtimes if child
loses interest easily.
- KR6: HTA5:
Have child eat with other family members. Child
learns eating skills more quickly through
observation and imitation.
- KR6: HTA6:
Talk to child during feeding with eye- KM2
to-eye contact.
- KR6: HTA7:
If a child refuses many foods, experiment with
different food combinations, tastes, textures and
methods of encouragement.
Key Recommendation (KR) 7: Give sick child extra fluid and offer small but frequent meals

Monitor sick child closely andregularly. Practice frequent breastfeeding.

Provide specific medical and nutritional For non-breastfed child, offer clean plain water
requirements for each sick child several times per day, even if child is not thirsty.

Teach parents/ caregivers the appropriate Encourage child to eat a variety of soft,
methods and approach to feed sick child. appetizing and favorite food.
- KR7: HTA4:
Encourage child to eat in small amount but
frequent, even if not hungry.
- KR7: HTA5:
Feed when child is alert and comfortable.
- KR7: HTA6:
Feed child more often and encourage to eat
more at each meal after illness.
37
Key Recommendation (KR) 8: Use fortified complementary foods or vitamin-mineral

supplements for the child, as needed.

Assess the child’s nutritional need for fortified Consider micronutrient-fortified complementary
foods or vitamin-mineral supplements. foods (e.g commercially prepared infant foods,
home fortification) if child is not consuming
adequate amount of animal source foods.

Advice parents/ caregivers on the appropriate Give vitamin-mineral supplements (e.g. syrup,
fortified complementary foods or vitamin- mineral chewable tablet, powder) to the child only upon
supplements for the child. assessment and recommendation by a medical
professional.

Consider micronutrient-fortified complementary Ensure careful choice of energy- dense and
foods (e.g commercially prepared infant foods, micronutrient-fortified complementary foods
KM2 home fortification) if child is not consuming when treating or preventing child malnutrition.
adequate amount of animal source foods.
KR8: HTA4: -
Give vitamin-mineral supplements (e.g. syrup,
chewable tablet, powder) to the child only upon
assessment and recommendation by a medical
professional.
KR8: HTA5: -
Ensure careful choice of energy- dense and
micronutrient-fortified complementary foods when
treating or preventing child malnutrition.
Key Recommendation (KR) 9: Practice good hygiene and proper food handling

Advise parents/ caregivers on the precaution When preparing and serving foods:
while preparing, serving, and storing foods. a. Use clean utensils (e.g. cup, bowl, spoons
etc).
b. Feed child immediately after food preparation.
c. Avoid using feeding bottles, which are
difficult to keep clean.

Teach parents/ caregivers on the correct ways of When storing foods:
using feeding bottle. a. Cover cooked foods and do not leave at
room temperature for more than 2 hours.
b. Keep perishable foods (e.g. meat, milk) and
cooked foods in the refrigerator (below 4°C).
38
Key Recommendation (KR) 9: Practice good hygiene and proper food handling (cont.)
c. Store baby food in a clean and closed

container in the amount of one feeding and
label the container with date of refrigeration.
d. Store frozen food for up to three months and
discard unused food beyond that period.
e. Thaw frozen food in the refrigerator or under
clean running water. Do not thaw at room
temperature.
f. Do not refreeze thawed baby food.

Advise parents/ caregiver on foods and drinks When using feeding bottles for breast milk or
that are not safe to be given to a child below infant formula:
1 year old. a. Choose ‘BPA free’ bottle.
b. Change bottle immediately if there is
discoloration or damage. KM2
c. Wash bottle and feeding preparation
apparatus thoroughly in hot soapy water.
d. Sterilize bottle and feeding apparatus before
feeding session using a commercial sterilizer
or in a pan of boiling water for 5 to 10
minutes.
e. Keep sterilized bottle in a sealed container
or covered in a clean place.
- KR9: HTA4:
Some foods and drinks are not safe for your child
to eat. Avoid giving your child:
a. Honey or foods containing honey (e.g
yogurt, cereals and crackers with honey)
before the age of 1 year old.
b. Unpasteurized drinks or foods such as
juices, milks, yogurt, or cheeses.
39
Key Recommendation (KR) 10: Ensure child has adequate fluid intake.

Provide parents/ caregivers with age and body Give fluid (eg: plain water, milk, soup etc) to child
weight-specific fluid daily requirement for child, based on daily intake requirement (Refer
if required. Table 2.2: Fluid requirement among young
children by age).

Advice parents/ caregivers on the appropriate Continue on-demand breastfeeding.
ways to give fluid to child.

Encourage intake of fluid from foods Offer plain, clean (boiled if necessary) and
(e.g. soup, fruits, vegetables, porridge). cooled water regularly, even if not thirsty.
KR10: HTA4:
KM2 Encourage water intake using cup and not
feeding bottle.
40
2.6 References
Abeshu, M.A., Lelisa, A., & Geleta, B. (2016). Complementary feeding: review of recommendations, feeding
practices, and adequacy of homemade complementary food preparations in developing countries –
Lessons from Ethiopia. Frontier Nutr, 17;3:41. doi: 10.3389/fnut.2016.00041. eCollection 2016.
Aneja, S., Kumar, P., Choudary, T.S,, Srivastava, A., Taneja, S., Bhandari, N., Daniel, A., Menon, P., Chellani, H.,
Bahl, R. &, Bhan, M.K. (2020). Growth faltering in early infancy: highlights from a two-day scientific
consultation. BMC Proceedings, 14(Suppl 12):12. https://doi.org/10.1186/s12919-020-00195-z -xx
Asare, H., Rosi, A., Faber, M., Smuts, C.M., & Ricci, C. (2022). Animal-source foods as a suitable
complementary food for improved physical growth in 6 to 24-month-old children in low-and middle-
income countries: a systematic review and meta-analysis of randomized controlled trials. Br J Nutr,
31-11. doi: 10.1017/S0007114522000290
Baidal, J.A.W., Locks, L.M., Cheng, E.R., Lamb, T.L.B., Perkins, M.E., & Taveras E.M. (2016). Risk factors for
childhood obesity in the first 1,000 days: A a systematic review. Am J Prev Med, 50(6):761-779. doi:
10.1016/j.amepre.2015.11.012.
Bailey, R.L., West, K.P., and & Black, R.E. (2015). The epidemiology of global micronutrient deficiencies. Ann.
Nutr. Metab. 66 (Suppl. 2):22–33. doi: 10.1159/000371618
Binns, C., Lee, M.K., Low, W.Y., Baker, P., & Bulgiba, A. (2020). Guidelines for complementary feeding of KM2
infants in the Asia Pacific Region: APACPH Public Health Nutrition Group. Asia Pac Journal Pub
Health, 1-9. DOI:10.1177/1010539520931328
Bong, M.W., Norimah, A.K., & Ismail, M.N. (2018). Nutritional status and complementary feeding among
Penan infants and young children in rural Sarawak, Malaysia. Mal J Nutr, 24(4): 539-550.
Bottin, J.H., Morin, C., Guelinckx, I., & Perrier, E.T. (2019). Hhydration in children: what do we know and
why does it matter? Ann Nutr Metab Annals of, Nutrition and Metabolism, 74(3), 11–18.
https://doi.org/10.1159/000500340
Bournez, M., Ksiazek, E., Charles, M.A., Lioret, S., Brindisi, M.C., Lauzon-Gullain, B., & Nicklaus, S. (2019).
Ffrequency of use of added sugar, salt, and fat in infant foods up to 10 months in the nationwide ELFE
Cohort Study: associated infant feeding and caregiving practices. Nutrients,. 11(4):733. doi:
10.3390/nu11040733. PMID: 30934918. PMCID: PMC6520717..
Campoy, C., Campos, D., Cerdo, T., Dieguez, E., & Garcia-Santos, J.A. (2018). Complementary feeding in
developed countries: The 3 Ws (When, What and Why?). Ann Nutr Metab, 73 (Suppl 1): 27-36. doi:
10.1159/000490086
Carole, T., Lauriane, D., Eléa, K., & Agnès, M. (2020). Factors associated with food texture acceptance in 4-
to-36- month-old French children: Findings from a survey study. Frontier Nutr. 7:616484. doi:
10.3389/fnut.2020.616484. PMID: 33598476. PMCID: PMC7882631.
Caroli, M., Vania, A., Verga, M.C., Mauro, G.D., Bergamini, M., Cuomo, B., DÁnna, R., DÁntonio, G., Iacono,
I.D., Dessi, A., Doria, M., Fanos, V., Fiore, M., Francavilla, R., Genovesi, S., Giussani, M., Gritti, A., Lafusco,
D., Leonardi, L., Miniello,V.L..,, Giudice, E.M.D., Palma, F., Pastore, F., Scotese, I., Simeone, G.,
Squicciarini, M., Tezza, G., Troiani, E., & Umano, G.R. (2022). Recommendations on complementary
feeding as a tool for prevention of non-communicable diseases (NCDs)—Paper Co-Drafted by the
SIPPS, FIMP, SIDOHaD, and SINUPE Joint Working Group. Nutrients, 14(2):257. doi:
10.3390/nu14020257. PMID: 35057438. PMCID: PMC8778394.
Centers for Disease Control and Prevention CDC (2021). Infant and toddler nutrition.
https://www.cdc.gov/nutrition/infantandtoddlernutrition/index.html (Accessed on 14 October 2022).
41
Centers for Disease Control and PreventionCDC (2022a). Four steps to food safety: clean, separate, cook,
chill.. https://www.cdc.gov/foodsafety/keep-food-safe.html. (Accessed on 29 October 2022).
Centers for Disease Control and Prevention CDC (2022b). Raw milk questions and answers.
https://www.cdc.gov/foodsafety/rawmilk/raw-milk-questions-and-answers.html
Centers for Disease Control and PreventionCDC (2022c). Prevention. Many cases of botulism are
preventable. Foodborne botulism. https://www.cdc.gov/botulism/prevention.html (Accessed on 29
October 2022).
Charboneau, J.P., & Koger, S.M. (2008). Plastics, Pesticides and PBDEs: Endocrine Disruption and
Developmental Disabilities. Journal of Developmental and Physical Disabilities. DOI:10.1007/S10882-
007-9083-3.
Chidziwisano, K., Slekiene, J., Kumwenda, S., Mosler, H.J., and & Morse T. (2019). Toward complementary
food hygiene practices among child caregivers in rural malawi. Am J Trop Med Hyg. 101(2): 294–303.
DÁuria, E., Borsani, B., Pendezza, E., Bosetti, A., Paradiso, L., Zuccotti, G.V., & Verduci, E., (2020).
Complementary feeding: Pitfalls for health outcomes. Intl Journal Env Res Publ Health 17(21):7931.
doi: 10.3390/ijerph17217931. PMID: 33137971 PMCID: PMC7662522.
Darling, J.C., Barnidis, P.D., Burberry, J., & Rudolf, M.C.J. (2020). The first thousand days: early, integrated
KM2 and evidence-based approaches to improving child health: coming to a population near you?. Arch
Dis Child. Arch Dis Child., 105(9):837-841. doi: 10.1136/archdischild-2019-316929. Epub 2020 Feb 28.
PMID: 32111596
De Jager, I., Borgonjen-Van Den Berg, K. J., Giller, K. E., & Brouwer, I. D. (2019). Current and potential role of
grain legumes on protein and micronutrient adequacy of the diet of rural Ghanaian infants and young
children: Using linear programming. Nutrition Journal, 18(1), 1–16. https://doi.org/10.1186/s12937-
019-0435-5
Degefa, N., Tadesse, H., Aga, F., & Yeheyis, T. (2019). Sick child feeding practice and associated factors among
mothers of children less than 24 months old, in Burayu Town, Ethiopia. International Journal Ped.:
2019:3293516. doi: 10.1155/2019/3293516. PMID: 31929806; PMCID: PMC6942812.
Department Of Health (DOH), New York State. (2011). Botulism (food-borne botulism
andinfantbotulism).https://www.health.ny.gov/diseases/communicable/botulism/fact_sheet.html
(Accessed on 29 October 2022)
Dewey, K.G. (2013). The challenge of meeting nutrient needs of infants and young children during the period
of complementary feeding: an evolutionary perspective. J Nutr. 143(12):2050-2054. doi:
10.3945/jn.113.182527.
DiMaggio, D.M., Cox, A., & Porto. A.F. (2017). Updates in infant nutrition. Pediatr. Rev. 38:449–462. doi:
10.1542/pir.2016-0239
EFSA Panel in Nutrition, Novel Foods and Food Allergens (NDA) (2019). Scientific opinion on the appropriate
age for introduction of complementary feeding of infants. EFSA J. 17(9):5780.
https://doi.org/10.2903/j.efsa.2019.5780EFSA Panel in Nutrition, Novel Foods and Food Allergens
(NDA) (2019). Scientific opinion on the appropriate age for introduction of complementary feeding of
infants. EFSA J. 17(9):5780
EFSA. (2009). Scientific opinion on the appropriate age for introduction of complementary feeding of infants.
EFSA J 7(12):1423. https://doi.org/10.2903/j.efsa.2009.1423
42
Ejemot-Nwadiaro, R.I., Ehiri, J.E., Arikpo, D., Meremikwu, M.M., & Critchley, J.A. (2015). Hand washing
promotion for preventing diarrhoea. Cochrane Database Syst Rev 1–95. doi:
10.1002/14651858.CD004265.pub3
FDA (2018). The Dangers of Raw Milk: Unpasteurized Milk Can Pose a Serious Health
Risk.https://www.fda.gov/food/buy-store-serve-safe-food/dangers-raw-milk-unpasteurized-milk-
can-pose-serious-health-risk FDA, 2018
FDA (2020). People at Risk of Foodborne Illness. https://www.fda.gov/food/consumers/people-risk-

foodborne-illnessFDA, 2020.
Fewtrell, M., Bronsky, J., Campoy, C., Domellöf, M., Embleton, N., & Mis, N.F. (2017). Complementary feeding:
a position paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition
(ESPGHAN) Committee on Nutrition. Journal of pediatric gastroenterology and nutrition.64(1):119-
32. doi: 10.1097/MPG.0000000000001454
Foodsafety.gov (2021). People at Risk: Children Under Five. https://www.foodsafety.gov/people-at-

risk/children-under-five
Gibson, S., Sahanggamu, D., Fatmaningrum, D., Curtis, V., & White, S. (2017). ‘Unfit for human consumption’:
a study of the contamination of formula milk fed to young children in East Java, Indonesia. Trop Med
Int Health. Trop Med Int Health. 22(10):1275-1282. doi: 10.1111/tmi.12927. Epub 2017 Aug 7. PMID:
28712156. KM2
Harbron, J., Booley, S., Najaar, B., & Day, C.E. (2013). Paediatric food-based dietary guidelines for South
Africa: Responsive feeding: Eestablishing healthy eating behaviour early on in life. S Afr J Clin Nutr
26(3)(Supplement):S141-149
Headey, D., Hirvonen, K., and & Hoddinott, J.F. (2018). Animal sourced foods and child stunting. Amer. J.
Agr. Econ.5: 1302–1319
Hirvonen, K., Wolle, A., Laillou, A., Vinci, V., Chitekwe, S., & Baye, K. (2021). Understanding delays in the
introduction of complementary foods in rural Ethiopia. Matern Child Nutr. e13247. doi:
10.1111/mcn.13247. Epub ahead of print. PMID: 34523796.
Institute of Medicine (IOM). (2005). Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and
Sulfate. Washington, DC
IPH (2019). National Health and Morbidity Survey (NHMS) 2019: Vol. I: NCDs – Non-communicable diseases:
Risk factors and other health problems. (Vol. I). Institute for Public Health, National Institutes of
Health, Ministry of Health Malaysia . From:
https://iku.moh.gov.my/images/IKU/Document/REPORT/NHMS2019/Report_NHMS2019-
NCD_v2.pdf. [Retrieved November 5 2021]
Jager, I.D., Giller, K.E., & Brouwer, I.D. (2018). Food and nutriirent gaps in rural Northern Ghana: Does
production of smallholder farming households support adoption of food-based dietary guidelines?
PLoS One 13(9):e0204014. doi: 10.1371/journal.pone.0204014. PMID: 30212549; PMCID: PMC6136797.
IPH (2016). National Health and Morbidity Survey (NHMS) 2016:: Maternal and child health. (Vol. 2). Institute
for Public Health, National Institutes of Health, Ministry of Health Malaysia
Jeon, G.W. (2022). Bisphenol A leaching from polycarbonate baby bottles into baby food causes potential
health issues. Clin Exp Pediatr. 65(9):450-452. doi: 10.3345/cep.2022.00661. Epub 2022 Jul 25. PMID:
35879867 PMCID: PMC9441614
Judy, A.B. (2018). Baby Bottles and Bisphenol A (BPA): Still a parental concern pediatric nursing. MCN Am
J Matern Child Nurs 43(6):349. doi: 10.1097/NMC.0000000000000477. PMID: 30339582.
43
Kamboj, S., Gupta, N. Bandral, J. D., Gadontra, G. Anjum, N. (2020). Food safety and hygiene: A review.
International Journal of Chemical Studies. 8(1): 358-368. DOI:
https://doi.org/10.22271/chemi.2020.v8.i2f.8794
Kavouras, S.A. (2019). Hydration, dehydration, underhydration, optimal hydration: are we barking up the
wrong tree? European Journal of Nutrition 58(2), 471–473. https://doi.org/10.1007/S00394-018-01889-
Z/FIGURES/1
Khor, G.L., Tan, S.Y., Tan, K.L., Chan, P.S., V.Amarra, M.S. (2016). Compliance with WHO IYCF Indicators and
Dietary Intake Adequacy in a Sample of Malaysian Infants Aged 6–23 Months. Nutrients 8(12):778.
doi: 10.3390/ nu8120778. PMID: 27916932 PMCID: PMC5188433.
Khor, G.L., & Lee, S.S. (2021). Complementary Foods and Milk-Based Formulas Provide Excess Protein but
Suboptimal Key Micronutrients and Essential Fatty Acids in the Intakes of Infants and Toddlers from
Urban Settings in Malaysia. Nutrients 13(7):2354. doi: 10.3390/nu13072354. PMID: 34371864; PMCID:
PMC8308842.
Kramer, M.S., & Kakuma, M. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database of
Syst. Rev.8:CD003517. doi: 10.1002/14651858.CD003517.pub2
Krasevec, J., Kumapley, R., & Frongillo, E. A. (2017). Diet quality and risk of stunting among infants and
young children in low-and middle-income countries. 13(November 2016), 1–11.
KM2 https://doi.org/10.1111/mcn.12430
Ministry of Health (MOH). (2016). National Plan of Action for Nutrition of Malaysia III (2016-2025). Nutrition
Division, Ministry of Health Malaysia.
Muñoz, C.X., Johnson, E.C., McKenzie, A.L., Guelinckx, I., Graverholt, G., Casa, D.J., Maresh, C.M., &
Armstrong, L.E. (2015). Habitual total water intake and dimensions of mood in healthy young women.
Appetite, 92, 81–86. https://doi.org/10.1016/J.APPET.2015.05.002
NCCFN (2017). Recommended Nutrients Intakes. A Report of the Technical Working Group on Nutritional
Guidelines National Coordinating Committee on Food and Nutrition, Ministry of Health Malaysia,
Putrajaya.
Osendarp, S.J.M., Broersen, B., Van Liere, M.J., De-Regil, L.M., Bahirathan, L., KLassen Klassen E and &
Neufel, L.M. (2016). Complementary feeding diets made of local foods can be optimized but additional
interventions will be needed to meet iron and zinc requirements in 6 – 23 month-old children in low-
and middle-income countries. Food and Nutr Bull.37(4):544-570. doi: 10.1177/0379572116655239
PAHO (2003). Guiding principles for complementary feeding of the breastfed child. Pan American Health
Organization. Washington, D.C.
Pant, M.K., Ahmad, A.H., Naithani, M., Pandey, H.S., Pandey, M., & Pant, J. (2020). Effect of exposure of
plastic infant feeding bottle leached water on biochemical, morphological and oxidative stress
parameters in rats. Toxics. 8(2): 34. Doi: 10.3390/toxics8020034
Pant, M.K., Ahmad, A.H., Naithani, M., & Pant, J. (2022). Plastic bottle feeding produces changes in
biochemical parameters in human infants – A pilot study. Clinical and Experimental Pediatrics
65(9):459-465.Doi: 10.3345/cep.2022.00234
Pant, M.K., Ahmad, A.H., Naithani, M., Pandey, H.S., Pandey, M., and & Pant, J. (2020). Effect of exposure of
plastic infant feeding bottle leached water on biochemical, morphological and oxidative stress
parameters in rats. Toxics. 8(2): 34. Doi: 10.3390/toxics8020034
44
Papanikolaou, Y. & Fulgoni, III V.L. (2019). Grain fFoods in US infants are associated with greater nutrient
intakes, improved diet quality and increased consumption of recommended food groups. Nutrients
11(12):2840. doi: 10.3390/nu11122840. PMID: 31756905 PMCID: PMC6950092.
Perez-Escamilla et al., 2017Pérez-Escamilla R, Segura-Pérez S, Lott M. (2017) Feeding guidelines for infants
and young toddlers: a responsive parenting approach. Nutr Today, 52(5):223–31. doi:
10.1097/NT.0000000000000234
Pérez-Escamilla, R., Segura-Pérez, S., & Hall Moran, V. (2019). Dietary guidelines for children under 2 years
of age in the context of nurturing care. Matern Child Nutr 15(3):e12855. doi: 10.1111/mcn.12855. PMID:
31240831 PMCID: PMC7199077.
Pérez-Escamilla, R., Jimenez, E.Y., and & Dewey, K.G. (2021). Responsive feeding recommendations:
Harmonizing integration into dietary guidelines for infants and young children: Curr Dev Nutr
5(6):nzab076. doi: 10.1093/cdn/nzab076. PMID: 34104850 PMCID: PMC8178105.
Poh, B.K., Ng, B.K., Siti Haslinda, M.D., Nik Shanita, S., Wong, J.E., Siti Balkis, B., Ruzita, A.T., Ng, L.O., Khouw,
I., & Norimah, A.K. (2013). Nutritional status and dietary intakes of children aged 6 months to 12
years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia). Br J Nutr 110
Suppl 3:S21-35. doi: 10.1017/S0007114513002092. PMID: 24016764.
Papanikolaou Y and Fulgoni III VL (2019). Grain Foods in US Infants Are Associated with Greater Nutrient
Intakes, Improved Diet Quality and Increased Consumption of Recommended Food Groups. Nutrients KM2
11(12):2840. doi: 10.3390/nu11122840. PMID: 31756905 PMCID: PMC6950092.
Reidy, K.C., Bailey, R.L., Deming, D.M., O’Neill, L., Carr, T.B., Lesniauskas, R., and & Johnson, W. (2018). Food
consumption patterns and micronutrient density of complementary foods consumed by infants fed
commercially prepared baby foods. Nutr Today 53(2):68-78. doi: 10.1097/NT.0000000000000265. Epub
2018 Mar 22. PMID: 29706668 PMCID: PMC5902138.
Rothstein, J.D., Mendoza, A.L., Cabrera, L.Z., Pachas, J., Calderón. M., Pajuelo, M.J., Caulfield, L.E., Winch,
P.J., and & Gilman, R.H. (2019). Household Contamination contamination of baby bottles and
opportunities to improve bottle hygiene in Peri-Urban Lima, Peru. Am J Trop Med Hyg 100(4):988-
997. doi: 10.4269/ajtmh.18-0301. PMID: 30834885 PMCID: PMC6447096.
Kamboj, S., Gupta, N., Bandral, J.D., Gandotra, G., and & Anjum. N. (2020). Food safety and hygiene: A review.
IJCS 2020 8(1): 358-368
Sall, N.S., Bégin, F., Dupuis, J.B., Bourque, J., Menasria, L., Main, B., Vong, L., Hun, V., Raminashvili, D., Chea,
C., Chiasson, L., & Blaney, S. (2020). A measurement scale to assess responsive feeding among
Cambodian young children. Matern Child Matern Child Nutr 16(3):e12956. doi: 10.1111/mcn.12956.
Epub 2020 Jan 30. PMID: 31999399 PMCID: PMC7296795.
Scientific Advisory Committee on Nutrition (SACN). (2018). Ffeeding in the first year of life.
https://www.gov.uk/government/publications/feeding-in-the-first-year-of-life-sacn-report (Accessed
October 19, 2021)
Suchdev, P.S., Jefferds,_M.E.D., Ota,_E., Lopes,_K.D.S. and & De-Regil,_L.M. (2020). Home fortification of
foods with multiple micronutrient powders for health and nutrition in children under two years of
age. Cochrane Database Syst Rev 2(2):CD008959. doi: 10.1002/14651858 .CD008959.pub3. PMID:
32107773; PMCID: PMC7046492.
Tam, E., Keats, E.C., Rind, F., Das, J.K., and & Bhutta, Z.A. (2020). Micronutrient supplementation and
fortification interventions on health and development outcomes among children under-five in low-
and middle-income countries: A systematic and meta-analysis. Nutrients 12(2):289. doi:
10.3390/nu12020289. PMID: 31973225; PMCID: PMC7071447.
45
UCSF (2022). Risks associated with Bbisphenol A in baby bottles.

https://cchp.ucsf.edu/sites/g/files/tkssra181/f/BisphenolEn0908.pdf (Accessed on 29 October 2022)
UNICEF (2016). Responsive Feeding: Supporting Close and Loving Relationships.

https://www.unicef.org.uk/babyfriendly/wpcontent/uploads/sites/2/2017/12/Responsive-Feeding-
Infosheet-Unicef-UK-Baby-Friendly-Initiative.pdf (Accessed on 20 October 2022)
UNICEF (2017). Meeting report on considering, refining, and extending the World Health Organization infant
and young child feeding indicators. UNICEF. New York
UNICEF (2020). Improving young children’s diets during the complementary feeding period. UNICEF
Programming Guidance.New York: UNICEF
UNICEF (2021a). Fed to fail? The crisis of children’s diets in early life. Child Nutrition Report. UNICEF, New
York.
UNICEF (2021b). Feeding your baby: 1–2 years. https://www.unicef.org/parenting/food-nutrition/feeding-

your-baby-1-years (Accessed on 20 October 2022)
UNICEF (2021). Fed to fail? The crisis of children’s diets in early life. Child Nutrition Report. UNICEF, New
York.
KM2 Vega, R.M, Avva, U.(2022, Aug 1). Pediatric Dehydration. In: StatPearls [Internet]. Treasure Island (FL).
https://www.ncbi.nlm.nih.gov/books/NBK436022/ U.S. Food aAnd Drug Administration (2018). The
Dangers of Raw Milk: Unpasteurized Milk Can Pose a Serious Health Risk.
https://www.fda.gov/food/buy-store-serve-safe-food/dangers-raw-milk-unpasteurized-milk-can-
pose-serious-health-risk (Accessed on 29 October 2022)
U.S. Food And Drug Administration. (2020). People at Risk of Foodborne Illness.
https://www.fda.gov/food/consumers/people-risk-foodborne-illness (Accessed on 31 October 2022)
UNICEF (2016). Responsive Feeding: Supporting Close and Loving Relationships.

https://www.unicef.org.uk/babyfriendly/wpcontent/uploads/sites/2/2017/12/Responsive-Feeding-
Infosheet-Unicef-UK-Baby-Friendly-Initiative.pdf (Accessed on 20 October 2022)
UNICEF (2017). Meeting report on considering, refining, and extending the World Health Organization infant
and young child feeding indicators. UNICEF. New York
UNICEF (2021). Feeding your baby: 1–2 years. https://www.unicef.org/parenting/food-nutrition/feeding-

your-baby-1-2 years (Accessed on 20 October 2022)
UNICEF (2021). Fed to Fail? The Crisis of Children’s Diets in Early Life. Child Nutrition Report. UNICEF,
New York.
UNICEF (2020). Improving Young Children’s Diets During the Complementary Feeding Period. UNICEF
Programming Guidance.New York: UNICEF
UCSF (2022). Risks associated with bisphenol A in baby bottles.

https://cchp.ucsf.edu/sites/g/files/tkssra181/f/BisphenolEn0908.pdf (Accessed on 29 October 2022)
Vega, R.M., & Avva, U. (2021). Pediatric dehydration. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing. PMID: 28613793.
WHO (2001). The optimal duration of exclusive breastfeeding. Report of an Expert Consultation. World
Health Organization, Geneva. WHO, 2001
46
WHO (2003). Infant and young child nutrition. Global strategy on infant and young child feeding. Fifty-fifth
World Health Assembly. A55/15. World Health Organization. Geneva
WHO (2005). Guiding Principles For Feeding Non-Breastfed Children 6-24 Months Of Age.
http://www.who.int/child-adolescent-health
WHO (2009). Infant and young child feeding: Mmodel chapter for textbooks for medical students and allied
health professionals. World Health Organization. Geneva.
WHO (2016). Use of multiple micronutrient powders for point-of-use fortification of foods consumed by
infants and young children aged 6–23 months and children aged 2–12 years. World Health
WHO (2018). Botulism. https://www.who.int/news-room/fact-sheets/detail/botulism (Accessed October

19, 2021)
WHO (2019). Appropriate Complementary Feeding. World Health Organization. Geneva

https://www.who.int/elena/titles/complementary_feeding/en/Updated February 26, 2019. (Accessed
October 19, 2021).
WHO (2020). Infant and young child feeding. World Health Organization.Geneva, Switzerland
WHO (2021a). Infant and young child feeding. https://www.who.int/en//news-room/fact- KM2

sheets/detail/infant-and-young-child-feeding.
WHO (2021b). Infant and young child feeding counselling: an integrated course. Trainer’s guide, second
edition(2nd ed.). World Health Organization, Geneva
WHO (2021c). Indicators For Assessing Infant And Young Child Feeding Practices: Definitions And
Measurement Methods. World Health Organization, Geneva
WHO (2021). Infant and young child feeding. Published June 9, 2021. https://www.who.int/en//news-
room/fact-sheets/detail/infant-and-young-child-feeding. (Accessed October 19, 2021)
WHO/UNICEF (1998). Complementary feeding of young children in developing countries: a review of

current scientific knowledge. World Health Organization, Geneva.WHO/NUT/98.1,1998.
WHO/UNICEF (2021). Indicators For Assessing Infant And Young Child Feeding Practices: Definitions And
Measurement Methods. Geneva: Licence: CC BY-NC-SA 3.0 IGO;
https://creativecommons.org/licenses/by-nc-sa/3.0/igo
World Bank (2022). Prevalence of underweight, weight for age (% of children under 5).
https://data.worldbank.org/indicator/SH.STA.MALN.ZS. (Accessed October 19, 2021).
Zalilah, M.S., Khor, G.L., Sarina, S., Huang, S. L., Chin, Y.S., Barakatun, N.M.Y., Chan, Y. M., & Maznorila, M.
(2015). The relationship between household income and dietary intakes of 1-10 year old urban
Malaysian. Nutrition Research and Practice 9(3):278-287. doi: 10.4162/nrp.2015.9.3.278
Zhang, X., Rosenthal, D.M., Benton, L., & Lakhanpaul, M. (2020). Cultural influences on complementary
feeding beliefs amongst new Chines immigrant mothers in England: A mixed method study. Int J
Environ Res Public Health 17(15):5468. doi: 10.3390/ijerph17155468. PMID: 32751218; PMCID:
PMC7432469.
WHO/UNICEF (2021). Indicators For Assessing Infant And Young Child Feeding Practices: Definitions And
Measurement Methods. Geneva: Licence: CC BY-NC-SA 3.0 IGO;
https://creativecommons.org/licenses/by-nc-sa/3.0/igo.
47
WHO (2021). Infant And Young Child Feeding Counselling: An Integrated Course. Trainer’s Guide, Second
Edition. Geneva
WHO/UNICEF (1998). Complementary feeding of young children in developing countries: a review of

current scientific knowledge. 1998 Geneva: World Health Organization, WHO/NUT/98.1,1998.
WHO (2003). Infant and Young Child Nutrition. Global Strategy on Infant and Young Child Feeding. Fifty-
fifth World Health Assembly. A55/15. World Health Organization. Geneva
WHO (2009). Infant and Young Child Feeding: Model Chapter For Textbooks For Medical Students And
Allied Health Professionals. World Health Organization. Geneva
WHO (2019). Appropriate Complementary Feeding.

https://www.who.int/elena/titles/complementary_feeding/en/Updated February 26, 2019. (Accessed
October 19, 2021).
WHO (2018). Botulism. https://www.who.int/news-room/fact-sheets/detail/botulism (Accessed October

19, 2021)WHO, 2020
WHO (2021). Infant and young child feeding. Published June 9, 2021. https://www.who.int/en//news-
room/fact-sheets/detail/infant-and-young-child-feeding. (Accessed October 19, 2021)
KM2 WHO (2016).Use of multiple micronutrient powders for point-of-use fortification of foods consumed by
infants and young children aged 6–23 months and children aged 2–12 years. Geneva: World Health
Organization.
World Bank (2022). Prevalence of underweight, weight for age (% of children under 5).
https://data.worldbank.org/indicator/SH.STA.MALN.ZS. (Accessed October 19, 2021).
Zalilah MS, Khor GL, Sarina S, Huang S L, Chin YS, Barakatun NMY, Chan Y M Maznorila M (2015). The
relationship between household income and dietary intakes of 1-10 year old urban Malaysian.
Nutrition Research and Practice 9(3):278-287
Zhang X, Rosenthal DM, Benton L. and Lakhanpaul M (2020). Cultural influences on complementary feeding
beliefs amongst new Chines immigrant mothers in England: A mixed method study. Int J Environ
Res Public Health 17(15):5468. doi: 10.3390/ijerph17155468. PMID: 32751218; PMCID: PMC7432469.
48
Key Message 3
Eat a variety of foods within your recommended intake

KM3
Key Message 3
Eat a variety of foods within your recommended

intake
Emerita Prof. Dr. Norimah A. Karim, Ms. Rusidah Selamat, Ms. Khairul Zarina Mohd Yusop,
Assoc. Prof. Dr. Gan Wan Ying, Ms. Wan Suria Yusoff @ Wan Yusoff, Dr. Sameeha Mohd Jamil, Dr. Nor Azwani Mohd Shukri
and Ms. Nor Hanisah Zaini
3.1 Terminology
Adequate diet Food groups

An adequate diet provides enough energy, nutrients A food group puts together foods of similar nutrient
and fibre to maintain an individual’s health. A diet content and function. There are five food groups
that is adequate for an individual may not be which are vegetables; fruits; rice, other cereals,
adequate for others (NCCFN, 2021). whole-grains cereal-based products and tubers; fish,
poultry/ eggs/ meat, and legumes; milk and milk
Balanced diet products. These food groups contain foods that are
A balanced diet is a diet that contains a similar in calories, carbohydrate, protein and fat
combination of foods that provide a proper balance contents (NCCFN, 2021).
of nutrients. The body needs many types of foods in
varying nutrients to maintain health. The right Food texture
balance of nutrients needed to maintain health can Food texture refers to the physical appearance or
be achieved by eating proper balance of all healthy consistency of baby’s solid food during
foods including fruit, vegetable, cereal, fish, poultry, complementary feeding period. A food texture
meat, legumes, milk and milk products (NCCFN, acceptance develops with age and is related to the
2021). development of the children's oral-motor skills and
also the ability of the children to chew and swallow
50
food (Tounier et al., 2021). According to WHO (2012), recommendations from the Malaysian Dietary
food texture suitable for children aged 6 to 8 months Guidelines and Malaysian Food Pyramid to help
is pureed or mashed; 9 to 11 months is mashed or Malaysians practise healthy eating concepts in
chopped; 1 to 2 years is shredded and 3 years is every main meal (NCCFN, 2021).
family food or food that baby can pick up.
Moderation
Healthy diet Moderation is a key to a healthy diet. Moderation
A healthy diet is a diet which provides a proper refers to eating the right amount of foods to
combination of energy and nutrients. The four maintain a healthy weight and to optimise the
characteristics of a healthy diet are varied, adequate, body’s metabolic process (NCCFN, 2021).
balanced and moderate (NCCFN, 2021)
Number of serving
Malaysian Food Pyramid 2020 In the Malaysian Food Pyramid, number of servings
A food pyramid is a visual tool that is used as a is the total recommended amount of foods
guide to your DAILY food intake in achieving a consumed daily for an individual according to their
healthy diet. It is developed to provide a guide for recommended energy requirement as in the RNI for
the types and amount of foods that can be eaten in Malaysians.
combination to provide a balanced diet. A food
pyramid consists of four levels that represent five Portion size
food groups. The recommended number of servings Portion size can be described as the amount of food
per day for each food group is indicated next to it. that we consume at one time or single eating
From the bottom to the top of the food pyramid, the occasion which vary in quantity whereby it can be
number of servings of each food group becomes bigger or smaller than the recommended food KM3
smaller indicating that an individual should eat serving size as in Food Pyramid. In the food
more of the foods at the base of the pyramid and less exchange method, a portion size refers to a

of the foods at the top of the pyramid. Malaysian standardised index of the nutritional content of food
Food Pyramid 2020 is targeted for the populations in standard measurement. It can be measured using
aged 7 years and above (NCCFN, 2021). household measurement tools such as tablespoon,
teaspoon, cup, scoop, glass or by number of pieces,
Malaysian Healthy Plate can or bottle. Portion size may not be equal to a
Malaysian Healthy Plate (MOH, 2016) is a visual serving size defined in a food label or in Malaysian
guide to show the total foods in each food group Food Pyramid 2020 and Malaysian Dietary
that needs to be consumed in a meal to achieve a Guidelines for Children and Adolescents 2013.
healthy and balanced diet based on the principle of (Faulkner et al., 2012).
quarter, quarter, half. It is used to translate
umes
d Leg
t an
ea Fr
M u
its
,
gs
Eg
ry,
oult
Fish, P
Rice l-bas
Cere
, Ot ed
a
he
r c pro
s
er
le
a
du ls, et
ab
e
ct Wh g
s a ole Ve
nd g
Tub rain
ers
Figure 3.1: Malaysian Healthy Plate 2016
51
Processed foods Unprocessed and minimal processed food

Edible parts of plants and animals after separation Unprocessed (or natural) foods are the edible parts
from nature or modified/ preserved by minimal of plants (such as fruit, leaves, stems, seeds, roots)
processes or modified with the addition of salt, or from animals (such as muscle, offal, eggs, milk),
sugar, oils or fats to preserve and enhance their and also fungi, algae and water, after separation from
sensory qualities. These include canned or bottled nature. Whilst, minimally processed foods are
vegetables or legumes (pulses) preserved in brine; natural foods altered by methods that include
whole fruit preserved in syrup; tinned fish preserved removal of inedible or unwanted parts, and also
in oil; some types of processed animal foods such as processes that include drying, crushing, grinding,
ham, nuggets, sausage, and smoked fish; most powdering, fractioning, filtering, roasting, boiling,
freshly baked breads; and simple cheeses to which non-alcoholic fermentation, pasteurisation, chilling,
salt is added (Monteiro et al., 2019). freezing, placing in containers, and vacuum
packaging. Unprocessed and minimally processed
Recommended Nutrient Intakes (RNIs) foods vary in energy density and in their content and
Recommended nutrient intakes are nutrient balance of fats, carbohydrates, proteins, and their
standards that are used to plan and assess dietary fractions, and in vitamins, minerals and other
nutrient intakes of healthy individuals or bioactive compounds. (Monteiro et al., 2019b; Lane
populations. Nutrient recommendations in RNI et al., 2020).
differ by age, sex, and physical activity level. The
range of intakes encompassed by the RNI should be Ultra-Processed Foods (UPFs)
considered sufficient to prevent deficiency, maintain Ultra-processed foods are characterised by NOVA
optimal health while avoiding toxicity (NCCFN, as industrial formulations generated through
KM3 2017). compounds extracted, derived or synthesised from
food or food substrates. Ultra-processed foods also
Serving size commonly contain artificial substances such as
Serving size is a standardised quantity used to colours, sweeteners, flavours, preservatives,

describe the amount of food as consumed at one thickeners, emulsifiers and other additives used to
time or in one eating occasion. One serving size promote aesthetics, enhance palatability and
provides a comparable amount of key nutrients from increase shelf life (Monteiro et al., 2019b; Lane et al.,
specific food groups which contain a standard 2020). Ready to eat foods and beverages, spreads,
amount of macronutrients in grams per serving. The packaged snacks and cookies, instant noodles, and
serving size can be quantified using household pre-prepared ready to heat products are some
measurement tools for example tablespoon, examples of ultra-processed foods high in sugar,
teaspoon, cup, scoop and glass; or by number of salt, fat and artificial substances.
pieces, can or bottle. The serving size defined in the
Malaysian Food Pyramid may not be equal to a Variety
serving size defined in a food label (Deena A. et al., Variety refers to eating many different types of foods
2008). Serving size used for this document is the each day and to ensure better selection of healthier
same as in MDG 2020. foods. By selecting a variety of foods, the chances of
consuming the multitude of nutrients the body
needs are optimised.
52
3.2 Introduction
A healthy diet is important to supply nutrients, groups which are placed at four levels. The
reduce malnutrition risk and to manage certain recommended servings of each food group in the
diseases. Healthy and balanced eating habits Malaysian Food Pyramid 2020 is within a calorie
provide energy and nutrients required by the body. range of 1500 to 2300 kcal per day. However,
The Malaysian Dietary Guideline 2020 suggested adolescents aged 13 to 15 years and aged 16 to 18
three important considerations when planning years have different recommendations for fruits
healthy meals, specifically, (i) eating a balanced diet which is 2 to 3 servings/ day and for milk and milk
(ii) consume a wide variety of foods and (iii) products which is 2 to 3 servings/ day, instead of
consume foods in moderation (NCCFN, 2021). These only 2 servings/day respectively. Whilst, for
recommendations have also been suggested by adolescents aged 16 to 18 years, the recommended
other dietary guidelines from various countries such serving for rice, other cereals, whole grain cereal-
as the USA (Dietary Guidelines for Americans, 2020- based products and tubers is at 3 to 6 servings/ day.
2025), and Australia (NHMRC, 2013).
As for children aged 6 months to below 7 years, the
The accelerated phase of urbanisation and food recommended serving for each food group is
industrialisation in recent decades has inevitably presented in Table 3.2 & 3.3 (page 62-64) in this
brought changes in the Malaysian dietary habits. A document. The calorie range for this group is
major shift can be seen in the availability, between 570 kcal to 1300 kcal per day. Thus, the
accessibility, affordability of processed and contribution of macronutrients to the total energy
convenient foods which influenced the consumer’s intake are 50-65% carbohydrate, 10-20% protein and
food preferences and choices. The dietary changes 25-35% fat. KM3
towards affluent and convenient processed foods
have been associated with the increasing The recommendations from the Malaysian Food

prevalence of obesity irrespective of age, ethnic and Pyramid could be translated into practice using the
social status. In Malaysia, there is an increased trend Malaysian Healthy Plate concept which gives
of malnutrition among children and adolescents guidance to individuals aged 7 years and above for
with both overweight and undernutrition their daily three main meals intake. The Malaysian
conditions. Unhealthy diet practices among school Healthy Plate incorporates the principles of quarter,
children has also been reported in the National quarter, half. To estimate the food portion, a 10-inch
Health and Morbidity Survey (NHMS) 2017 & 2022. (25 cm) plate is used. It is recommended that the
It is very important that an individual ensures first half of the plate should be filled with vegetables
getting appropriate foods and incorporates the and fruits. This is followed by filling the first quarter
principle of good nutrition and eating in moderation. of the plate with either rice, noodles, breads, grains,
The adoption of Malaysian Food Pyramid 2020 cereal products or tubers. The other quarter of the
recommendation provides a balanced daily diet with plate is filled with either fish, poultry, meat or
a variety consumption of all food groups and legumes. In addition, plain water or unsweetened
promotes freshly prepared dishes made from beverages should be consumed with the meal. The
unprocessed or minimally processed foods. This will visual of Malaysian Healthy Plate does not reflect
enhance and optimise the nutrient absorption and the total calories intake and number of servings for
needs of the body. In addition, eating foods within each food group to be taken daily (MOH, 2016).
the recommended number of servings is crucial.
Malaysian Dietary Guidelines 2020 specifically Taking into consideration the emerging issue on
highlighted the messages on the limitation of ultra- double-burden of malnutrition and poor dietary
processed foods (UPF) and beverages. This is in pattern among children and adolescents, it is timely
consideration of the scientific findings which for the revision of MDG for Children and
associated UPF consumption with increased risk of Adolescents 2013 (NCCFN, 2013). The reviewed
obesity, non-communicable diseases (NCDs) and version of the MDG for Children and Adolescents
cancer. 2023 is expected to provide more relevant and
accurate key messages and recommendations of
The Malaysian Food Pyramid 2020 is a reference of healthy eating practices targeted to various
daily food intakes for the healthy population aged 7 stakeholders.
years and older. The pyramid consists of five food
53
3.3.1 Importance and health benefits of food various problems of double malnutrition such as
variety for children and adolescents stunting, wasting, obesity, anaemia and calcium as
well as iodine deficiency.
A nutritionally adequate and balanced diet is crucial
for optimal growth and development of children and Complementary foods should provide sufficient
adolescents. The Malaysian Dietary Guidelines for energy and all nutrient (macro- and micro-)
Children and Adolescents 2023 was reviewed based requirements (including iron, calcium, iodine,
on the latest Recommended Nutrient Intake (RNI) vitamin A) This can be achieved by consuming a
2017 for Malaysians (NCCFN, 2017). These nutrient variety of foods, including poultry, fish, legumes,
requirements for Malaysians were established based fruits, vegetables and other foods that can all be
on the latest scientific evidence which take into introduced (in appropriate texture and size) from 6
consideration the age, sex and their physical activity months. The variety in foods should also include
levels. The RNI is intended to guide nutrition different textures , colours and flavours as variety
recommendations for adequate macronutrients and results in more complete nutrition, provides
micronutrients which further support a varied diet phytonutrients, improves safety, and reduces
as food within a food group can differ in their allergies. No nuts in solid form should be given until
nutrient composition (Haytowitz & Pehrson, 2016). the infant is old enough to eat safely (about 3 years
In ensuring that the children get all the required old). However, nut pastes are safe for consumption
nutrients for growth and development, it is therefore from 6 months (Binns et al., 2020).
crucial for them to eat a variety of foods within the
KM3 recommended intake. This early appropriate dietary 3.3.2 Importance and health benefits of
practices from a young age is of utmost importance eating the appropriate portion size and
for the prevention and control of diet related meeting the recommended number of
diseases such as diabetes and hypertension at later serving size for children and
life. Globally, processed foods constituted the adolescents
predominant source of energy which accounted for
about 50%-90% of intake (Baraldi et al., 2018). Milk is widely considered as a beneficial product for
Greater intake of processed food is associated with growing children. A population-based observational
health consequences such as obesity, type 2 cohort study was conducted by Kwon et al. (2021)
diabetes and cardiovascular diseases (Schwinshackl by dividing 425,583 Korean children into three
et al., 2017). Thus, the paradox of having surplus on groups based on daily milk consumption at age 30-
the dietary intake, there are insufficient 36 months: low milk group (do not drink or drink
micronutrient intakes. This reflects on the <200 mL milk per day, n = 139,659), reference group
compliance of the population with food based (drink 200–499 mL milk per day, n = 255,670), and
dietary recommendations which were repeatedly high milk group (drink ≥500 mL milk per day, n =
reported to be low (Moore et al., 2012). 30,254). At 42-72 months, 8.54%, 10.19% and 12.39%
children in the low milk group, the reference group,
The importance of taking a variety of foods daily is and the high milk group, respectively were found to
well documented in various studies. Scientific be obese (p<0.001). Further analysis showed that
studies have shown that higher food variety scores the aRRs for obesity occurrence were 0.856 (95%
are associated with a range of health benefits. These CI=0.835–0.878) in the low milk group and 1.120
include lower risk of developing type 2 diabetes, (95% CI=1.077–1.165) in the high milk group.
lower risk of metabolic syndromes and a longer life Compared with the reference group, the risk of
expectancy. The emphasis on consuming a variety obesity was significantly greater for children who
of foods is also recommended in most national drank ≥500 mL milk per day. These results indicated
dietary guidelines as no food supplies all nutrients that children aged 30-36 months who consumed
except for breastmilk during the first 6 months of life. ≥500 mL milk per day were at an increased risk of
Different foods provide different types and amounts obesity at the age of 42–72 months, controlling for
of key nutrients. It is also important to choose a various confounding variables. On the other hand,
variety of foods from within each food group. This their study also determined the relationship
would also make the meal more exciting, interesting between milk intake and iron deficiency anaemia
and nutritious. Apart from the food consumption (IDA). Results found that 1.86% children in the
frequency, taking a variety of foods in adequate reference and low milk groups and 2.06% children
quantities as recommended is crucial. Lack of food in the high milk group were diagnosed with IDA and
intake in a daily diet of the children would lead to prescribed iron, respectively (p = 0.047). The risk of
54
IDA was significantly increased in children who cluster-randomised crossover trial evaluated the
drank ≥500 mL milk per day (aRR, 1.079; 95% effects on children’s intake by increasing the
CI=1.000–1.176) compared with the reference group. proportion of vegetables and fruits using two
No statistical significance was detected between strategies, which were adding (increased portions
the low milk group and the reference group. of low-energy-dense vegetables and fruits by 50%) KM3
Findings of the Early Childhood Longitudinal or substituting (increased portions of vegetables and
Survey–Birth cohort showed that higher milk fruits by 50% and also reduced portions of other

consumption was associated with higher z-scores foods by an equivalent weight) extra portions as
of BMI, height and weight-for-height at 4 years (all side dishes at meals and snacks over 5 days (Roe et
p<0.05) (DeBoer et al., 2015). Children drinking al., 2021). The findings showed that the Addition
<1 and ≥4 servings of milk daily were approximately strategy increased daily vegetable and fruits
increased 1 cm in height and 0.15 kg in weight. At consumption by 24% (mean ± SEM 12±3 g/d; p =
4 years of age, children drinking ≥3 servings of milk 0.0002) and 33% (60±6 g/d; p < 0.0001), respectively;
daily were more likely to be overweight/obese than while the substitution strategy increased vegetables
those drinking 0.5–2 servings of milk daily (AOR = and fruits consumption by 41% (22±3 g/d;
1.16, 95% CI = 1.02–1.32, p=0.02). At 5 years of age, p< 0.0001) and 38% (69±8 g/d; p< 0.0001),
only the association with height remained respectively. Daily energy intake compared to the
significant (p<0.001). Children drinking 2, 3, and ≥4 control group (served with typical portions for all
servings of milk daily were taller than those drinking food groups) increased by 5% with addition (57±17
≤1 and 1 serving daily (p<;0.05) (DeBoer et al., 2015). kcal; p = 0.001) but decreased by 6% with
Findings from previous studies support substitution (-64±21 kcal; p = 0.004) groups,
recommendations that children consume 2 servings suggesting that substituting vegetables and fruits
of milk daily. It can be difficult to encourage young for other foods is a better option than simply serving
children to eat enough vegetables, but a recent more when excess energy intake is a concern (Roe
study in the United States found that simply adding et al., 2022).
more vegetables to their plates increased the
amount of vegetables consumed during the meal A national cross-sectional study carried out by Yang
(Diktas et al., 2021). The researchers discovered that et al. (2018) on 18,757 adolescents, aged 13-17 years
increasing the amount of broccoli and corn offered from seven provinces in China found that
at a meal from 60g to 120g increased the amount of adolescents who consumed vegetable ≥3 servings
vegetables consumed by 68%, or 21g among 3 to 5 daily showed a lower risk of developing high blood
years old preschool children. However, seasoning pressure (OR = 0.74, 95% CI = 0.58–0.94, p= 0.013)
the vegetables with butter or salt had no effect on compared to those with daily vegetable
their consumption (Diktas et al., 2021). consumptions of <1 serving. When stratified by BMI,
overweight adolescents with 2 to 3 or ≥3 servings
Another recent study also showed that serving of vegetables daily had a lower risk of developing
vegetables and fruits in larger portions can be a high blood pressure compared with the non-
good strategy to increase their consumption among overweight adolescents (Yang et al., 2018).
children aged 3 to 5 years (Roe et al., 2022). A
55
The findings from the National Health and Nutrition The findings from the Healthy Lifestyle in Europe by
Examination Survey (NHANES 2005–2014) on 2286 Nutrition in Adolescence (HELENA), a cross-
adolescents aged 12–18 years suggested that sectional multicentre study showed a positive
adolescents who consume at least 1 serving per day association between portion size and BMI for some
of whole grains may be less likely to have impaired energy-dense foods (Flieh et al., 2021). The study
fasting glucose, which shows implication for found that male adolescents who were plausible
diabetes prevention in adolescents (Tester et al., reporters with overweight or obesity showed
2020). Tester et al. (2020) reported that whole grains significantly higher portion mean intake from
intake was associated with lower BMI percentile, “cheese” and “carbonated soft drink” compared
higher income and higher diet quality, while refined with normal weight males. Female adolescents who
grains intake was associated with lower diet quality were plausible reporters with obesity had higher
and higher total energy intake (p<0.05), but it was mean portion intake from “bread and rolls” and
not associated with income or BMI. Their findings “confectionary non chocolate” compared with
further demonstrated that compared with those normal weight females (Flieh et al., 2021).
with no whole grain consumption, adolescents who
had consumed at least one ounce-equivalent Both portion size and energy density have
serving (16g) of whole grains daily had a 40% significant influence on energy intake, and these two
reduction in odds of having impaired fasting glucose factors are associated with obesity in children
(aOR = 0.60; 95% CI, 0.38–0.93), after adjusting for (Pourshahidi et al., 2014). Serving larger portions to
sex, ethnicity, diet (energy intake and diet quality preschool children has been consistently shown to
index), and adiposity (Tester et al., 2020). increase their energy intake (Kling et al., 2016;
Mooreville et al., 2015; Smethers et al., 2019), known
KM3 A systematic review of prospective observational as the ‘portion size effect’.
studies by Reynolds et al. (2020) supported the
health benefits of dietary fibre intake in children and A sample of 636 British adolescents aged 11 to 18
adolescents, in which it is recommended that years old showed that for each 418 kJ (100 kcal)
dietary fibre intake can start at 13-16 g per day for increase in energy intake, BMI increased by 0.19
2-year-old children and gradually increases until the kg/m2 (95% CI=0.10, 0.28; p< 0.001). The results
age of 10 years, when values are comparable to an further found that the portion sizes of a high-energy-
adult range of 25-30 g per day. dense foods (high- fibre breakfast cereals, cream and
high-energy soft drinks) were positively associated
Another national cross-sectional study, the Korea with a higher BMI among adolescents after
School Health Examination Survey (KSHES), carried adjusting for misreporting (Albar et al., 2014).
out by Kim et al. (2017) on 136,739 children and
adolescents aged 9, 12, and 15 years old found that In terms of sugar-sweetened beverages (SSBs)
6.3% of the children and adolescents who consumed consumption, a recent systematic review and dose-
>5 servings of meat (including beef, pork, and response meta analysis showed that high SSBs
chicken) per week were obese, compared with 9.1% intake was associated with increased in BMI, waist
who consumed <1 serving of meat per week (OR = circumference and body fat percentage (Farhangi et
1.44, 95% CI = 1.21-1.70). Compared to those who al., 2022) as well as systolic blood pressure and
consumed >5 servings of meat per week, those who hypertension in children and adolescents (Farhangi
consumed <3 servings of meat per week had a et al., 2020). Similarly, a study done by Yu et al. (2022)
higher systolic blood pressure (SBP) and diastolic involving 1,068 children and 751 adolescents aged
blood pressure (DBP) after adjusting for BMI. The 6–18 years in China found that SSB sugar intake
intake of milk, fruit, and vegetables were not >25 g/day increased the risk of overweight/obesity
associated with either SBP or DBP (p>0.05). The (OR = 1.391, 95% CI = 1.115–1.734). Another study
findings suggested that consuming an appropriate in China by Liu et al. (2022) found that SSB
amount of meat is important for healthy growth for consumption of ≥1 serving/day increased the risk
children and adolescents (Kim et al., 2017). depressive symptoms (OR = 2.28, 95% CI = 1.30-
4.01) in children and adolescents aged 7 to 17 years,
in which this association was more evident in
children and adolescents who had higher body fat
or lower fat-free mass (FFM) or muscle.
56
3.3.3 Consumption of ultra-processed foods relationship was observed in both sexes, with a 10%
(UPF) and association with overweight increase in the consumption of ultra-processed
and obesity foods being associated with a 18% increase in the
prevalence of obesity in men and 17% increase in
To date, there are no studies reporting on the UPFs women (Rauber et al., 2020).
consumption among children and adolescents in
Malaysia (Ali et al., 2019). However, there have been A prospective study shows that adherence to the
several studies on consumption of UPFs among Dietary Obesity-Prevention Score (DOS) which
adults (Asma et al., 2020; Asma et al., 2019; Foo et include reducing fast food and processed food
al., 2021). PAHO (2015) reported that the annual intake was significantly associated with a reduced
retail sales of ultra-processed food and drink risk of developing overweight/obesity in a
products in Malaysia was 56.6 kg/person. A study Mediterranean cohort of initially normal-weight,
in Kuala Terengganu among mostly Malay adults middle-aged adults (Gomez-Donoso et al., 2018).
reported that the energy contribution of UPFs was Taxation or increase in food prices reduces fast food
24%. Sodium and added sugar contributions of the consumption in the western countries. Each 10%
ultra-processed group were 26% and 63%, price increase reduces fast foods consumption by
respectively (Asma et al., 2019; Asma et al., 2020). 3% (95%CI = 1–5%) (Afshin et al., 2017).
Foo et al. (2021) evaluated the type and quality of
food and beverages sold in school canteens in public 3.3.4 Using Healthy Plate as a guide to
primary and secondary schools in Kelantan. The healthy balanced meals
study showed that the total sugar content of all pre-
packaged foods, especially beverages (29.1%) were In a study by Talati et al. (2017), 10 focus groups
classified as high. 19.1% of confectionery and 10% were conducted in Perth, Western Australia with KM3
of flavoured milk and fruit drinks both exceeded the adults (aged 18+ years) and children (aged 10-17
recommended sugar levels of＞22.5 g per 100 g and years) to explore their preference towards two food

＞11.25 mL per 100 mL, respectively. The systematic guides currently being widely used in Australia: the
review on worldwide consumption of UPFs reported Healthy Eating Pyramid and the Australian Guide to
that the United States and the United Kingdom were Healthy Eating Plate. The participants were
the countries with the highest percent energy intake segmented into groups based on their gender (male,
from UPFs (generally > 50%), whereas Italy had the female) and age (10-13, 14-17, 18-25, 26-45, 46+
lowest levels (about 10%) among adults (Marino et years). The study found that a large majority of
al., 2021). In children and adolescents, studies in participants chose the plate as their preferred
Brazil (Bielemann et al, 2018), UK (Onita et al., 2021) nutrition guide. The style of presentation used for
and USA (Neri et al., 2019) show that UPFs the plate was reportedly clearer and more
contributed between 40.3%, 65.4% and 64.6% aesthetically pleasing. In terms of precision, the
respectively to the total energy intake (TEI). plate with its clear divisions was perceived to be
more instructive than the pyramid.
Recent systematic review and meta-analysis of
observational studies reported a significant In the same study, younger children (10-13 years)
association between UPF intake and overweight reported a strong preference for the plate, due to its
(pooled effect size: 1.02 (95% CI: 1.01, 1.03, p < 0.001) aesthetic and precision elements. Both adults and
and obesity (pooled effect size: 1.26; 95% CI: 1.13, adolescents viewed the pyramid to be more child-
1.41, p < 0.001). UPF is directly associated with friendly due to its cartoon drawings. Some parents
excess weight gain and 26% increase in the odds of in the study found that the plate would be useful for
obesity among participants from both developed them to teach their own children about healthy
and developing countries (Mohammadreza et al., eating and serve as an effective tool for one-on-one
2020). Data from the UK National Diet and Nutrition interactions where an adult can provide individual
Survey (2008–16) reported that consumption of UPF guidance in interpreting the plate and applying it to
was associated with an increase in BMI, WC and specific food decisions.
prevalence of obesity in both sexes. A dose response
57
3.4 Current Status
3.4.1 Food intake and dietary practices
Food intake of children and adolescents have been assessment of habitual food intakes. The findings
studied in at least three nationwide-surveys; the showed that the overall mean energy intake was
Malaysian School-based Nutrition Survey (2012), 1,659 kcal/day. Male adolescents were found to
Southeast Asia Nutrition Survey (SEANUTS) consume significantly higher energy than their
Malaysia (Poh et al., 2013), and National Health and female counterparts (1,774 vs 1,595 kcal/day). Mean
Morbidity Survey (2012 & 2017). The Nutrition energy intake was also found to be significantly
Survey of Malaysian Children was conducted as a higher among adolescents in the rural area (1,706
part of the SEANUTS, which was a multicentre kcal/day) compared to those in urban locations
international nutrition survey of children aged 6 (1,612 kcal/day). The mean energy intake was also
months to 12 years. A total of 16,744 participants significantly different according to the BMI status of
from four countries (Malaysia, Indonesia, Thailand, the adolescents with the intake being lowest among
and Vietnam) were included in the study. The the underweight adolescents (1,571 kcal/day) and
dietary intake of the Malaysian children (N=3,542) highest among those who were categorised as
was assessed using a validated semi-quantitative obese (1,987 kcal/day). The Malaysian School-based
FFQ. The findings of the survey demonstrated that Nutrition Survey (2012) was conducted on 2,235
the mean total energy intake was significantly children aged 10 to 12 years using a validated FFQ.
higher among the boys than girls (in the same age The findings indicated that the mean intakes
group) for 4.0 to 6.9 years’ (1,492 vs 1,412 kcal/day) (servings per day) of rice/cereals/grains, fruits, and
KM3 and 7.0 to 12.0 years’ (2,029 vs 1,926 kcal/day) age protein sources such as poultry, meat, egg, fish, and
groups, but was similar in the younger age groups. legumes among the standard 4 to 6 pupils in this
In terms of geographical locations, no significant country met the MDG recommendations. However,
difference in mean total energy was detected their vegetables as well as milk and milk product
between rural and urban children across the age intakes did not meet the MDG recommendations.
groups. However, the mean energy intakes were The school children were reported to be taking only
significantly higher among rural than urban children 1 serving (of the recommended 3 servings) of
of the same sex in the 1-3 year age group (boys: vegetables and 0.6 serving (of the recommended 1-
1,201 vs 1,078 kcal/day; girls: 1,191 vs 1,078 3 servings) of milk and milk products, daily. In
kcal/day). The National Health and Morbidity addition, more than 50% of the children consumed
Survey, NHMS (Institute for Public Health, 2017) less than the recommended servings per day for the
included a nutrition survey on 13-17 years old majority of the food groups (fruits, vegetables, milk
Malaysian adolescents (N=999) using a single 24- and milk products, fish and legumes). Whilst NHMS
hour diet recall. From the national survey, it was (2017) found that more than 50% of the 13-17 years
demonstrated that the median energy intake of old Malaysian adolescents did not meet the
these adolescents was 1,848 kcal/day. In terms of recommended servings per day for fruits (61.9%),
locality, urban adolescents were found to have vegetables (91.4%), milk and milk products (64.3%),
higher energy intake than their rural counterparts and fish (76.3%) (IPH, 2017).
(1,909 vs 1,805 kcal/day). The energy intake was also
significantly different according to gender with boys Furthermore, the SEANUTS Malaysia showed that
consuming 2,068 kcal/day and girls 1,670 kcal/day. among children aged 7–9 years (n=890), only 13.4
As expected, older adolescents (16-17 years old) and 9.5% met the MDG for fruits and vegetables per
recorded higher energy intake (1,983 kcal/day) day, respectively. The pattern was similar among
compared to the 13-15 years old counterparts the older children aged 10–12 years (n=883),
(1,786). In addition, the findings according to BMI- although slightly higher, whereby only 19.6 and
for-age status revealed that adolescents with 16.1%, respectively, met the MDG for fruits and
obesity recorded the highest median intake of vegetables. For the milk group, only very low
energy (2,232 kcal /day) whereas adolescents with percentages (5.5%) of children aged 7–9 years and
thinness recorded the lowest (1,673 kcal/day). among those aged 10–12 years (3.7%) met the MDG
for milk/dairy products (Koo et al., 2016). The
The Malaysian Health and Adolescents Longitudinal MyBreakfast study on the other hand showed that
Research Team (MyHeART) Study, was conducted UHT (ultraheat-treated) milk was commonly
among 794 adolescents aged 13 years in the central consumed at breakfast among RTEC (Ready to eat
and northern regions of Peninsular Malaysia (Abdul cereals) consumers, despite the low milk drinking
Majid et al., 2016). Dietary assessment was habits (Mohd Nasir et al., 2017). Thus, the
conducted using a validated 7-day historical consumption of RTEC at breakfast can promote milk
58
consumption among the children and, subsequently, 3.4.2 Knowledge, attitude and practise
may increase the prevalence of children meeting the
MDG for milk/dairy products. A small study by Mashitah et al. (2020) assessed
preference, attitude, knowledge, and recognition of
Also from the SEANUTS Malaysia study (Chong et fruits and vegetables among children. This cross-
al., 2016) found that 56.1% of children consumed 3 sectional study was conducted among 134 Malay
main meals every day. One in five children children aged 9-12 years from five primary schools
consumed snacks 3 times per day, while one in 10 in Kuala Lumpur. The results showed that almost
ate fast food on a weekly basis. They also showed three quarters (70.9%) of these children were from
that irregular meal patterns were significantly families earning less than RM3,900 per month, with
associated with lower micronutrient intakes, and a majority of their fathers (61.9%) and mothers
the groups with higher odds for this pattern were (56.0%) having a secondary school education level.
older children, Malays, and those living in rural The children have a moderate level of attitude,
areas. Considering the relatively high rate of recognition and knowledge of fruits and vegetables.
irregular meal consumption and its potential Half of the children (53.0%) were not aware of the
influence on dietary nutrient intake, concerted daily recommendation for fruits and vegetables.
efforts must be continued to promote and inculcate These children were more interested in trying new
healthy eating habits among children from an early fruits (75.4%) than new vegetables (68.7%). A study
age. poultry or eggs (Cheong et al., 2021). to determine the level of knowledge, attitude, and
practice, on vegetable intake among adolescents
A study on fast food consumption among was also conducted in rural schools in Marang and
adolescents reported that 13.5% of the adolescents Hulu Terengganu districts by Mohd Adzim et al
consumed fast-food 4 to 7 days, 69.3% consumed (2021). This study involved 160 secondary school KM3
fast food 1 to 3 days, and 17.2% did not consume students aged 14-16 years and was conducted from
fast-food in a typical week. Frequency of fast-food January until May 2019. It was found that

consumptions (4 to 7 days and 1 to 3 days per week) respondents had ‘good’ knowledge (41%), ‘good’
was significantly associated with age; sex; ethnicity; attitude (41%) and ‘fair’ practices (52%) against
locality of schools; frequency of eating out; and not vegetable intake. There were positive correlations
consuming recommended intake of cereals or between attitude and knowledge (r=0.38), as well as
grains, vegetables, and meat or poultry or eggs between attitude and practices (r=0.25) (p<0.05).
(Cheong et al., 2021). The findings also showed that the respondents’
intake of vegetables was significantly correlated
Foo et al. (2020) carried out a study on sugar- with knowledge (p=0.014) and attitude (p=0.006).
sweetened beverage (SSB) consumption among pre- There were also significant differences in mean of
schoolers aged 3-6 years (n= 590) from urban and knowledge scores between male and female
rural areas of Kota Bharu. Children were recruited respondents (p=0.041). Majority of the respondents
from 16 preschool centres from 169 kindergartens. did not consume adequate intake of vegetables and
The children consumed, on average, 5.0 ± 3.9 SSB only 9% of the respondents achieved the
per week with more than half (61.2%) being recommendation for vegetable intake per day.
consumed weekly. The common SSBs consumed
were coffee, tea, and flavoured and malted 3.4.3 School-based intervention
beverages (46.0%), followed by sugar-sweetened
soda drinks (22.7%), fruit-flavoured drinks (15.8%) School-based intervention plays an important role
and flavoured milk drinks (15.5%). Children with to prevent malnutrition and promote a healthy
higher snack intake of five times or more in a week lifestyle among school children. A study by Teo et
[OR 2.88;95% CI, 1.72-4.84, p<0.001] and al. (2021) introduced the School Nutrition
consumption of fast food at least once a week [OR Programme (SNP) that emphasised on nutrition
3.76; 95% CI, 2.04-6.92; p<0.001] had significantly education and a healthy school canteen
higher SSB intake compared to those with lower environment. The quasi-experimental study design
intake of snack and fast food. In addition, children involved 523 primary school children aged 7-11
with four or more siblings had significantly higher years from six national schools. After the
weekly consumption of SSB [OR 3.O8;95% CI:1.80- intervention program, there was an increase in the
5.26; p<0.001] than those with three or less. There frequency of breakfast, lunch, and dinner
was no difference in the pattern of SSB consumption consumption, as well as morning tea snacking, and
between boys or girls. a significant decrease in the frequency of afternoon
tea and supper snacking at three-month follow-up,
in the intervention group (p<0.05) (Teo et al., 2021).
59
Another study by Chin et al. (2020) has succeeded lunch, dinner, and mid-morning snack but a lower
in conducting a Healthy Kids Programme (HKP) consumption frequency of late-evening snack as
aimed at improving body weight status, knowledge, well as meal skipping behaviours than their control
practices and attitudes among children. This counterparts, indicating the effectiveness of the
longitudinal intervention study was conducted over intervention (Teng et al., 2018).
3 years (2011-2013) involving 386 Standard three
pupils from 12 primary schools in the Klang Valley. On the other hand, a study indicated that
The results demonstrated that there was an intervention aimed to increase whole grain intake
increase in the pre- and post-impact surveys for as a strategy to improve the quality of diet in
each topic, a significant increase in knowledge, and combating obesity among school children improved
a decrease in overweight and obesity rates (Chin et overall short-term but not long-term dietary intake
al., 2020). among schoolchildren (Koo et al., 2020). The GReat-
Child Trial involved a 12-week intervention and 6-
In view of the importance of healthy eating among month follow up among overweight/obese children
adolescents, a 3-year, school-based Healthy aged 9 to 11 years. The intervention consists of
Lifestyle Program was conducted by pre-trained nutrition lessons using the Malaysian Food Pyramid,
teachers among Malaysian adolescents living in day daily deliveries of wholegrain foods to schools, and
school hostels using a Healthy Eating and Be Active parental diet counselling. A total of 63 children
Eating (HEBAT) module (Teng et al., 2018). This (N=31 intervention; N=32 control) from two primary
intervention focused on the importance of energy schools in Kuala Lumpur completed the trial. The
balance through healthy eating and active living to intervention group demonstrated significantly
achieve healthy body weight status among the higher intakes of whole grain, dietary fibre, calcium,
KM3 adolescents. A total of 2,635 13-year-old thiamin, riboflavin, niacin, and vitamin C compared
respondents (comprising N=921 intervention and to the control group at 3 months. Unfortunately, the
N=1,714 control) from 100 day schools completed results were not sustained at the 9th month follow
the trial during which they were followed from Form up when intervention had been discontinued (Koo
1 to Form 3. The intervention respondents et al., 2020).
demonstrated higher consumption frequencies of
Key Recommendation (KR) 1: Choose and consume a variety of foods based on daily calorie
needs.
General Parents/ Caregiver Caregivers/ Teacher Health Professional

(to children and adolescents)

Determine the calorie Learn about calorie Find out the energy Educate individuals on
needs based on their needs and determine requirement range of the recommended
sex, age group, and your children's calorie your students. calorie needs based
physical activity level requirement. on their sex, age
as shown in Table 3.1. group, and physical
activity level as shown
in Table 3.1.

Choose and consume Prepare a variety of foods for children that can Educate the public to
a variety of foods which fulfil their daily calorie needs as shown in consume a variety of
can fulfil daily calorie Table 3.1. foods from all food
needs. groups.
60
Key Recommendation (KR) 1: Choose and consume a variety of foods based on daily calorie
needs. (cont.)


Consume foods from Prepare and encourage children and adolescents Educate children,
the different food to eat from the different food groups based on the parents and teachers
groups based on the recommended number of servings as shown on food groups and
recommended number in Table 3.2 & 3.3. types of foods in each
of servings as shown food group.
in Table 3.2 & 3.3.

Vary the food choices Provide different types of food from the same food Educate children,
in the same group. group between main meals. parents and teachers
on various types of
food in the same food
group.
KM3
Table 3.1: Recommended caloric intake of children and adolescents by age and sex according to
Recommended Nutrient Intakes for Malaysian (2017)

Age groups PAL Boys (kcal) Girls (kcal)
6 to 8 months 1.4 630 570

9 to 11 months 1.4 720 660
1 to 3 years 1.4 980 900
4 to 6 years 1.4 1300 1210
7 to 9 years 1.6 1750 1610
10 to 12 years 1.6 1930 1710
13 to 15 years 1.6 2210 1810
16 to 18 years 1.6 2340 1890
Source: RNI 2017

* PAL (Physical Activity Level) refers to low active (PAL 1.4), moderately active (PAL 1.6), active (PAL 1.8) and very active (PAL 2.0).
61
KM3
Table 3.2: Recommended food portion per day according to age groups (age 6 months to 3 years)
Number of servings per day according to age groups*

Food group
6 to 8 months 9 to 11 months 1 to 2 years 3 years
(570-630 kcal) (660-720 kcal) (900-980 kcal) (900-980 kcal)
Vegetables 1 dessert spoon (10g) of 2 dessert spoons (20g) of 3 dessert spoons (30g) of 4 dessert spoons (40g) of
cooked vegetables. cooked vegetables. cooked vegetables. cooked vegetables.
Fruits 1 ½ dessert spoons (30g) of 1 ½ dessert spoons (30g) of 1 pisang berangan (60g) 1 pisang berangan (60g)
banana. banana.
Rice, other cereals, 1 ½ cup (250g) of porridge 2 ½ cups (410g) of thick 2 ½ cups (250g) of cooked 2 ½ cups (250g) of cooked
wholegrain cereal-based porridge rice rice
products and tubers
Poultry/ Meat 1 dessert spoons (10g) of 1 dessert spoons (10g) of 1 ½ dessert spoons (15g) of 1 ½ dessert spoons (15g) of
mashed/ blended poultry. fine minced poultry. soft/ shredded poultry. diced poultry.
or or or or
62
1 dessert spoons (10g) 1 dessert spoons (10g) 1 ½ dessert spoons (15g) of 1 ½ dessert spoons (15g) of
mashed/ blended meat. fine minced meat. soft/ shredded meat. shredded meat.
Egg - - ¼ whole egg (10g) (medium ¼ whole egg (10g) (medium

size) size)
Fish 1 teaspoon (10g) of minced 2 teaspoons (20g) of ¼ whole medium size (20g) ½ whole medium size (40g)
fish. shredded fish. of fish. of fish.
or or
2 dessert spoons (20g) of 4 dessert spoons (40g) of
soft/ shredded fish. soft/ shredded fish.
Food group
Legumes ⅓ teaspoon (5g) of soft ½ teaspoon (8g) of soft 1 teaspoon (15g) of soft 1 teaspoon (15g) of soft
tau hoo tau hoo tau hoo tau hoo
Milk & Milk Products** Breast milk on demand Breast milk on demand 2 glasses (500ml) of full 2 glasses (500ml) of full
cream milk cream milk
Fats/ Oils (teaspoon) 1 ½ teaspoons (7.5g) 2 teaspoons (10g) 2 ½ teaspoons (12.5g) 2 ½ teaspoons (12.5g)
* Recommended amount of each food group refers to the maximum requirement of each age group.
**For age 2 years and below, total energy intake is divided into 2 sources: complementary feeding and milk feeding. For infants fed with infant formula, the amount intake of formula milk must not exceed 413
kcal/day and 379 kcal/day for infants aged 6 to 8 months and 9 to 11 months respectively. (Dewey et. al., 2004); or not more than 5 feedings per day and 4 feedings for infants aged 6 to 8 months and 9 to 11
months respectively. (FAO/WHO, 2020).
Note:
63
• Malaysian Breastfeeding Policy states that all mothers are encouraged to breastfeed their children with breast milk from birth until six months old continuing until two years of age. Complementary foods
should be given from 6 months old.
• Added sugar is not allowed for children below 2 years old, WHO 2015 recommends that intake of added sugar for children 3 years old not more than 2 teaspoons per day.
• Recommended amount of fats/ oil intake per day is including oil used in cooking and food preparation.
• Refer to figure 3.2 for standard household measurements used in this dietary guidelines.

KM3
KM3
Table 3.3: Recommended number of servings of food groups by age (4 to <18 years) and energy requirement per day (kcal)
Number of Servings*
4 to 6 years 7 to 9 years 10 to 12 years 13 to 15 years 16 to <18 years

Food group
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
1300 kcal 1210 kcal 1750 kcal 1610 kcal 1930 kcal 1710 kcal 2210 kcal 1810 kcal 2340 kcal 1890 kcal
Vegetables 2 2 3 3 3 3 3 3 3 3
Fruits 2 2 2 2 2 2 3 2 3 2
Rice, other cereals, 3 2½ 4 3 5 4 5 4 6 5

wholegrain cereal-based
products and tubers
64
Poultry/ Meat ¼ ¼ ½ ½ 1 ½ 1 ½ 1 ½
Egg ¼ ¼ ½ ½ 1 ½ 1 ½ 1 ½
Fish ½ ½ 1 1 1 1 1 1 1 1
Legumes ½ ¼ 1 1 1 1 1 1 1 1
Milk & Milk Products 2 2 2 2 2 2 3 2 3 2
Fats/ Oils (teaspoon) 4 3 6 5 6 6 6 6 6 6
Sugar (teaspoon) 2 2 3 3 3 3 5 3 5 3
* Serving size same as in the Malaysian Food Pyramid 2020

Table 3.4: Example of menu for children aged 6 months – 3 years

Meals
Breakfast ½ cup (80g) rice porridge ½ cup (80g) rice porridge 1 slice (30g) bread 1 slice (30g) bread
½ teaspoon (5g) chicken ½ teaspoon (5g) chicken scramble egg scramble egg
⅓ teaspoon (5g) of soft tau hoo ½ teaspoon (8g) of soft tau hoo - ¼ whole egg - ¼ whole egg
½ teaspoon oil ½ teaspoon oil - 1 teaspoon butter/ margarine - 1 teaspoon butter/ margarine
2 slices (15g) cucumber 2 slices (15g) cucumber
1 slice (20g) cheese 1 slice (20g) cheese
Morning Tea ¾ dessert spoons (15g) banana 2 ½ dessert spoons (25g) papaya 1 pisang goreng cheese (30g) ½ apple (50g)
Lunch ½ cup (80g) rice porridge ¾ cup (120g) rice porridge ¾ cup (75g) of rice ¾ cup (75g) of rice
1 teaspoon (10g) fish Vegetable soup with chicken Chicken soup Chicken soup
1 teaspoon (5g) spinach - ½ medium (40g) potato - ½ whole potato (40g) - ½ whole potato (40g)
½ teaspoon oil - 1 dessert spoon (10g) - 1 ½ teaspoon (15g) chicken - 1 ½ teaspoon (15g) chicken
broccoli/ cabbage - 1 ½ dessert spoon (15g) - 1 ½ dessert spoon (15g)
- ½ teaspoon (5g) chicken diced carrot diced carrot
65
1 teaspoon oil
Afternoon Tea ¾ dessert spoons (15g) banana 2 dessert spoons (25g) mango ¼ whole (50g) mango mango pudding
2 dessert spoon (40g) taufufa - ¼ whole (50g) mango
- ½ glass (125 ml) of milk
1 piece (30g) tauhu bergedil
Dinner ½ cup (80g) rice porridge 1 cup (165g) rice porridge 1 cup (100g) of rice 1 cup (100g) of rice
½ teaspoon (5g) chicken 2 teaspoon (20g) fish 2 teaspoon (20g) fried fish 2 teaspoon (20g) fried fish
1 teaspoon (5g) pak choy 2 teaspoon (10g) red spinach 2 dessert spoon (15g) mixed 2 dessert spoon (15g) mixed
½ teaspoon oil ½ teaspoon oil vegetable (carrot+broccoli) vegetable (carrot+broccoli)
Supper 1 glass (250g) of milk 1 glass (250g) of milk

* Recommended amount of each food group refers to the maximum requirement of each age group.
** 1 dessertspoon = 10 ml = 2 teaspoons.
***For age 2 years and below, total energy intake is divided into 2 sources: complementary feeding and milk feeding (Dewey et. al., 2004).
Note:
- Added sugar is not allowed for children below 2 years old, WHO 2015 recommends that intake of added sugar for children 3 years old not more than 2 teaspoons per day.
- Recommended amount of fats/ oil intake per day is including oil used in cooking and food preparation.
Sources: Album Makanan Kanak-Kanak (2009), MOH; MDG (2020), MOH

KM3
Key Recommendation (KR) 2: Consume daily a variety of foods from all five food groups based
on the recommended number of servings in the Malaysian Food Pyramid 2020


Vary your daily food choices within each level in the Malaysian Educate children,
Food Pyramid 2020. parents and teachers
on Malaysian Food
Pyramid 2020.

Choose foods from the Ensure and provide complete main meals Educate and give
five food groups based consisting of foods from all food groups in the examples of complete
on the Malaysian Food Malaysian Food Pyramid 2020. main meals to fulfil
Pyramid 2020 to get daily food intake
all nutrients needed based on Malaysian
by the body. Food Pyramid 2020.
KM3 KR2: HTA3: KR2: HTA3: KR2: HTA3:

Limit fats, oils, salt, Cook and prepare foods with low fats, oils, salt Educate and conduct
sugar, flavour and sugar and use natural flavour enhancers. hands-on cooking
enhancers and demonstration to

sauces. parents and caregiver/
teachers on how to
cook healthier meals
with low salt, sugar, oil
and fats as well as
using natural flavour
enhancers.
Key Recommendation (KR) 3: Eat your main meals (breakfast, lunch and dinner) as
recommended by the Malaysian Healthy Plate.
General Parents Caregivers/ Teacher Health Professional


Use the Malaysian Use the Malaysian Educate children and public on the concept of
Healthy Plate for your Healthy Plate for Malaysian Healthy Plate #Quarter-quarter-half.
daily main meals, children daily main
which is based on the meals, which is based
quarter-quarter-half on the quarter-quarter-
concept. half concept.
a. Fill in half of your a. Fill in half of your

plate with child’s plate with
vegetables and vegetables and fruits.
fruits.
66
recommended by the Malaysian Healthy Plate. (cont.)

b. Fill in a quarter of b. Fill in a quarter of - -

your plate with rice/ your child’s plate with
other cereals (e.g: rice/ other cereals
meehoon)/ (e.g: meehoon)/
wholegrain cereal- wholegrain cereal-
based products based products (e.g:
(e.g: wholegrain whole grain bread)/
bread)/ tubers (e.g: tubers (e.g: sweet
sweet potato). It is potato). It is
recommended to fill recommended to fill
in this first quarter in this first quarter
with whole grains. with whole grains.
c. Fill in the second c. Fill in the second - -

quarter of your quarter of your child’s KM3
plate with fish/ plate with fish/ poultry/
poultry/ meat/ meat/ legumes (e.g: ,

legumes (e.g: dhall, dhall tempeh, soy
tempeh, soy bean beancurd)/ dairy
curd)/ dairy products.
products.

Drink plain water or Encourage and serve plain water or unsweetened Advocate and promote
unsweetened beverages at all times. plain water intake.
beverages with the
meal.

Avoid buying sugar sweetened beverages (ie: cordial, carbonated drinks, Promote and educate
premix drinks the importance of daily such as 3 in 1). the importance of daily
intake of milk or milk
products as
recommended.

Consume milk or milk Encourage and serve milk or milk products daily Provide healthy
products as to children as recommended. recipes and conduct
recommended. hands on cooking
demonstration to
parents and caregiver/
teachers on how to
cook meals using
various types of
legumes (ie: tauhu
sumbat, vadai, soya
milk, taufufa, bubur
kacang hijau, bubur
kacang merah,
chickpea, kacang
rebus).
67
recommended by the Malaysian Healthy Plate. (cont.)


Consume legumes as Ensure to serve legumes daily in the main meals Educate and conduct
snacks if not included or as snacks for children aged 1 year and above. hands-on cooking
in your main meals (ie: demonstration to
tauhu sumbat, vadai, parents and caregiver/
soya milk, taufufa, teachers on how to
bubur kacang hijau, cook healthier meals
bubur kacang merah, with minimum use of
chickpea, kacang soy sauce, tomato
rebus). sauce, chilli sauce,
oyster sauce and other
sauces and optimise
usage of natural
flavour enhancers.
KM3
KR3: HTA6: KR3: HTA6: -
Limit additional soy Cook and prepare food with minimum use of soy
sauce, tomato sauce, sauce, tomato sauce, chilli sauce and optimise
chilli sauce and gravies usage of natural flavour enhancers.
high in salt, sugar and
fat to your main meal
and replace it with
natural flavours
(e.g: lime, lemon,
herbs, spices).
68
Key Recommendation (KR) 4: Limit intake of processed foods and avoid ultra-processed foods.


Limit intake of ultra- Limit purchasing on Avoid and limit the Educate children,
processed foods such ultra-processed foods serving of ultra- parents and caregiver/
as soft drinks, such as soft drinks, processed foods such teachers on the
sweetened breakfast sweetened breakfast as soft drinks, danger of ultra
cereals, salty fatty cereals, salty fatty sweetened breakfast -processed foods to
packaged snacks and packaged snacks and cereals, salty fatty health and provide
instant noodles, which instant noodles. packaged snacks and examples of ultra-
are nutritionally instant noodles to processed food
unbalanced. children. products in the
market.

Prepare or choose natural ingredients for cooking instead of using Provide recipes and
ingredients made from commercially prepared processed or conduct hands-on
ultra-processed foods such as fish balls, meat balls, salami, sausage cooking KM3
and etc. demonstrations to
parents and caregiver/

teachers on how to
cook healthier meals
using natural
ingredients and flavour
enhancers.

Reduce frequency of eating at fast food outlets Educate children and public on unhealthy
and buying ready-to-eat or frozen processed processed foods sold in fast food outlets,
foods (ie: chicken nugget, fries, sausage) sold in convenience stores or supermarkets.
convenience stores or supermarkets.

Be aware of ultra-processed products Educate children Create awareness on
advertisements which dominate commercial on harmful harmful marketing of
advertising of food; it often conveys incorrect marketing of ultra- ultra-processed
or incomplete information about diet and health. processed products products which
which dominates dominates commercial
commercial advertising advertising of food; it
of food; it often conveys often conveys
incorrect or incomplete incorrect or incomplete
information about diet information about diet
and health. and health.
69
Key Recommendation (KR) 4: Limit intake of processed foods and avoid ultra-processed foods. (cont).


Reduce consuming Shop mindfully. Limit Educate children and public on unhealthy
processed foods (ie: purchasing of processed foods sold in fast food outlets,
nugget, sausage, fries, processed and avoid convenience stores or supermarkets.
ham) and avoid ultra- ultra-processed
processed foods such products.
as soft drinks,
sweetened breakfast
cereals, packaged
snacks (ie: potato
chips, corn chips,
cakes, pastries), and
instant noodles.
KM3
Key Recommendation (KR) 5: Choose and consume healthy snacks between your main meals


Practise consuming Prepare healthy snacks made from (ie: nuts, cut Educate on the types
healthy or nutritious fruits, plain yoghurt, milk, lentils, chickpeas, of healthy and
snacks (ie: nuts, cut steamed bun, sandwiches). nutritious snacks (ie
fruits, plain yoghurt, nuts, cut fruits, plain
milk, lentils, chickpeas, yoghurt, milk, lentils,
steamed bun, chickpeas, steamed
sandwiches). bun, sandwiches).

Eat your snacks Ensure your fridge is always filled up with finger Educate children or
without distraction such cut fruits and vegetables. parents to eat snacks
as watching tv, using a without distraction.
tablet, or playing.

Choose snacks with Ensure your children Educate children or Educate children and
low sugar, salt and fat eat their snacks without parents to eat snacks parents how to read
content. distraction. without distraction. food labels and create
awareness on
Healthier Choice Logo
(HCL).
70
Key Recommendation (KR) 5: Choose and consume healthy snacks between your main meals (cont).


Add whole grains, Read food labels and Educate children and Educate children and
legumes or nuts and choose snacks with low parents how to read publics on types of
seeds to your snacks. sugar, salt and fat food labels and create wholegrains (ie: corn,
(ie: corn, wholemeal content. awareness on wholemeal bread,
bread, wholegrain Healthier Choice wholegrain biscuits)
biscuits) legumes (ie: Logo (HCL). legumes (ie: tauhu
tauhu sumbat, vadai, sumbat, vadai, soya
soya milk, taufufa, milk, taufufa, bubur
bubur kacang hijau, kacang hijau, bubur
bubur kacang merah, kacang merah,
chickpea, kacang chickpea, kacang
rebus), nuts (ie: rebus), nuts (ie:
cashew, peanut, cashew, peanut,
almond) and seeds (ie: almond) and seeds (ie:
sunflower seed, sunflower seed, KM3
pumpkin seed, chia pumpkin seed, chia
seed, sesame seed). seed, sesame seed).

Consume milk and milk Provide, prepare and Educate children and Create awareness on
products (such as buy whole grains, publics on types of healthy snacks such
yoghurt, yoghurt drink) legumes or nuts and wholegrains (ie: corn, milk and milk products
as snacks. seeds as snacks for wholemeal bread, and choose these as
your children. wholegrain biscuits) snacks between main
legumes (ie: tauhu meals.
sumbat, vadai, soya
milk, taufufa, bubur
kacang hijau, bubur
kacang merah,
chickpea, kacang
rebus), nuts (ie:
cashew, peanut,
almond) and seeds (ie:
sunflower seed,
pumpkin seed, chia
seed, sesame seed).
- KR5: HTA6: KR5: HTA6: KR5: HTA6:

Prepare and buy milk Create awareness Conduct hands-on
and milk products (such on healthy snacks such cooking
as yoghurt, yoghurt milk and milk products demonstrations on
drink) as snacks. and choose these as healthy snack
snacks between main preparation using milk
meals. and milk products.
71
3.6 References
Abdul Majid H, Ramli L, Ying SP, Su TT, Jalaludin MY, Abdul Mohsein NA-S (2016) Dietary Intake among
Adolescents in a Middle-Income Country: An Outcome from the Malaysian Health and Adolescents
Longitudinal Research Team Study (the MyHeARTs Study). PLoS ONE 11(5): e0155447.
doi:10.1371/journal.pone.0155447
Afshin A, Peñalvo JL, Del Gobbo L, Silva J, Michaelson M, O’Flaherty M, et al. (2017) The prospective impact
of food pricing on improving dietary consumption: A systematic review and meta-analysis. PLoS
ONE 12(3): e0172277. doi:10.1371/journal.pone.0172277.
Ahmad Ali Z. et al. 2019. Changes in Energy and Nutrient Intakes in the Adult Population of Malaysia:
Findings from the Malaysian Adult Nutrition Survey (MANS) 2003 and MANS 2014. MJN 25(2): 273-
285
Ahmad Ali Z. et al. 2019. Under-reporting of energy and nutrient intake is still a persistent issue in the
Malaysian Adult Nutrition Surveys. MJN 25(2): 261-271
Albar, S. A., Alwan, N. A., Evans, C. E. L., & Cade, J. E. (2014). Is there an association between food portion
size and BMI among British adolescents? Br J Nutr. 112(5), 841-851. doi:10.1017/S0007114514001548.
Ali HI, NG SW, Zaghloul S, Harrison GG, Qazaq HS, Wl Sadiq M, Ywatts K (2013). High proportion of 6 to 18-
KM3 year old children and adolescents in the United Arab Emirates are not meeting dietary
recommendations. Nutr Res. 33.447-456.
Asma A, Lokman N.A.H, Hayati M. Y and Zainuddin A.A (2019). Ultraprocessed food classification, their
contribution to sodium and added sugar availability, and its relationship with nutritional status among
adults in Terengganu, Malaysia International Medical Journal Malaysia 18(3): 49-
58.DOI:10.31436/imjm.v18i3.193
Asma’ Ali, Nurul Atiqah Khasbullah, Fauziah Tufail Ahmad, Hayati Mohd Yusof (2020) Ultra-processed Food
Consumption in Relation to BMI and Body Fat Percentage of Adults in Terengganu. Malaysian Journal
of Medicine and Health Sciences (eISSN 2636-9346
Baraldi LG, Martines Steel E, Cannela DS, Monteiro CA (2018). Consumption of ultra-processed foods and
associated sociodemographic factors in the USA between 2007 and 2017: Evidence from a nationally
representative cross-sectional study. BMJ Open. 8. E020574.
Bielemann, R.M.; Santos, L.P.; dos Santos Costa, C.; Matijasevich, A.; Santos, I.S. Early feeding practices
and consumption of ultraprocessed foods at 6 y of age: Findings from the 2004 Pelotas (Brazil) Birth
Cohort Study. Nutrition 2018, 47, 27–32.
Binns C, Lee MK., Low WY., Baker P., Bulgiba A., Dhalui M., Duong DTT., Guldan G., Hairi N., Hokama T.,
Kagawa M., Karunathilake I., Abdul Majid H., Maycock B., Nanishi K., Qiu L, Abdul Raheem R., Scott
J. and Tang L. Guidelines for Complementary Feeding of Infants in the Asia Pacific Region: APACPH
Public Health Nutrition Group. Asia Pacific Journal of Public Health 1–9 (2020). doi:
10.1177/1010539520931328
Chin Y. S., Tee E. S., Zawiah H., Rasyedah A. R., Norimah A. K., Effectiveness Of a Nutrition Education
Intervention For Primary School Children: The Healthy Kid Programme, Malaysia. Malaysia Journal
Medicine and Health Science 16 (2020) (SUPP6): 1-10.
Cheong S. M., Ruhaya S., Mohamad Hasnan A. Azli B., Poh. B. K., Tahir A., Dietary Patterns and Associated
Factors Among Adolescents in Malaysia: Finding from Adolescent Nutrition Survey 2017. Int J Environ
Res Public Health. 2020 May;17 (10):3431. Doi:3390/ijerph17103431.
72
Chong KH, Wu SK, Noor Hafizah Y, Bragt MCE and Poh BK on behalf of SEANUTS Malaysia (2016). Eating
habits of Malaysian children: Findings of the South east asian Nutrition Surveys ( SEANUTS). Asia
Pacific Journal of Public Health; 28 (SS)S9S-73S APJPH. DOI:10.1 177/10105395 1665 4260.
Chong K. H., Lee S. T., Ng S. A., Ilse K., Poh B. K., Fruit and Vegetable Intake Patterns and Their Associations
with Sociodemographic Characteristics, Anthropometric Status and Nutrient Intake Profiles among
Malaysia Children Aged 1-6 Years. Nutrient 2017,9,723; doi:10.3390/nu9080723.
www.mdpi.com/jounal/nutrients (tahun??)
Deena A, Hanadi R & Buthaina A. (2008) Food based dietary guidelines technical background and
description, Task force for the development and implementation of the Omani Food Based Dietary
Guidelines
Dewey K. G., Cohen R. J. and Rollins N. C. (2004). WHO Technical Background Paper: Feeding of non-
breastfed children 6 to 24 months of age in developing countries. Food and Nutrition Bulletin, vol. 25,
no. 4 © 2004
Diktas, H. E., Roe, L. S., Keller, K. L., Sanchez, C. E., & Rolls, B. J. (2021). Promoting vegetable intake in
preschool children: Independent and combined effects of portion size and flavour enhancement.
Appetite, 164, 105250. doi: 10.1016/j.appet.2021.105250.
FAO/WHO (Amended 2020). Standard for Infant Formula and Formulas for Special Medical Purposes
Intended for Infants. Codex Alimentarius International Food Standards. KM3
Faulkner G.P, Pourshahidi K., Wallace J.M.W., Kerr M.A., McCorrie T.A. and Livingstone M.B.E (2012), Serving

size guidance for consumres: is it effective?: Proceeding of the Nutrition Society 71,610-621 doi:
10.1017/S0029665112000766
Flieh, S. M., Miguel-Berges, M. L., González-Gil, E. M., Gottrand, F., Censi, L., Widhalm, K., Manios, Y., Kafatos,
A., Molnár, D., Dallongeville, J., Stehle, P., Gonzalez-Gross, M., Marcos, A., De Henauw, S., Molina-
Hidalgo, C., Huybrechts, I., & Moreno, L. A. (2021). The association between portion sizes from high-
energy-dense foods and body composition in European adolescents: The HELENA Study. Nutrients,
13(3), 954. doi: 10.3390/nu13030954
Foo L. H., Lee Y. H., Suhaida C. Y., Andrew P.H., Correlated of Sugar Sweetened Beverage consumption of
Malaysia preschoolers aged 3 to 6 years. BMC Public Health (2020) 20;552.
https://doi.org/10.1186/s12889-020-08461-7.
Foo L. H and Tan Y.J ( 2021). Assessment of food quality in school canteens: A comparative quantitative
study between primary and secondary schools in Malaysia. Nutrients 13(9)3009
;https://doi.org/10.3390/nu13093009.
Gomez-Donoso C et al., A food-based score and incidence of overweight/obesity: The Dietary Obesity-
Prevention Score (DOS). 2018. Clinical Nutrition, https://doi.org/10.1016/j.clnu
Haytowitz DB & Pehrsson PR (2016). USDA’s National Food and Nutrient Analysis Programme (NFNAP)
produces high quality data for USDA food composition databases: Two decades of collaboration.
Food Chem. 238. 134-138.
Institute for Public Health (IPH) 2014. National Health and Morbidity Survey 2014: Malaysian Adult Nutrition
Survey (MANS) Vol. II: Survey Findings. Ministry of Health, Malaysia.
Institute for Public Health (IPH) 2017. National Health and Morbidity Survey (NHMS) 2017: Adolescent
Nutrition Survey 2017. Ministry of Health, Malaysia.
73
Kim, G. H., Shin, S. W., Lee, J., Hwang, J. H., Park, S. W., Moon, J. S., Kim, H. J., & Ahn, H. S. (2017). Red meat
and chicken consumption and its association with high blood pressure and obesity in South Korean
children and adolescents: a cross-sectional analysis of KSHES, 2011-2015. Nutr J. 16(1), 31. doi:
10.1186/s12937-017-0252-7.
Kling, S. M., R., Roe, L. S., Keller, K. L., & Rolls, B. J. (2016). Double trouble: Portion size and energy density
combine to increase preschool children's lunch intake. Physiol Behav. 162, 18-26. doi:
10.1016/j.physbeh.2016.02.019.
Koo, H. C., Poh, B. K., Ng, B. K., Lee, S. T., Chong, K. H., Marjolijn C. E. B., Ruzita, A. T., & SEANUTS Malaysia
Study Group (2016). Are Malaysia Children Achieving Dietary Guidelines Recommendations? Asia
Pasific Journal of Public Health 28(S5) S8-S20.
Mirko Marino , Federica Puppo, Cristian Del Bo, Valentina Vinelli, Patrizia Riso , Marisa Porrini and Daniela
Martin (2021). Systematic Review of Worldwide Consumption of Ultra-Processed Foods: Findings and
Criticisms. Nutrients 13, 2778. https://doi.org/10.3390/nu13082778.
Mashitah S. A. A., Nur Azreen M. N., Zaharah A. M., Preference, Attitude, Recognition and Knowledge of
fruit and Vegetable intake among Malay Chidren. Malay J Med Sci. (Mac- April 2020);27(2)101-111.
www.mjms.usm.my. (http://creativecommons.org/licenses/by/4.0/).
Mohammadreza Askari, Javad Heshmati, Hossein Shahinfar, Nishant Tripathi, Elnaz Daneshzad.(2020) Ultra-
KM3 processed food and the risk of overweight and obesity: a systematic review and meta-analysis of
observational studies. International Journal of Obesity https://doi.org/10.1038/s41366-020-00650-z.
Mohd Adzam K. R., Norhayati A. H., Farah Adriana M. R., Siti Syarma M. S., Norhaslinda R., Prevalence of
Vegetable Intake and its associated Personal, Socio-environmental, Physical Environmental factors
among Malay Adolesent in Rural Terengganu, Malay J Med Sci 16(4): 177-185, Dec 2020.
Mohd Nasir MT, Nurliyana AR, Norimah AK, hamid Jan BJM, Tan SY, Hopkins S, Thielecke F, Ong MK and
Ning (2017) Consumption of ready -to-eat-cereals (RTEC) among Malaysian children children and
association with sociodemographic and nutrient intakes-findings from the MyBreakfast study. Food
& Nutrition Research ;611304692. http://dx.doi.org/10.1080/16546628.2017.1304692.
Moore LL, Singer MR, Qureshi MM, Bradlee ML, Daniels SR. 2012. Food group intake and micronutrient
adequacy in adolescent girls. Nutrients.4, 1692-1708.
Mooreville, M., Davey, A., Orloski, A., Hannah, E. L., Mathias, K. C., Birch, L. L., Kral, T. J. E., Zakeri, I. F., &
Fisher, J. O. (2015). Individual differences in susceptibility to large portion sizes among obese and
normal-weight children. Obesity (Silver Spring), 23(4), 808-814. doi: 10.1002/oby.21014.
National Coordinating Committee on Food and Nutrition (NCCFN) (2013). Malaysian Dietary Guidelines for
Children and Adolescents. Ministry of Health Malaysia.
National Coordinating Committee on Food and Nutrition (NCCFN) (2017). Recommended Nutrient Intakes
(RNI). Ministry of Health Malaysia.
Neri, D.; Martinez-Steele, E.; Monteiro, C.A.; Levy, R.B. Consumption of ultra-processed foods and its
association with added sugar content in the diets of US children, NHANES 2009–2014. Pediatr. Obes.
2019, 14, e12563.
Onita, B.M.; Azeredo, C.M.; Jaime, P.C.; Levy, R.B.; Rauber, F. Eating context and its association with ultra-
processed food consumption by British children. Appetite 2021, 157, 105007.
74
Poh Bee Koon, Boon Koon Ng, Mohd Din Siti Haslinda, Safii Nik Shanita, Jyh Eiin Wong, Siti Balkis Budin,
Abd Talib Ruzita, Lai Oon Ng, Ilse Khouw and A. Karim Norimah. 2013. Nutritional status and dietary
intakes of children aged 6 months to 12 years: Findings of the Nutrition Survey of Malaysian Children
(SEANUTS Malaysia). British Journal of Nutrition. 110, S21–S35.
Pourshahidi, L. K., Kerr, M. A., McCaffrey, T. A., & Livingstone, M. B. E. (2014). Influencing and modifying
children's energy intake: the role of portion size and energy density. Proc Nutr Soc. 73(3), 397-406.
doi: 10.1017/S0029665114000615.
Rauber F, Steele EM, Louzada MLdC, Millett C, Monteiro CA, Levy RB.(2020). Ultra-processed food
consumption and indicators of obesity in the United Kingdom population (2008- 2016). PLoS ONE
15(5), e0232676. https://doi.org/ 10.1371/journal.pone.0232676.
Reynolds, A. N., Pham, H. T. D., Montez, J., & Mann, J. (2020). Dietary fibre intake in childhood or adolescence
and subsequent health outcomes: A systematic review of prospective observational studies. Diabetes
Obes Metab. 22(12), 2460-2467. https://doi.org/10.1111/dom.14176
Roe, L. S., Sanchez, C. E., Smethers, A. D., Keller, K. L., & Rolls, B. J.. (2021). Portion size can be used
strategically to increase intake of vegetables and fruits in young children over multiple days: a cluster-
randomized crossover trial. Am J Clin Nutr. nqab321. doi: 10.1093/ajcn/nqab321
Schwingshackl L, Hoffmann G, Lampousi AM, Knuppel S, Igbal K, Schwedhelm C, Bechthold A, Schlesinger

S, Boeing H, (2017). Food groups and risk of type 2 diabetes mellitus: A systematic review and meta- KM3
analysis of prospective studies. Eur J Epidemiol.32, 363-375.

Smethers, A. D, Roe, L. S., Sanchez, C. E., Zuraikat, F. M., Keller, K. L., Kling, S. M. R., & Rolls, B. J. (2019).
Portion size has sustained effects over 5 days in preschool children: a randomized trial. Am J Clin
Nutr. 109(5), 1361-1372. doi: 10.1093/ajcn/nqy383.
Talati, Z., Pettigrew, S., Moore, S., & Pratt, I. S. (2017). Adults and children prefer a plate food guide relative
to a pyramid. Asia Pac J Clin Nutr. 26(1), 169-174. doi: 10.6133/apjcn.112015.04.
Teo C. H., Chin Y. S., Lim P. Y., Shahril Azian M., Zalilah M. S., Impacts of School Based Intervention that
Incorporates Nutrition Eduction and Supportive Healty School Canteen Environment among Primary
School Children In Malaysia. http://www.mdpi.com/journal/nutrients. Nutrients 2021.(13) 1712.
Teo C. H., Chin Y. S., Lim P. Y., Shahril Azian M., Zalilah M. S., School-based intervention that integrates
nutrition education and supportive healthy school food environment among Malaysian Primary school
children: A study protocol. BMC Public Health (2019)19:1427
Tester, J. M., Stiers, K. B., Garber, A., & Leung, C. W. (2020). Whole grain intake and impaired fasting glucose
in adolescents, National Health and Nutrition Examination Survey, 2005-2014. Prev Chronic Dis. 17,
E130. doi: 10.5888/pcd17.190439.
Tournier C., Domenteil L, Ksiazek E, Marduel A., Weenen H, Nicklaus S. (2021). Factors Associated With
Food Texture Acceptance in 4- to 36-Month-Old French Children: Findings From a Survey Study.
Frontiers in Nutrition, doi: 10.3389/fnut.2020.616484
Yang, Y., Dong, B., Zou, Z., Wang, S., Dong, Y., Wang, Z., & Ma, J. (2018). Association between vegetable
consumption and blood pressure, stratified by BMI, among Chinese adolescents aged 13-17 years: A
national cross-sectional study. Nutrients, 10(4), 451. doi: 10.3390/nu10040451.
WHO (2003), Guiding principles for complementary feeding of the breastfeed child. Division of Health
Organization, World Health Organization, Washington, DC
WHO (2015), Guidelines: Sugars intake for adults and children. Division of Health Organization, World Health
Organization, Washington, DC
75
Appendices
Table 3.5 : The total daily energy requirement from complementary foods
Total energy Energy from
requirement Milk energy complementary food
Age (kcal/day)* (kcal/day)
intake**
(months/ years)
(kcal/day)
Boys Girls Boys Girls
6-8 months 630 570 413 217 157
9-11 months 720 660 379 341 281
1-2 years 980 900 346 634 554
* NCCFN (2017)
** Dewey et al. (2004)
Table 3.6 : Examples of vegetables equivalent to one serving size
Groups of Vegetables Serving size (Weight)
KM3 Vegetables, cruciferous, cookeda / cup

1 2 (50 g)
Vegetables, green leafy vegetables with edible stem, cookedb / cup
1 2 (40 g)
Vegetables, fruit, cookedc / cup

1 2 (40 g)
Vegetables, leafy ulam, rawd 1 cup (50 g)
Vegetables, beans, cookede / cup
1 2 (50 g)
Vegetables, flowers, cookedf / cup
1 2 (50 g)
Vegetables, sprouting, cookedg / cup
1 2 (50 g)
Vegetables, starchyh / cup
1 2 (60 g)
Vegetable juice, with pulp, no sugar added / glass
1 2 (125 ml)
Other vegetablesi:
Mushroom (white/ brown/ shitaki/ enoki, erygii, button, / cup/ 6 pieces
1 2 (40 g)
oyster mushroom), fresh/ soaked, cooked
Fungus (black fungus, white fungus), cooked / cup

1 2 (40 g)
Mixed vegetables, cookedj / cup
1 2 (50 g)
Wolfberry (Goji berry), dried 1 cup (50 g)
Note:
* Serving size and food weight are measured in edible portions.
a Cruciferous such as cabbage, broccoli and cauliflower.
b Green leafy-vegetables with edible stem such as kangkung, sawi, pucuk manis, bayam, sayur meranti, kau kee, daun keledek, drumstick leaf, gongura,
tropical amaranths, sessile joyweed, tong ho kalan and makchoi.

c Fruit vegetables such as brinjal, tomato, chayote (fo shou gua), capsicum, angled loofah (petola), bitter gourd, sour eggplant (terung asam Dayak), squash,
snake gourd, pointed gourd (parwal), ridged gourd (turai) and bottle gourd.
d Leafy ulam such as pegaga, ulam raja, lettuce and garden salad.
e Vegetables, beans such as string bean, snow pea, lady fingers and French bean.
f Vegetables, flowers such as daylily (golden needles/ jin zhen cai) and asparagus.
g Vegetables, sprouting such as soya sprout, green bean sprout (taugeh), pea sprout (dou miao) and alfalfa.
h Vegetables, starchy such as carrot, radish, pumpkin, beet root, lotus root, yam bean (sengkuang), water chestnut (sengkuang cina), Chinese yam (huai
san) and arrowroot (fen ge).

i Other vegetables such as mushroom, fungus and seaweed are rich sources of micronutrients such as iron, iodine and Vitamin B12 but low in fibre. Consume
with other vegetable groups such as cruciferous, green leafy-vegetables and fruit vegetables to obtain optimum phytonutrients.
j Mixed vegetables refers to a combination of several types of vegetables such as cabbage + carrot + baby corn + French bean.
76
Table 3.7 : Examples of fruits equivalent to one serving size
Fruits *Serving size (weight)
Ambarella (kedondong) 6 whole medium sized (200 g)
Guava 1 big slice (110 g)
Banana, berangan 1 whole medium sized (60 g)
Banana, Cavendish 1 2 / whole medium sized (60 g)
Banana, mas 2 whole medium sized (60 g)
Ciku 1 whole medium sized (80 g)
Dragon fruit, red 1 slice/ 1/3 whole medium sized (135 g)
Langsat 20 whole fruits (180 g)
Mango 1 2 / whole large sized (100 g)
Papaya 1 slice/ 1/4 whole medium sized (110 g)
Pineapple 1 slice/ 1/4 whole medium sized (150 g)
Water apple (jambu air) 10 whole fruits (500 g) KM3

Watermelon 1 big slice (250 g)

Apple 1 whole medium sized (110 g)
Durian (7 x 3 cm) 5 ulas (40 g)
Grapes 8 small (90 g)
Jackfruit (cempedak) 4 pieces (60 g)
Jackfruit (nangka) 5 pieces (190 g)
Pear, green 1 2 / whole medium sized (100 g)
Pear, yellow/ Orange 1 whole medium sized (160 g)
Rambutan (4.5 X 3cm) 6 whole fruits (110 g)
Orange (Limau manis) 1 whole, medium (134 g)
Dates, pitted, dried 2 pieces (20 g)
Raisin 1 heap dessert spoon (20 g)
Prunes, pitted, dried 4 pieces (20 g)
Figs, dried 3 pieces (25 g)
Fruit juice, with pulp & without added sugar 1 2 / glass (125 ml)
Note:
*Serving size and food weight are measured in edible portions.
77
Table 3.8 : Examples of rice, other cereals, wholegrain cereal-based products and tubers equivalent to one
serving size
Rice, other cereals, whole grain cereals-based
*Serving size (weight)
products and tubers
Rice, brown/ multigrain/ unpolished/ 1 cup/ 2 rice scoops (100 g)

parboiled/ white, cooked
Noodles, mee-hoon made of brown/ white 1½ cups (150 g)

rice flour/ sago noodles (tang-hoon), soaked
Noodles, mee/ kuih-teow / laksa, wet 1 cup (100 g)
Pasta/ spaghetti/ macaroni, cooked 1½ cups (150 g)
Porridge, brown/ white rice, plain, cooked 2 cups (330 g)
Corn, without skin and cob, cooked / medium ear

1 3 (40 g)
Corn kernel, without margarine, cooked 3 dessert spoons/ (40 g)

/ commercial cup
1 3
Cornflake, without milk and added sugar 1 cup/ 8 dessert spoons (30 g)
KM3 Bran, coarse, uncooked 1 cup/ 10 dessert spoons (100 g)
Oats (rolled/ processed)/ wheat germ, uncooked 6 dessert spoons (40 g)

Muesli, without milk 4 dessert spoons (45 g)
Quinoa, cooked 1 cup/ 2 rice scoops (150 g)
Wheat (gandum)/ barley, without gravy, cooked 12 dessert spoons/ 3/4 cup (150 g)
Potatoes, without skin, raw 2 whole medium sized (160 g)
Sweet potato/ yam (taro)/ tapioca, without skin, / cup/ 1/3 of a whole medium sized
1 2 (70 g)
raw (1 cm cube)
Bread, wholemeal/ ryemeal/ white 2 square slices (60 g)
Roti canai 1 piece (95 g)
Bread, pita, wholemeal / piece

1 2 (40 g)
Buna 1 rectangular bun/ 2 small buns (50g)
Capati (D= 20cm) / piece

1 2 (50 g)
Dosai/ rawa dosai (D=20cm) 1 piece (80 g)
Idli (D= 6cm) 2 small pieces (110 g)
Pau, with filling / piece

1 2 (40 g)
Putu mayam 2 pieces (100 g)
Biscuit, wholemeal crackers/ Marie/ milkb 5 pieces (30 g)
Biscuits, plain/ cream crackers/ oatmealb 4 pieces (45 g)
Note:
* Serving size and food weight are measured in edible portion.
** Preferably choose wholegrain foods in your daily diet.
a Choose healthier bun such as less sweet, no cream or sweet filling, and fortified with micronutrients or healthy ingredients.
b Choose healthier biscuits such as low fat, sugar, no cream or sweet filling and low sodium.
78
Table 3.9 : Examples of legumes, nut and seeds equivalent to one serving size
Legumes, nuts and seeds Serving size (weight)
Soya bean, yellow/ black, cooked 1 cup (180 g)
Soya bean cake, fermented (tempeh) 2 rectangular pieces (90 g)
Soya bean curd, tau-kua/ hard/ traditional/ 11/2 pieces (150 g)

fried tau-hoo, compressed tau-hoo (dou fu gan),
(6 x 6 cm)
Soya bean curd, soft tau-hoo (tauhu lembut), 1 box (240 g)

(18 x 5 cm)
Soya bean curd, tau-hoo-pok, (D= 3 cm) 4 round pieces (60 g)
Egg tau-hoo (tauhu telur) 11/2 packet (200 g)
Soya bean chip (dou bao), fresh (5 x 5 cm) 5 pieces (50 g)
Soya bean sheet (fucok sheets), dried, raw 1 sheet (30 g)

(42.5 x 14 cm)
Soy bean milk, fresh, unsweetened 11/2 glasses (375 ml) KM3
Soy bean dessert, tau-hoo-fah, unsweetened 2 containers (700 g)

Gram, chickpeas/ black-eyed peas/ kidney beans, 1 cup (180 g)
without gravy, cooked
Gram, red beans/ mung beans, without gravy, 11/2 cups (260 g)
cooked
Dhal, various split pea/ lentils (chana dhal/ kadalei, 1 cup (180 g)
red lentils/ masoor, green lentils, urad), cooked
Baked beans/ green peas, beans only, canned 11/2 cups/ 1 whole medium canned (400 g)
Lotus seedsa 1 cup (120 g)
Nuts, peanuts/ almonds/ cashew nutsb 10 pcs/ 2 dessert spoons (15 g)
Nuts, walnutb 1 pc (15 g)
Seeds, chia seeds/ flax seeds/ pumpkin seeds/ 2 dessert spoons (15 g)
sesame seeds/ watermelon seeds/ sunflower
seedsb
Seeds, kuacib 10 pcs/ 2 dessert spoons (15 g)
Note:
a Lotus seeds are categorised as nuts and seeds group, but considering this food is a good source of protein and low in fat. Therefore, the serving size of lotus
seed was calculated based on protein content instead of fat.

b Nuts and seeds were calculated based on fat exchange. 1 serving of nuts/ seeds = 5 g of fat.
79
Table 3.10 : Examples of fish and seafood equivalent to one serving size
Fish and seafood Serving size (weight)
Fish, mackerel, Indian, without head & entrails, 1 whole medium sized (70 g)
rawa
Fish, bream, African (ikan tilapia), 1 whole medium sized (90 g)

without head & entrails, raw
Fish, sardine/ tamban, without head & entrails, 2 whole small sized (60 g)
fresh, raw
Fish, scad, yellow tail (ikan selar), / of a whole medium sized

2 3 (70 g)
without head & entrails, raw b
Fish cut, mackerel, Spanish (Ikan tenggiri), 1 piece (70 g)

rawc (14 cm x 8 cm)
Fish, sardine, canned 3 small pieces/ 2/3 of a small can (90 g)
Anchovies, whole/ without head & entrails, dried / cup

2 3 (25 g)
Prawn, without head & shell, raw 12 pieces (80 g)

KM3
Squid, without skin & entrails, raw 1 whole medium sized (80 g)
Note:
a Fish, mackerel Indian include ikan kembong, pelaling, mabung and termenung.
b Similar serving size and food weight for ikan cincaru, Selayang, bawal (hitam, tambak, putih) and keli.
c Similar serving size and food weight for barred Spannish (ikan tenggiri batang), sting ray (ikan pari) and salmon.
Table 3.11 : Examples of poultry, meat and egg equivalent to one serving size
Poultry, meat and egg *Serving size (weight)
Chicken, drumstick/ thigh, without bone, raw 1 piece (100 g)
Chicken, breast, without skin, raw (14 x 7 x 1 cm) / medium sized piece
1 2 (70 g)
Chicken, cut into 12 pieces, raw 1 piece (70 g)
Beef, lean (1 palm size), raw 1 piece (60 g)
Egg, century/ duck 2 whole (120 g)
Egg, hen, grade A, without shell 2 whole (100 g)
Egg, quail, without shell 12 whole (120 g)
Note:
80
Table 3.12 : Examples of milk and milk products equivalent to one serving size
Milk & milk products Serving size (weight)
Milk, full cream/ fresh/ low fat 1 glass (250 ml)
Milk, evaporated / glass

1 2 (125 ml)
Milk, powdered, full cream/ skimmed (heap) 4 heap dessert spoons (30 g)
Cheese, cottage/ spread 3 heap dessert spoons (40 g)
Cheese, processed, slice (8 x 8 cm) 2 square slices (40 g)
Yoghurt, natural/ fat free/ low fat, plain 2 yoghurt pots (270 g)
Yoghurt, Greek style 1 yoghurt pot (135 g)
Standard household measurements used in this dietary guideline are as follows:

Figure 3.2 : Standard household measurements used in this dietary guideline
• 1 rice scoop = 50 g • 1 teaspoon (tsp) = 5 ml
• 1 tablespoon (tbsp) = 15 ml • 1 glass = 250 ml

KM3
• 1 dessert spoon (dsp) = 10 ml • 1 cup = 200 ml
1 rice scoop 1 tbsp 1 dsp 1 tsp 1 glass 1 cup
81
KM3
82
Key Message 4
Attain healthy weight for optimum growth

KM4
Attain Healthy Weight for Optimum Growth
Key Message 4
Attain healthy weight for optimum growth
Prof. Dr. Poh Bee Koon, Dr. Nurzalinda Zalbahar, Dr. Denise Koh Choon Lian, Ms.Teh Wai Siew,
Assoc Prof. Dr. Ng Ruey Terng, Ms. Nur Azlina Abdul Aziz and Emeritus Prof. Dr. Mohd Ismail Noor
4.1 Terminology
Body image Eating disorders

Body image refers to the perception that a person Eating disorders refer to a group of conditions
has of their physical self, and the thoughts and defined by abnormal eating habits that may involve
feelings that result from that perception. An either insufficient or excessive food intake to the
individual with negative body image may have body detriment of an individual’s physical and mental
size dissatisfaction, incorrect perception of body health.
weight status, and be involved in body change
strategies in order to achieve the ideal body image. Energy requirement
The energy requirement of children and adolescents
Development is the amount of dietary energy needed for growth,
Development refers to the increased ability of the and to maintain health as well as an appropriate
body to function physically and intellectually. level of physical activity.
Physical and intellectual developments proceed at
different rates in different individuals.
84
Growth Normal body weight

Growth refers to the acquisition of tissue and the In children below 5 years old, BMI-for-age above -
consequent increase in body size. Linear growth 2SD to +1SD is considered normal weight based on
refers to the increase in length or height of a child. the WHO 2006 child growth standards. In children
Growth faltering refers to a slower rate of weight aged 5 to 19 years old, BMI-for-age above -2SD to
gain in infancy and childhood than is expected for +1SD is considered normal weight based on the
age and sex. WHO 2007 growth reference.
Head circumference Obesity

In children below 2 years old, head circumference In children below 5 years old, BMI-for-age above
should be routinely measured. Head circumference +3SD are considered obese based on WHO 2006
is a measurement of a child’s head just above the child growth standards. In children aged 5 to 19
eyebrow and ears, and around the back of the head years old, BMI-for-age at above +2SD is considered
at the maximum circumference. Head obese based on WHO 2007 growth reference.
circumference assessments are undertaken as part
of a holistic assessment to identify deviations in Overweight
head growth and brain development. It is the most In children below 5 years old, weight-for-age above
sensitive anthropometric measure of prolonged +2SD is considered overweight based on WHO 2006
undernutrition during infancy, associated with child growth standards. In children agred 5 to 19
intellectual impairment and poor cognitive years old, BMI-for-age at above +1SD is considered
development. However, when head circumference overweight based on WHO 2007 growth reference.
measurements are outside the expected norm,
possible growth deviations may be related to non- Underweight KM4
nutrition factors such as achondroplasia, In children below 5 years old, weight-for-age less
microcephaly, hydrocephalus, craniosynostosis than -2SD and below is considered underweight

(craniostenosis) and Autism Spectrum Disorder based on WHO 2006 child growth standards. In
(ASD). children aged 5 to 19 years old, BMI-for-age at less
than -2SD and below is considered thin based on
Internalization the WHO 2007 growth reference.
The nonconscious mental process by which the
characteristics, beliefs, feelings, or attitudes of other Stages of childhood
individuals or groups are assimilated into the self The period of childhood spans from infancy to
and adopted as one’s own. adolescence, and can be divided into different
stages of growth and development. The definitions
used in this guideline is as shown in Table 4.1.
Table 4.1: Stages of childhood
Stages of childhood Age
Children Below 18 years old
Children under 5 Below 5 years old / up to 59 months
Infants A child not more than 12 months of age
Toddlers 1 – 3 years old / 12 – 47 months
Preschoolers 4 – 6 years old / 48 – 83 months
Primary school-aged children 7 – 12 years old
Secondary school-aged children 13 – 17 years old
Adolescents 10 – < 18 years old
Source: Rivers (2016).
85
Stunting Wasting
In children and adolescents below 18 years old, In children below 5 years old, weight-for-height and
height-for-age less than –2SD is considered stunting BMI-for-age less than -2SD and below is considered
based on WHO 2006 child growth standards and wasting based on WHO 2006 child growth
WHO 2007 growth reference. A child or adolescent standards. A low weight for height indicates recent
who is short for his/her age is the result of chronic and severe weight loss due to acute significant food
or recurrent undernutrition, usually associated with shortage and/or infection, such as diarrhoea, which
poor socioeconomic conditions, poor maternal led to the child losing weight. A young child who is
health and nutrition, frequent illness, and/or moderately or severely wasted has an increased risk
inappropriate infant and young child feeding or care of death, but treatment is possible.
in early life. Stunting holds children back from
reaching their physical and cognitive potential.
4.2 Introduction
Childhood is the period between birth and Weight gain and increase in body size are part of the
adulthood. It is often further divided into various growing process during childhood and adolescence.
stages of growth and development. This is also the There is increasing evidence of the importance of
period during which children undergo many optimum growth and adequate nutrition in
developmental milestones – including verbalising childhood towards cognitive development (De Onis,
their first words and learning to crawl usually during 2017) and bone mass in adulthood (Proia et al., 2021).
KM4 infancy (0-1 year old); learning to walk, jump and Ensuring optimum growth and development can be
run, and speak in short sentences that allows them achieved through maintaining a positive energy
to discover the world around them during balance and adequate intake of nutrients such as
toddlerhood (1-3 years); as well as learning to speak protein, fats, carbohydrate, vitamins and minerals.
in longer sentences, dress themselves and interact During periods of rapid growth, deprivation of
with people outside the family during the preschool adequate energy intake, whether intentionally
years (4-6 years). Primary school-aged children (7- through inappropriate dieting behaviours or due to
12 years) develop quickly in their physical, mental impoverishment will restrict weight gain and height
and social skills, followed by secondary school years attainment. Micronutrients, such as Vitamin A,
(13-17 years) which coincides with the teenage Vitamin D, iron, zinc and folate, is also important as
years. In the later part of primary school years, its deficiencies can have severe consequences
children often undergo pubertal development and including reduced growth, cognitive impairment,
begin their adolescence. The adolescent years are decreased school performance and work
defined as 10-19 years by the World Health productivity. A pooled analysis of individual-level
Organization (WHO, 1995). Adolescence is when data from population-representative surveys by
children undergo rapid physical growth and sexual Stevens et al. (2022) suggests that during the period
maturation; it is also a period during which they between 2003 and 2019, there were 372 million
learn independence, and may develop concerns preschool-aged children and 1.2 billion non-
related to body size, shape or weight. This period is pregnant women of reproductive age with one or
an important one not just to ensure that children more micronutrient deficiencies worldwide. The
obtain proper nutrition in order to reach their full problem was not only prevalent in low-income and
potential in growth and development, but it is also middle-income countries, but nearly half of women
a period during which they can learn about healthy and children in high-income countries were
lifestyles and behaviours. estimated to have at least one micronutrient
deficiency.
86
The recommended dietary energy requirements in Social trends in a progressive society, such as
children and adolescents are defined to maintain Malaysia, have also influenced the food habits of
health, promote optimal growth and maturation and children and adolescents (Khor, Cobiac & Skrzypiec,
support a desirable level of physical activity. Dietary 2002). In urban societies within Malaysia where
energy recommendations must also be compatible both parents are working, a major trend observed is
with health, prevention of underweight, stunting the increasing number of meals bought and
and obesity, and sufficient for adequate social and consumed outside the home and the frequency of
psychological development (NCCFN, 2017). eating in fast food outlets. Frequent eating out that
is associated with intake of energy-dense foods is
Parents and caregivers play an important role in an important contributing factor of the rising obesity
determining the food habits of young children while trend in our society. Changes in dietary intake and
peer group norms and media advertising are physical activity may contribute to the development
important determinants of food habits amongst of healthy adult lifestyles, and thus help to reduce
adolescents. In recent years, there has been chronic disease incidence (Tandon et al., 2016; Kohl
increasing concern on issues such as childhood & Cook, 2013).
obesity and those arising from unhealthy body
image. Inaccurate body weight perception and The previous edition of the Malaysian Dietary
distorted body image may lead to engagement in Guidelines for Children and Adolescents offered key
unhealthy eating habits and subsequently eating recommendations and how to achieve them
disorders. The resultant negative psychological (NCCFN, 2013). This current version provides an
effects and obesity can persist into adulthood with update incorporating the latest evidence, and
associated health risks (Nurjasmine et al., 2019). introduces specific guidelines tailored for
individuals who significantly influence the lifestyle KM4
choices of children and adolescents, namely parents
and other family members, teachers, and healthcare

professionals.
4.3.1 General growth patterns
Normal growth is the progression of changes in During adolescence, there is a marked increase in
height, weight and head circumference that are the rate of gain in both weight and height—referred
compatible with established standards for a given to as the adolescent growth spurt. The spurt in
population. The progression of growth is interpreted height begins on average at 10 to 11 years in girls
within the context of the genetic potential and and at 12 to 13 years in boys, although there is wide
environmental influences such as diet for a variation in this. During the adolescent growth
particular child (Jelenkovic et al., 2016). spurt, boys gain an average of 20 cm in height and
Understanding the normal patterns of growth 20 kg in weight and girls around 16 cm and 16 kg,
enables the early detection of deviations which may respectively. In girls, the onset of menstruation
be pathological, such as poor weight gain due to a generally occurs after the peak in height velocity; in
metabolic disorder, or due to socioeconomic factors. boys, the development of secondary sexual
characteristics is less closely related to the
During early childhood, the rate of increase in adolescent growth spurt (AAP, 2019). Peak height
weight and length is essentially linear. During velocity, interindividual variation in the onset and
adolescence, however, growth accelerates over a rate of pubertal growth and development, is
period of 1 to 3 years and then decelerates rapidly significant because of interaction between a child’s
until growth in height ceases at about 16 years of genetic potential and the environment.
age in girls and 18 years in boys. Growth during
adolescence is accompanied by an increased
proportion of body fat in girls and likewise for lean
body mass and blood volume in boys (AAP, 2019).
87
4.3.2 Growth indicators
Nutritional status is a determinant of growth that Implications of obesity are likely greater for
directly affects growth and development during adolescents compared with children below 5 years
childhood. Body mass index (BMI), a measure of old, as adolescents have reached their adult height,
body mass relative to height, has emerged as the while children could still grow (linearly) into his
most practical, universally applicable, inexpensive weight. Therefore, clinicians might focus on
and non-invasive anthropometric indicator for individual growth trajectory and clinical assessment
classifying overweight and obesity. BMI-for-age is instead of classifying weight status. Measures of
used to define overweight and obesity amongst body fat in individual children, such as the triceps
children and adolescents. Increased BMI-for-age in and subscapular skinfolds, for which WHO
childhood and adolescence is associated with standards are also available, should be assessed (de
higher percentages of body fat and known risk Onis, 2015).
factors for cardiovascular disease. It is important to
note that, in preschool-aged children, weight-for- A child’s growth and well-being could be indicated
length (below two years of age) and weight-for- by his/her linear growth. Stunting in childhood is a
height (above two years of age) are also valid critical global nutrition issue. Stunting is one of six
indicators for classifying young children into global nutrition targets that the WHO have endorsed
overweight or obese categories, and can be used for improving maternal, infant and young child
instead of BMI-for-age as they yield very similar nutrition by 2030. Consequences of stunting has
results (de Onis, 2015). The Z-score cut-off points negative impacts on individuals and societies,
and interpretation for BMI-for-age as recommended including impaired cognitive development, poor
KM4 by the World Health Organization (WHO) is shown health and reduced productive capacity, and
in Table 4.2. increased risk of disease and mortality (Kim et al.,
2021). The cut-off points of Z-score and
interpretation of height-for-age as recommended by

WHO is shown in Table 4.3.
Table 4.2: Interpretation of Z-scores for BMI-for-age
Z-score 0 to <5 years1 5 to 19 years2
Above +3SD Obese Severely obese
Above +2SD to +3SD Overweight Obese
Above +1SD to +2SD Possible risk of overweight Overweight
Median to +1SD Normal Normal
Median to -2SD Normal Normal
Below -2SD to -3SD Wasted Thinness
Below -3SD Severely wasted Severe thinness
Source: WHO(2006)1; WHO(2007)2
Table 4.3: Interpretation of Z-Scores for height-for-Age

Z-score 0 to <5 years WHO, 20061 5 to 19 years WHO 20072
Above -2SD Normal Normal

Below -2SD to -3SD Stunted
Stunted
Below -3SD Severely Stunted
Source: WHO(2006) 1; WHO(2007) 2
88
4.3.3 Body composition 4.3.4 Basal Metabolic Rate (BMR)
Gender differences in body composition prior to Basal metabolism is the energy expended for
puberty are modest compared with postpubertal cellular and tissue processes that maintain life. It is
differences (Loomba-Albrecht & Styne, 2009). measured under standard conditions of
Throughout infancy, females have a greater thermoneutrality, immobility and fasting. The basal
percentage body fat than males, though the metabolic rate (BMR) relative to weight increases
difference between genders is only 1 – 3% during from birth to two years and then gradually declines
the first year of life (Butte et al., 2000). Male infants through adolescence. The effect of age on BMR is a
have roughly 0.25kg more fat free mass at birth and function of changes in body composition through
roughly 0.5kg more fat free mass at 12 months when childhood and adolescence. The BMR is strongly
compared with female infants. correlated with fat free mass (FFM) that comprises
the bulk of active metabolic tissue. Marked sex
In early childhood, males and females have differences in the intensity and duration of the
comparable absolute fat mass and fractional fat free adolescent growth spurt and in the proportion of
mass (Loomba-Albrecht & Styne, 2009). By later FFM are key determinants of the energy and
childhood, girls begin to gain fat more readily such nutrient needs of boys and girls. BMR for children
that by 10 years of age girls have on average 2kg and adolescents may be calculated using the
more fat mass than boys. Meanwhile, boys gain formula proposed by (Schofield, 1985) or by using the
slightly more absolute fat free mass, leading to local equations of Poh et al. (1999 & 2004) as shown
approximately 1kg difference in fat free mass. in Table 4.4.
At roughly age 12, fat free mass gain in females 4.3.5 Assessment of childhood growth KM4
begins to plateau and males begin gaining fat free
mass at an increased rate. Total fat free mass is Children’s growth should be monitored over time.

stable by 15–16 years in females and by 17–19 years The extent to which serial data for a child can
in males, similar to the timing of achievement of deviate from a given Z-score or percentile range
adult height and adult bone mineral density. By before concern is warranted depends on several
adulthood, males have 20kg greater fat free mass factors, namely the age of the child, the child’s
than females on average (Veldhuis et al., 2005). position on the Z-score or percentile range, the
length of time for which the rate of growth deviates
from the norm, and the coexistence of any medical
conditions. In general, the more pronounced the
change in growth rate, the younger the child, and
the more extreme the percentile, the greater is the
concern.
Table 4.4: Basal Metabolic Rate (BMR) formulas used in calculating total energy expenditure (TEE)
Age group Males Females Reference
1 – 3 years 0.249 W – 0.127 0.244 W – 0.130 Schofield (1985)

3 – 9 years 0.095 W + 2.110 0.085 W + 2.033 Schofield (1985)
10 – 12 years 0.0558 W + 3.187ᵃ 0.05444 W + 2.781ᵇ ᵃPoh et al. (2004)
ᵇPoh et al. (1999)
13 – 18 years 0.0558 W + 3.187 0.0534 W + 2.182 Poh et al. (2004)
Note: BMR is expressed in MJ/day, W= body weight in kg
89
4.3.5.1 Head circumference-for-age 4.3.6 Height, body weight status and health
consequences in children and
Head circumference is generally measured among adolescents
infants and children up to 3 years of age. Head
circumference is measured over the most prominent 4.3.6.1 Stunting in children
part of the occiput and just above the supraorbital
ridges using flexible and non-stretchable tape. The Stunting is the most common consequence of
head circumference-for-age WHO (2006) growth undernutrition in young children and it is
chart is used as reference. irreversible. Stunting has short- and long-term
effects on individuals, which may include reduced
4.3.5.2 Length/height-for-age cognitive and physical development, decreased
productivity, poor health, and increased risk of non-
For children under 2 years, recumbent length is communicable diseases, such as diabetes, in
measured lying down. Height is measured standing adulthood (de Sanctis et al., 2021). Children who are
upright among children aged 2 years and older. stunted may continue to be undernourished through
WHO 2006 child growth standards of length/height- their teenage years. Undernourished female
for-age for boys and girls should be referenced, adolescents may go on to have poor health during
whereas for children aged 5 to 19 years, the WHO their reproductive age and pregnancy, and
2007 growth reference is used (Refer to Table 4.3). subsequently give birth to children with low birth
weight (Prendergast & Humphrey, 2014). In this
4.3.5.3 Body Mass Index-for-age manner, the vicious cycle of stunting will continue.
KM4 For children and adolescents, height and body 4.3.6.2 Underweight and growth faltering in
composition are continually changing. For children children
from birth up to 5 years, it is recommended that the The most serious consequences of inappropriate
WHO 2006 child growth standards for BMI-for-age dietary intake in infancy and early childhood are
be used (Appendix 4.1 to Appendix 4.4). For those underweight and growth faltering. Growth faltering,
aged 5 to 19 years, the WHO 2007 growth reference previously called ‘failure to thrive’, refers to a slower
is recommended for use (Appendix 4.5 and 4.6). rate of weight gain in infancy and childhood than is
expected for a child’s age and sex.
90
4.3.6.3 Overweight and obesity in children appropriate management of other health conditions.
The American Academy of Pediatrics has recently
Children and adolescents require adequate energy published a clinical practice guideline for the
intake for proper growth but too many calories and evaluation and treatment of children and
too little physical activity can lead to obesity. adolescents with obesity. Screening for BMI,
Persistent obesity in childhood is associated with comprehensive evaluation, motivational
other lifestyle-related diseases that may persist into interviewing, intensive health behaviour and
adulthood. These include cardiovascular diseases, lifestyle treatment, and concurrent treatment of
type-2 diabetes mellitus (now occurring in children), obesity and obesity-related comorbidities are
osteoarthritis, breast and alimentary cancers, skin among the recommendations for successful options
disorders, aggravation of rheumatic diseases, to diagnose and treat children and adolescents with
asthma and other respiratory diseases. Childhood obesity (Hampl et al., 2023).
obesity increases the risk of childhood metabolic
syndrome which consists of hyperinsulinaemia, 4.3.7.2 Body image and eating disorders
hypertension and dyslipidaemia (Llewellyn,
Simmonds, Owen & Woolacott, 2016). Moderately Adolescence is a critical period for body image
higher adiposity during adolescence has been development as there are various social, cultural,
associated with premature death in younger and physical, and psychological changes occurring
middle-aged adults in the U.S. (Berenson, Srinivasan, during this stage. The relationship between weight
Xu & Chen, 2016). status and body image become complex and are
connected with various psychological factors such
Evidence shows that childhood obesity is as appearance-ideal internalisation, pressures and
associated with major cardiovascular risk factors concerns, social comparison, bullying and KM4
(McCrindle, 2015). Obese children and adolescents subsequent comparisons to media-based body
often suffer from poor self-esteem, adopt unhealthy ideals (Voelker et al., 2015; Ramos et al., 2019;

behaviours and may encounter social isolation and Hosseini & Padhy, 2021). Body image distortion and
discrimination (Pont, Puhl, Cook, & Slusser, 2017). body image dissatisfaction are global issues among
Overweight children are likely to be obese as adults. adolescents. Body image distortion is defined as the
Evidence from a systematic review and meta- discrepancy in body weight perception of an
analysis shows that children with overweight or individual’s own weight status irrespective of actual
obese parents have a higher risk of obesity. Lee, Jin body mass index. Body image distortion is central
and Lee (2022) reported that the odds of children to several health implications, including eating
being overweight or obese are 97% when both disorders, obesity, anxiety and depression (IPH,
parents were overweight or obese. 2017; Hosseini & Padhy, 2021).
4.3.7 Dietary habits and weight gain Body image plays an important role in weight
control and eating behaviours as well as in mental
4.3.7.1 Management of overweight and health among adolescents (Ramos et al., 2019).
obesity in children Several cross-sectional surveys from the United
For children who are experiencing overweight or States, Canada, Europe, Pakistan, Korea, and China
obesity, maintaining the growing child's existing indicate that approximately 45% of children and
weight in the short term, as they grow taller is an adolescents experience body image-related
appropriate short-term aim. This is because it will concerns. The prevalence of body image
result in improved BMI over time, and is often dissatisfaction can be as high as 71% among
described as 'growing into their weight' (NICE, adolescents (Al Sabbah et al., 2009; Moehlecke et al.,
2013). However, for young people who are 2020). Most studies report consistent findings that
experiencing overweight or obesity, but no longer gender and parental income are significant variables
growing taller, they will ultimately need to lose that influence self-perception of weight
weight to improve their BMI. For weight appropriateness (Voelker et al., 2015; Cheah et al.,
maintenance and weight loss, inculcating healthy 2015; Nurjasmine et al., 2019). A 24-country, cross-
eating habits and encouraging physical activity and sectional survey of school-aged children indicated
lifestyle changes are better than restricting diet. that body dissatisfaction is highly prevalent and is
Parental involvement is important for successful more common among girls than boys, among older
weight management of the child. Consultation with adolescents than younger adolescents, and among
a healthcare professional about weight overweight compared to non-overweight (Al
management strategies is important to ensure Sabbah et al., 2009; Moehlecke et al., 2020).
91
Evidence consistently indicates that unhealthy body 4.3.8 Maintaining healthy weight in children
image is associated with obesity and physical and adolescents
inactivity and plays a pivotal role in the
development of eating disorders during adolescence Weight maintenance is achieved when dietary
(Voelker et al., 2015). Longitudinal studies suggest energy intake is balanced with physical activity. The
that high BMI during adolescence is a strong recommended dietary energy requirements in
predictor of body dissatisfaction, whilst body children and adolescents are defined to maintain
dissatisfaction has been consistently suggested as health, promote optimal growth and maturation and
the strongest predictor of eating disorders across support a desirable level of physical activity (AAP,
psychosocial variables such as perfectionism and 2019). To meet the population nutrient intake goals,
locus of control (Voelker et al., 2015; Neves et al., WHO/FAO (2003) report suggested intake of total
2016). Eating disorders are strongly associated with carbohydrate from 55% to 75%, total protein 10% to
adolescent mental and physical health. Depression 15% and total fat 15% to 30% of total energy intake.
and anxiety can be caused by the negative However, to promote a healthy diet and meet
psychological effects of poor body image and nutrient needs, the Recommended Nutrient Intake
distorted perception of body weight (Nurjasmine et (RNI) for Malaysia (NCCFN, 2017) has recommended
al., 2019). intake of 50 to 65% energy from carbohydrates, 10
to 20% energy from proteins, and from fats between
However, disordered eating and dieting behaviours 25 to 35% of energy. Consuming high-calorie or
that do not meet full clinical criteria for eating energy-dense foods or meals may contribute to
disorder diagnoses are much more common excessive calorie intake. Children should be
(Voelker et al., 2015). Fad diets are popular among encouraged to reduce their consumption of
KM4 adolescents who are attempting to lose weight sweetened beverages and eat fewer high-fat
quickly. Adolescents are not yet mature enough to snacks. Programs designed to reduce the amount of
make the best decision with regard to their health time engaged in sedentary activity, such as
and health-related behaviour (Nurjasmine et al., television watching, have been successful in
2019). Thus, guidance and support from parents, reducing weight gain and improving fitness.
teachers and healthcare professionals are required
to prevent them from adopting improper weight For underweight children, a detailed medical and
control behaviours as well as to promote healthy diet history including a review of the weight and
eating habits (Ramos et al., 2019). Nevertheless, height is essential to establish the pattern of growth
approximately 50-86% of parents do not accurately as well as the underlying cause of growth faltering
perceive their child to be overweight and were to prevent the problem from recurring, meanwhile,
unconcerned about their child’s weight (Jeffery et the nutrition education for the mother is essential to
al., 2005; Parry et al., 2008). The misperception and develop good eating behaviours for the whole family
lack of awareness would likely have a detrimental including the underweight child. A balanced diet
effect on the parents’ ability to recognize the need should be given in small frequent meals to increase
for lifestyle modifications and to promote weight the total food intake. Healthy, calorie-dense meals
loss in their child (White et al., 2016). and snacks provide enough additional calories to
meet the demands of growth (AAP, 2019).
The importance of developing a healthy body image Participating in adequate physical activity is
during adolescence should be emphasised given the important to maintain healthy body weight among
associated detrimental health consequences. The children and adolescents. Physical activity has been
development of body image is dynamic and found to lower the risk of obesity (Hong et al., 2016).
changes over the lifespan (Voelker et al., 2015). Thus, For many children, increasing physical activity may
promotion of healthy body image and accurate be sufficient to prevent the onset of obesity.
perception of actual weight should be integrated Healthy-weight children who are physically active
across all prevention and intervention strategies tend to have less fat tissue than physically inactive
aimed to address obesity, eating disorders, and peers. Most daily physical activity for children and
other health-related concerns among specific target adolescents should be aerobic activities (Kahlmeier
adolescent groups (Voelker et al., 2015; Nurjasmine et al., 2015; WHO, 2019).
et al., 2019; Ramos et al., 2019).
92
On the other end of the spectrum, sedentary preterm child, brings benefits to the child's growth.
behaviour has been associated with adiposity. Diego et al. (2014) found that passive flexion and
However, a previous study has found that not all extension of the limbs, starting on the eighth day to
sedentary behaviour has the same effect on body the fourth week of life among low-birth-weight
weight, and that characteristics of sedentary infants, increased bone strength. A recent
behaviour other than duration were associated with systematic review found a positive effect of physical
adiposity in children (Shakir et al., 2018). This study activity on weight gain and linear growth among
found that screen-time sedentary behaviour was preterm babies (Schulzke et al., 2014). These effects
positively associated with adiposity among children on growth appear to occur through stimuli that
aged 10-13 years. However, a study with objectively promote the growth of long bones, and include
measured sedentary behaviour found that higher increased bone mass and mineral deposition
daily sedentary behaviour time was associated with (Stalnaker et al., 2016; Shaw et al., 2018).
higher BMI whereas higher moderate-intensity
physical activity has an inverse effect Among young children, a randomised control trial
(Schwarzficher et al., 2018). A more recent study in Germany have shown that parental counselling
found that sedentary behaviour, such as sitting aiming at increasing physical activity levels among
watching TV or video, was associated with fat preschool children have a positive effect on growth.
accumulation among children and adolescents, The study found that children in the intervention
independent of physical activity level (Liao et al., group had lower adipose tissue growth compared
2021). Further, sedentary behaviour has also been with the control group. Girls in the intervention
identified as a key determinant of metabolic group also had lower weight and smaller abdominal
inflexibility (Rynders et al., 2018), and a recent study circumference (de Vries et al., 2015). Physical activity
supported this when they found that metabolic participation among this age group has also shown KM4
flexibility was 23.5% lower in children with obesity to improve the development of motor skills, muscle
compared with controls, independent of age, sex strength, flexibility, and coordination (Krneta et al.,

and pubertal effects (Chu et al., 2021). 2015). Physical activity was also found to be
important for the growth of bone, muscle, and
In conclusion, maintaining a healthy weight not only adipose tissue (Twisk et al., 2001; Alves & Alves,
involves the balance between dietary behaviour and 2019). Literature has indicated that physical activity
participation in sufficient physical activity, new pattern and body composition in childhood tend to
evidence has suggested that sedentary behaviour persist into adult life (Fraser et al., 2017).
also plays a crucial role in children and adolescents'
body weight. In older children, studies have found that vigorous-
intensity physical activity and strength training
4.3.9 Physical activity and growth does not have a negative impact on school
children's linear growth (Frois et al., 2014; Jauregui
Many factors are known to influence child's growth et al., 2012). Vigorous-intensity physical activity was
directly or indirectly, and recently physical activity also found to limit adipose tissue growth in school
has been acknowledged to influence the growth of children (Jauregui et al., 2012). A systematic review
children and adolescents. Moreover, physical confirmed the importance of physical activity for
activity has long been shown to have health benefits bone mass growth, especially during phases of
on the prevention of disease, as well as the greater growth, such as in the first months of life and
treatment and rehabilitation of certain conditions during puberty (Bielemann et al., 2013). Current
(Warburton et al, 2017). Children and adolescents evidence indicates that physical activity has
who participate in physical activity tend to maintain positive benefits to bone and muscle mass growth,
that lifestyle into adulthood and throughout life and no height growth impairment caused by
(Telama et al., 2014). Studies have shown that resistance or strength exercises among school
passive or assisted physical exercises, for example, children (Alves & Alves, 2019).
another person flexing or extending the limbs of the
93
4.4 Current Status
Malaysia is currently facing the double burden of 2019, while prevalence of stunting went up from
malnutrition among children and adolescents. 16.6% to 21.8% over the same time period. The
Children below 5 years old are at risk of prevalence of wasting decreased from 12.4% in 2011
undernutrition, while adolescents aged 10 – 17 years to 8.1% in 2015, but rose to 9.7% in 2019 (IPH, 2019).
with over nutrition poses a larger problem than This latest prevalence of stunting is classified as of
undernutrition. The prevalence of stunting, high public health significance while that of wasting
underweight and wasting among children below is classified as medium significance based on de
the age of 5 have increased in recent times. On the Onis et al. (2018). The National Plan of Action for
other hand, one third of children and adolescents are Nutrition in Malaysia (NPANM) 2016-2025 has set a
either overweight or obese. target to reduce the prevalence of stunting to 11 per
cent by 2025.
4.4.1 Children below 5 years old
4.4.2 Adolescents aged 10-17 years old
In Malaysia, underweight and growth faltering
persist especially amongst children living in poor The NHMS 2017 reported that the prevalence of
conditions (Khor, 2003) where the aetiology of the overweight (15.6%) and obesity (14.8%) totalling
problem rests in a complex mix of social and 30.4% was higher than thinness (6.6%) and stunting
economic factors. Faltering growth is also a (8.2%) among Malaysian adolescents (IPH, 2017). In
common result of child neglect in some addition, the latest Adolescent Health Survey 2022
communities. A nationwide survey by Lee et al. also reported that among 13-17 year olds,
KM4 (2022) involving children aged 1-5 years seeking prevalence of overweight (16.2%) and obesity
healthcare services in 2019 reported a prevalence of (14.3%) remains higher than thinness (8.3%) and
16% for stunting while severe and moderate wasting stunting (6.8%) (IPH, 2022). Table 4.6 shows a rising
were at 4.0% and 6.1%, respectively. Prevalence of trend in the prevalence of obesity among
at risk of and overweight were 14.2% and 7.3%, adolescents aged 10 – 17 years old, i.e. from 6.1 % in
respectively. Overall, one in fifth (25%) children had 2011 to 14.8% in 2019 (IPH, 2019).
at least one form of undernutrition (stunting and/or
underweight). This study also found that parental Eating patterns are changing among Malaysian
report of feeding difficulties and poor dietary intake children. These include increased number of meals
were risk factors for undernutrition. eaten in schools and outside the home, larger
portion sizes, shifts in beverage consumption from
The National Health and Morbidity Survey (NHMS) milk-based drinks to sweetened drinks and
of Malaysia reported a rising trend for underweight changing meal patterns and frequency, with
and stunting over the past decade among children declining breakfast consumption and increase in
below 5 years old (Table 4.5). Prevalence of snacking (Ismail et al., 2003). A study conducted by
underweight rose from 11.6% in 2011 to 14.1% in Lai et al. (2022) among adolescents aged 12 to 18
Table 4.5: Trend in nutritional status of children below 5 years in Malaysia
2011 2015 2019 2022
Underweight 11.6 12.4 14.1 15.3
Stunting 16.6 17.7 21.8 21.2
Wasting 12.4 8.1 9.7 11.0
Source: IPH (2019)
Table 4.6: Trend in obesity of adolescents aged 10 – 17 years old in Malaysia
2011 2015 2019 2022
Obesity 6.1 11.9 14.8 14.3
Source: IPH (2019)
94
years old found that regular breakfast intake was the weekend. Both, Malaysian School-Based
associated with a lower likelihood of overweight and Nutrition Survey 2012 and NHMS 2017 showed older
obesity among the adolescents. The finding was children were more inactive, and girls were more
consistent with some local studies, for instance, the inactive than boys (IPH, 2017).
MyBreakfast Study, where the proportion of
overweight and obesity was significantly higher 4.4.3 Body image
among breakfast-skippers and irregular breakfast
eaters compared to regular breakfast eaters. Tee et The NHMS 2017 reported that 41.4% of Malaysian
al. (2018) and Lai et al. (2022) also reported that poor adolescents aged 10-17 years old perceived that
self-efficacy for healthy eating, body dissatisfaction, they have normal weight, whereas 29.4%, 25.0% and
body perception and low physical activity level were 4.2% perceived that they were thin, overweight and
significant predictors of overweight and obesity. obese, respectively (IPH, 2017). A higher percentage
Furthermore, the Adolescent Nutrition Survey 2017 of girls (30.3%) perceived themselves to be
also reported that unhealthy dietary pattern was overweight compared to boys (19.6%). However,
associated with not just ethnicity and locality of more primary school children perceived themselves
schools, but also snacking habit and eating out as to be thin (37.4%) and overweight (29.8%) compared
well as self-perceived weight status (Cheong et al., to secondary school students (24.5% vs. 17.2%,
2020). respectively). In a study among students aged 11-
12 years old, it was found that 60.1% of students had
The Malaysia 2022 Report Card on Physical Activity body image dissatisfaction. Girls had a 2.07 times
for Children and Adolescents similar to the 2016 higher rate of body image dissatisfaction compared
Report Card demonstrates that Malaysian children to boys, whereas students who were overweight or
and adolescents have low levels of physical activity obese had 4.06 times greater body image KM4
and active transportation, high levels of screen time, dissatisfaction compared to students with normal
and very poort compliance with dietary BMI (Azmira et al., 2018). Body image perception

recommendations, particularly intake of fruits and was found to contribute significantly towards BMI
vegetables (Shahril et al., 2022). According to the of adolescents aged 15 to 17 years in Sibu, Sarawak
NHMS 2017, about 55.4% children and adolescents (Law & Gan, 2020). Similarly, Xanthopoulos et al.
in Malaysia were found to be inactive. The most (2011) also reported that body dissatisfaction among
favourite activities during spare time were walking children with overweight was significantly greater
for exercise, jogging or running, badminton, tagging than their normal weight counterparts. Tung & Md
and cycling. More than half of the children and Mizwanur (2021) in Samarahan, Sarawak found that
adolescents were found to be engaged with screen body image dissatisfaction level was low among
time of more than 2 hours daily, including watching rural adolescents aged 10-19 years old.
television, playing computer or video games, during
95
Key Recommendation (KR) 1: Monitor the growth of children and adolescents using appropriate
growth standards or charts to ensure healthy growth
General Parents/ Family

Teacher Health Professional
(to children and adolescents) members

Measure, plot and For healthy growth of For children below 2 Measure weight, length,
monitor weight, length infants and young years, obtain children’s and head circumference
or height and head children, practice growth record (length/ accurately with
circumference regularly. exclusive breastfeeding height and weight) from appropriate equipment
from birth until 6 parents based on Child using standardised
a. Measure length or months, and continue Health Record. measurement
height and to breastfeed until two techniques for children
determine the status years old. below 2 years old.
using length/
height-for-age.
KM4 b. Measure weight and

height, calculate
Body Mass Index
(BMI) and determine
weight status using

BMI-for-age
indicator.
c. Measure head
circumference and
plot on head
circumference-for-age
chart for children
under 2 years.

Monitor growth by Prepare weighing scale Monitor growth of Measure weight and
plotting measurements and height measurement children above 2 years height accurately with
on the growth chart instrument to monitor until adolescence at appropriate equipment
using WHO 2006 child your child’s weight and nursery, kindergarten, using standardised
growth standards for height at home. or school at least twice measurement
children below 5 years a year. techniques for children
old, and WHO 2007 above 2 years old.
growth reference for
children 5 to 19 years
old.

Monitor growth of Keep your child’s Communicate with the Screen and look for any
children below 2 years growth chart and parents/ caregiver to unexpected incline,
at the following regularly monitor his or seek medical advice if decline or plateauing in
intervals: within one to her growth. Seek there is any concern the growth curve over
two weeks of birth, medical advice if there regarding the child’s time.
then at 2, 4, 6, 9, 12, is any concern with his growth.
18 and 24 months of or her growth.
age.
96
Key Recommendation (KR) 1: Monitor the growth of children and adolescents using appropriate
growth standards or charts to ensure healthy growth. (cont.)

KR1: HTA4: KR1: HTA4: - KR1: HTA4:

Monitor growth of Bring your child to the Accelerations or
children above 2 years clinic on appointment decelerations in head
till adolescence at least day for growth circumference is an
twice a year. monitoring. indication for further
investigation.

Illness may affect Discuss your child’s Ask parents/ caregiver
children’s growth, growth with healthcare regarding young
including their weight professionals such as children’s diet to assess
and height. Therefore, doctors, nurses, nutritional risks, and
growth assessment nutritionists or dietitians. provide relevant advice,
should be conducted or refer to nutritionist/
for all sick children dietitian if necessary.
during clinic visits. KM4

Key Recommendation (KR) 2: Children and adolescents should consume adequate amounts of
calories and nutrients as recommended, and participate in regular physical activity needed for
healthy growth and development.


Eat according to calorie Provide healthy and Make sure food served Ask about the child’s
recommendations by balanced meals with in childcare facilities dietary habits and
age, sex and physical calories suitable for and school canteen physical activity level as
activity level. your child's age and have a variety of part of routine
needs. Get reliable healthy options. consultation practice.
information on children’s
nutrition requirements
(e.g. Malaysian Dietary
Guidelines for Children
and Adolescents,
official nutrition
websites and nutrition
pamphlets from MOH).

Eat a variety of foods Provide healthy food Include water drinking Give appropriate advice
from all food groups in options at home. For breaks between to the parents on dietary
appropriate amounts to example, provide meals activities so children recommendations and
obtain adequate that consist of a variety can consume adequate encourage children to
nutrients. of food groups, and water throughout the play actively and
ensure fresh fruits are day. increase physical
available at home. activity.
97
Key Recommendation (KR) 2: Children and adolescents should consume adequate amounts of
calories and nutrients as recommended, and participate in regular physical activity needed for
healthy growth and development. (cont.)


Be active throughout Encourage active play Ensure students Make appropriate
the day, and engage in and physical activity achieve physical activity referrals to address
moderate to vigorous- throughout the day. If recommendations by family problems that
intensity physical children have long conducting physical could lead to childhood
activity every day. For periods of sedentary education lessons as malnutrition.
more detailed activities, encourage scheduled without fail.
recommendations, short breaks by asking
please refer to them to get up and
Key Message 5. move around.
KR2: HTA4: KR2: HTA4: - -

Sleep following a Ensure your child
regular schedule sleeps on a regular
KM4
according to age basis, according to age
requirements for requirements, in order
optimum health. For to promote optimum
specific health. For specific

recommendations refer recommendations refer
to Key Message 5. to Key Message 5.
- KR2: HTA5:
If you suspect that your - -
child has issues with
growth and
developmental issues
of your child, consult
with a doctor or
healthcare
professionals.
98
Key Recommendation (KR) 3: Advise children and adolescents with overweight or obesity
problems to practise healthy eating and be physically active for gradual weight loss.

I. Encourage overweight and obese children to practise healthy eating.

Control the amount of Monitor your child's Encourage students to Evaluate whether the
calories consumed eating habits and drink plain water or child with overweight or
based on specific ensure that they do not other unsweetened obesity needs to
requirements overeat. drinks at kindergarten maintain or lose weight.
according to age, sex and school/
and physical activity kindergarten. a. Bear in mind that
level. growing children can
improve their BMI
status over time, as
they grow taller,
without having to lose
weight. KM4
Eat only to satisfy Take note of your Raise awareness on Measure waist

needs when hungry; children's eating habits, the detrimental effects circumference for
do not overeat. especially if they of energy drinks. children who are
frequently skip meals. overweight or obese to
assess abdominal
obesity.

Eat 3 main meals per Encourage children to Enlist the entire family
day, plus 1 or 2 drink plain water or rather than only the
nutritious snacks in other unsweetened individual child in weight
between meals. Avoid drinks at home. management
skipping meals as it programme.
will lead to eating
bigger meals or
snacks later on.

Replace calorie-dense, Be a role model for Evaluate for
nutrient-poor foods with your child, practise psychosocial
healthier options (e.g. healthy eating comorbidities, and
replace sugar behaviours and be prescribe assessment
sweetened beverages physically active. and counselling when
with plain water or milk; psychosocial problems
consume whole fruits are suspected.
rather than fruit juice).
KR3: HTA5: - - KR3: HTA5:

Reduce consumption Ensure intervention is
of high calorie foods multi-component
by eating smaller including diet, physical
servings. activity, and behaviour.
99
problems to practise healthy eating and be physically active for gradual weight loss. (cont.)

KR3: HTA6: - - -
Avoid intake of ultra-
processed foods
(UPFs), for example
soft drinks, ice-cream,
fries, sausages, chips,
instant noodles.
KR3: HTA7: - - -
Avoid using meal
replacement and
slimming products,
such as slimming teas
and slimming pills, to
reduce weight as they
KM4 can lead to detrimental
side effects.
KR3: HTA8: - - -
Reduce or minimise
consumption of energy
drinks as it contains
excess sugar that can
lead to unhealthy
dietary behaviour. In
addition, energy drinks
may contain stimulants,
such as caffeine, that
may lead to poorer
sleep quality and other
undesirable health
implications.
II. Encourage overweight and obese children to increase physical activity level.

Reduce sedentary Monitor physical activity Create more Advise overweight or
activities, such as patterns of overweight opportunities for obese children to
watching television or obese children. overweight and or increase physical activity
and video, playing obese children to and reduce sedentary
computer games, and participate in physical behaviour.
other non-academic activity.
sedentary activities, to
no more than 2 hours
per day.
100
problems to practise healthy eating and be physically active for gradual weight loss. (cont.)


Encourage children Ensure your child Advise parents to Advise parents to
below 5 years to be sleeps on a regular make lifestyle (diet and ensure their overweight
active in as many ways basis according to age physical activity) or obese child gets
as possible. For requirements for changes and/ or to adequate sleep daily.
specific optimum health. For consult a health
recommendations, specific professional for advice
refer to recommendations, if children show
Key Message 5. refer to Key Message 5. unexpected change in
their weight.

For children and Seek advice from
adolescents aged health professionals if
5-17 years, perform at you are concerned
least 60 minutes of about your child’s KM4
moderate to vigorous- weight or development.
intensity physical

activity every day.
For specific
recommendations,
refer to
Key Message 5.
KR3: HTA4: - - -
Ensure children get
sufficient sleep daily.
For specific
recommendations,
refer to
Key Message 5.
101
Key Recommendation (KR) 4: If the child or adolescent has undernutrition, namely underweight,
wasting or stunting, increase calorie intake and give a variety of nutrient-dense foods as
recommended.


Practise healthy Encourage your child to For caregivers at Engage parents in
dietary eat and snack childcare centres, identifying possible
recommendations daily frequently. For young encourage the child to causes of undernutrition.
to obtain adequate children, six small eat and snack frequently.
nutrition in order to meals may be easier to Three to four small
improve children’s eat than three larger meals may be easier to
growth status: meals. eat than two larger meals.
a. For young children a. Your child should eat a. The child should eat
below 2 years old, as much as he or as much as he or
eat 3 to 5 main meals she can without she can without
per day, plus 1 or 2 feeling uncomfortable. feeling uncomfortable.
nutritious snacks Do not pressure your Do not pressure your
KM4
between meals. child to eat. child to eat.
b. For children and b. Offer a variety of b. Offer a variety of

adolescents, eat 3 meals and snacks meals and snacks

main meals per day, to your child to the child
plus 2-3 nutritious throughout the day. throughout the day.
snacks between
meals. For example;
sandwiches, fruits,
milk.
c. Eat a variety of
foods to achieve the
calories needed
based on specific
Requirements
according to age,
sex, physical activity
level and nutritional
status.
d. Choose nutrient-
dense foods with
higher calorie and
protein content,
including sources of
animal proteins,
such as milk, egg,
poultry, beef, fish like
kembong, tenggiri,
or anchovies, and
sources of plant
proteins such as
taukua, chickpea,
dhal, fortified biscuits,
and fortified bread.
102
recommended. (cont.)


For children, provide Provide healthy, In childcare centres, Recommend age-
small, frequent meals diversified meals, provide healthy, appropriate dietary
throughout the day. preferably nutrient- diversified meals, advice for the problem
dense high-calorie preferably nutrient- identified.
foods. dense high-calorie
foods.
a. For young children a. For young children

below 2 years old, below 2 years old,
mix additional fats or mix additional fats or
oils, (e.g. example; oils (eg. sesame oil,
sesame oil, margarine, shallot oil)
margarine, shallot on rice or porridge,
KM4
oil) on rice or vegetables or
porridge, vegetables anchovy fritters, and
or anchovy fritters, provide snacks such

and provide snacks as banana or dried
such as banana or fruits.
dried fruits.
b. For children and

adolescents, give
snack foods, such
as crackers, dried
fruits (like raisins),
carrots and nuts.

For adolescents with For children, offer a For teachers at school, Set goals for improving
unrealistic body image, wide variety of foods to encourage children and the growth of an
avoid skipping meals stimulate their appetite. adolescents to eat 3 undernourished child or
and excessive physical main meals per day, adolescent.
activity. plus 2-3 nutritious
snacks in between
meals.

Keep children active as For older children and Refer the For infants and children
movements stimulate adolescents, undernourished child or below 2 years old,
appetite and build a. Have family adolescent for food strengthen
muscle and bone mealtimes together. assistance programme breastfeeding promotion
mass. b. Continue to offer such as School Meal and complementary
healthier foods. Programme. feeding education with
c. Encourage eating on food provision in food
a regular basis if they insecure populations.
often skip meals.
103
recommended. (cont.)


Take complete Monitor your child’s Recognise For adolescents,
balanced nutritional growth status closely undernutrition and strengthen nutrition
supplements and and continue nutrition inform parents or education and
drinks to ensure care. caregivers and refer the counselling to improve
sufficient calorie and child to the nearest knowledge and skills to
nutrient intake, if health clinic for medical choose nutritious foods
required, based on attention. and to develop healthy
medical advice. eating patterns.
KR4: HTA6: - - -
Consult with a health
care professional
regularly to ensure
KM4
appropriate
management of weight
and height according
to the child/
adolescent age.
Key Recommendation (KR) 5: Instill a healthy body image in children and adolescents.


Learn the concept of Be aware of your child’s Measure and classify Increase awareness and
healthy body image growth status and growth status of continuously educate
concept and recognize the need for students correctly. the public, including
understand normal lifestyle modifications to parents and
variations in body promote healthy growth. grandparents, about
sizes and shapes. measurements and
classification of growth
status for children and
adolescents, instead of
focusing only on weight
status.

Identify and Encourage realistic Teach children and Increase awareness and
acknowledge own body goals and aim for adolescents to monitor continuously educate
weight status. gradual change in body their weight and growth children and
Recognize the need for weight. If your child is status correctly. adolescents about
lifestyle modifications overweight, do not accuracy of body size
towards healthy body criticize his or her perception and healthy
image. appearance. body image.
104
Key Recommendation (KR) 5: Instill a healthy body image in children and adolescents. (cont.)


Set realistic goals, and Learn to judge the Encourage realistic Inculcate beliefs about
aim for gradual change reliability of body image goals and aim for positive appearance and
in body weight. messages that are gradual change in body healthy body image
being spread on social weight. If the child or through professional
media; explain to your adolescent is advice.
child and discuss with overweight, do not
your adolescent. criticize his or her
appearance.

Adopt healthier Look out for signs of Discuss with Refer to family medicine
lifestyles, including distorted body image adolescents how the specialist or psychiatrist
healthy eating and perception in your child; media can use a if the child or adolescent
physical activity, for instance, if they are variety of techniques to has eating disorder
instead of extremely concerned create unrealistic body symptoms. KM4
overemphasising on about weight, eating, images.
body weight and dieting or dislike of

appearance due to certain parts of their
body dissatisfaction. body.

Focus on other Provide psychosocial
aspects of self-image, support for children and
such as family, adolescents who are
friendship or academic, having weight-related
to help overcome concerns.
negative body image.

Instil the ability to Inform parents or refer
identify healthy body the student who is
image and accurate having weight control
weight perception, and issues to the School
not be influenced by Health Team or nearest
misinformation in the health clinic.
media or among peers.
KR5: HTA7: - - -
Reduce exposure to
media that focus on
appearance, such as
photo sharing, which is
common and
synonymous with
unhealthy body
perceptions.
105
Key Recommendation (KR) 5: Instill a healthy body image in children and adolescents. (cont.)

KR5: HTA8: - - -
Seek advice from
medical practitioners
and psychosocial
support from parents
and peers if the child
or adolescent has
weight issues.
Key Recommendation (KR) 6: Conduct simple oral screening for tooth decay

KM4

Perform simple oral Perform simple oral Perform simple oral Perform simple oral
screening by lifting the screening by asking screening on the screening to check for
lip while standing in your child to say “ahhh”. students to see any discoloration (i.e. white,
front of the mirror to Check for any discolouration (i.e. yellow, brown, black
see any discoloration discoloration (i.e. white, white, yellow, brown, spot) or fractured tooth
(i.e. white, yellow, yellow, brown, black black spot) or broken structure, and swelling
brown, black spot) or spot) or broken teeth, teeth, and swelling or or bleeding gum.
fractured tooth and swelling or bleeding gum.
structure, and swelling bleeding gum.
or bleeding gum.

Encourage children Encourage your child to Encourage students to Educate the child,
and adolescents to perform simple oral perform simple oral parents, teachers and
perform simple checks screening. screening by creating caregiver on how to
on their own teeth and an interactive period in perform simple oral
mouth. the school timetable. screening.

Bring the child to a Bring your child to the Refer the student to Refer to dental
dental personnel for nearest dentist for dental personnel for personnel for further
regular dental check- regular dental check-up. dental check-up if management if
ups. necessary. necessary.
- - - KR6: HTA4:
Prepare relevant
education materials on
simple oral screening.
106
4.6 References
AAP (American Academy of Pediatrics) (2019). Adolescent nutrition. In: Pediatric nutrition handbook (8th
ed.). Committee on Nutrition American Academy of Pediatrics. Kleinman, RE (ed.), Elk Grove Village,
IL.
Al Sabbah, H., Vereecken, C.A., Elgar, F.J., Nansel, T., Aasvee, K., Abdeen, Z., Ojala, K., Ahluwalia, N., Maes,
L. (2009). Body weight dissatisfaction and communication with parents among adolescents in 24
countries: international cross-sectional survey. BMC Public Health, 9(1), 1-10.
Alves, J.G., Alves, G.V. (2019). Effects of physical activity on children’s growth. Jornal de pediatria, 95, S72-
S78. https://doi.org/10.1016/j.jped.2018.11.003
Archives of Pediatrics and Adolescent Medicine (2019).57: 746-52.
Azmira, A.L., Juliawati, M., and Razlina, A.R. (2018). Body image dissatisfaction and its determinants among
young primary-school adolescents. Journal of Taibah University Medical Sciences.13(1), 34-41.
Berenson, G. S., Srinivasan, S. R., Xu, J. H., & Chen, W. (2016). Adiposity and cardiovascular risk factor
variables in childhood are associated with premature death from coronary heart disease in adults:
the Bogalusa Heart Study. The American journal of the medical sciences, 352(5), 448-454.
Bielemann, R.M., Martinez-Mesa, J., Gigante, D.P. (2013). Physical activity during life course and bone mass: KM4
a systematic review of methods and findings from cohort studies with young adults. BMC
Musculoskeletal Disorders 2013, 14(77). https://doi.org/10.1186/1471-2474-14-77

Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., De Onis, M., Ezzati, M., ... & Maternal and Child
Undernutrition Study Group. (2008). Maternal and child undernutrition: global and regional exposures
and health consequences. The lancet, 371(9608), 243-260.
Butte, N. F., Hopkinson, J. M., Wong, W. W., Smith, E. O. B., & Ellis, K. J. (2000). Body composition during the
first 2 years of life: an updated reference. Pediatric research, 47(5), 578-585.
Campbell, K. J., Waters, E., O'Meara, S., Kelly, S., & Summerbell, C. D. (2002). Interventions for preventing
obesity in children. Cochrane Database of Systematic Reviews, (2).
Chaput, J. P., Willumsen, J., Bull, F., Chou, R., Ekelund, U., Firth, J., ... & Katzmarzyk, P. T. (2020). 2020 WHO
guidelines on physical activity and sedentary behaviour for children and adolescents aged 5–17 years:
summary of the evidence. International Journal of Behavioral Nutrition and Physical Activity, 17(1),
1-9.
Cheah, W.L., Hazmi, H., & Chang, C.T. (2017). Disordered eating and body image issues and their associated
factors among adolescents in urban secondary schools in Sarawak, Malaysia. International Journal
of Adolescent Medicine and Health, 29(2). Doi:10.1515/ijamh-2015-0044.
Cheong, S.M., Salleh, R., Ahmad, M.H., Baharudin, A., Poh, B.K., Aris, T. (2020). Dietary patterns and associated
factors among adolescents in Malaysia: findings from adolescent nutrition survey 2017. International
Journal Of Environmental Research And Public Health. 17(10), 3431.
Chu, L., Morrison, K. M., Riddell, M. C., Raha, S., & Timmons, B. W. (2021). Metabolic Flexibility during
Exercise in Children with Obesity and Matched Controls. Medicine and Science in Sports and
Exercise, 53(1), 159-164.
de Onis. (2017). Child growth and development. In De Pee, S., Taren, D., & Bloem, M.W. (Eds.), Nutrition and
Health in a Developing World, Nutrition and Health (pp. 119-141). Springer.
107
de Onis M (2015). World Health Organization Reference Curves. In M.L. Frelut (Ed.), The European Childhood
Obesity Group (ECOG)’s eBook on Child and Adolescent Obesity. Retrieved from ebook.ecog-
obesity.eu
De Onis, M., Borghi, E., Arimond, M., Webb, P., Croft, T., Saha, K., ... & Flores-Ayala, R. (2019). Prevalence
thresholds for wasting, overweight and stunting in children under 5 years. Public health nutrition,
22(1), 175-179. doi:10.1017/S1368980018002434.
De Onis, M., Onyango, A. W., Borghi, E., Siyam, A., Nishida, C., & Siekmann, J. (2007). Development of a WHO
growth reference for school-aged children and adolescents. Bulletin of the World health Organization,
85(9), 660-667.
De Sanctis, V., Soliman, A., Alaaraj, N., Ahmed, S., Alyafei, F., & Hamed, N. (2021). Early and Long-term
Consequences of Nutritional Stunting: From Childhood to Adulthood. Acta bio-medica: Atenei
Parmensis, 92(1), e2021168. https://doi.org/10.23750/abm.v92i1.11346
De Vries, A. G. M., Huiting, H. G., Van Den Heuvel, E. R., L'abée, C., Corpeleijn, E., & Stolk, R. P. (2015). An
activity stimulation programme during a child's first year reduces some indicators of adiposity at the
age of two and a half. Acta Paediatrica, 104(4), 414-421.
Diego, M. A., Field, T., & Hernandez-Reif, M. (2014). Preterm infant weight gain is increased by massage
therapy and exercise via different underlying mechanisms. Early human development, 90(3), 137-
KM4 140.
Emond, A. M., Blair, P. S., Emmett, P. M., & Drewett, R. F. (2007). Weight faltering in infancy and IQ levels at
8 years in the Avon Longitudinal Study of Parents and Children. Pediatrics, 120(4), e1051-e1058.
E. Rivers, 2016 Children: Stages of Growth and Development in Encyclopedia of Forensic and Legal
Medicine (Second Edition), (Textbook).
https://www.sciencedirect.com/science/article/pii/B9780128000342000604.
Fraser, B. J., Schmidt, M. D., Huynh, Q. L., Dwyer, T., Venn, A. J., & Magnussen, C. G. (2017). Tracking of
muscular strength and power from youth to young adulthood: Longitudinal findings from the
Childhood Determinants of Adult Health Study. Journal of science and medicine in sport, 20(10), 927–
931. https://doi.org/10.1016/j.jsams.2017.03.021.
Frois, R. R. D. S., Pereira, L. A., Cardeal, C. M., Asano, R. Y., Bartholomeu Neto, J., Oliveira, J. F. D., & França,
N. M. D. (2014). Treinamento de força para crianças: uma metanálise sobre alterações do crescimento
longitudinal, força e composição corporal. Rev. bras. ciênc. mov, 137-149.
Government of Western Australia (2018). Head circumference assessment

https://www.cahs.health.wa.gov.au/~/media/HSPs/CAHS/Documents/Community-
Health/CHM/Head-circumference-assessment.pdf?thn=0
Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age. Geneva:
World Health Organization; 2019.
Hampl SE, Hassink SG, Skinner AC, Armstrong SC, Barlow SE, Bolling CF, Avila Edwards KC, Eneli I, Hamre
R, Joseph MM, Lunsford D, Mendonca E, Michalsky MP, Mirza N, Ochoa ER, Sharifi M, Staiano AE,
Weedn AE, Flinn SK, Lindros J, Okechukwu K. Clinical Practice Guideline for the Evaluation and
Treatment of Children and Adolescents With Obesity. Pediatrics. 2023 Feb 1;151(2):e2022060640. doi:
10.1542/peds.2022-060640. PMID: 36622115.
Hallal, P. C., Victora, C. G., Azevedo, M. R., & Wells, J. C. (2006). Adolescent physical activity and health.
Sports medicine, 36(12), 1019-1030.
108
Holliday M. A. (1971). Metabolic rate and organ size during growth from infancy to maturity and during
late gastation and early infancy. Pediatrics, 47(1), 169+.
Homan, G. J. (2016). Failure to Thrive: A Practical Guide. American family physician, 94(4), 295–299.
Hong, I., Coker-Bolt, P. Anderson, KR., Lee, D., Celozo, CA. (2016). Relationship between physical activity
and overweight and obesity in children: Findings from the 2012 National Health and Nutrition
Examination Survey National Youth Fitness survey. American Journal of Occupational Therapy. 70(5).
Doi:10.5014/ajot.2016.021212.
Hosseini SA, Padhy RK (2021). Body Image Distortion. [Updated 2021 Sep 9]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
https://www.ncbi.nlm.nih.gov/books/NBK546582/.
Institute for Public Health (2015). National Health and Morbidity Survey 2015 (Volume 2). Ministry of Health
Malaysia, Kuala Lumpur.
Institute for Public Health (2016). National Health and Morbidity Survey 2016 (Volume 2). Ministry of Health
Malaysia, Kuala Lumpur.
Institute for Public Health (2017). National Health and Morbidity Survey (NHMS) 2017: Adolescent Nutrition
Survey 2017, Institute for Public Health, Malaysia.
KM4
Institute for Public Health (IPH). (2019). National Institutes of Health, Ministry of Health Malaysia. 2020.
National Health and Morbidity Survey (NHMS) 2019: Vol. I: NCDs – Non-Communicable Diseases:

Risk Factors and other Health Problems. Institute for Public Health, Malaysia.
Institute for Public Health (IPH). (2022). National Health and Morbidity Survey (NHMS) 2022: Adolescent
Health Survey - Key Findings. Institute for Public Health, Malaysia.
IOM (2002). Dietary References Intakes: Energy, carbohydrate, fibre, fat, fatty acids, cholesterol, protein and
amino acids. Institute of Medicine, The National Academy Press, Washington DC.
Ismail, M.N., Norimah, A.K., Poh, B.K., Ruzita, A.T., Nik Mazlan, M. & Nik Shanita, S. (2003). Nutritional status
and dietary habits of primary school children in Peninsular Malaysia. UKM/Nestle Report. Department
of Nutrition and Dietetics, Faculty of Allied Health Sciences, UKM, Kuala Lumpur.
Jáuregui, A., Villalpando, S., Rangel-Baltazar, E., Lara-Zamudio, Y. A., & Castillo-García, M. M. (2012). Physical
activity and fat mass gain in Mexican school-age children: a cohort study. BMC pediatrics, 12(1), 1-
7.
Jeffery, A. N., Voss, L. D., Metcalf, B. S., Alba, S., & Wilkin, T. J. (2004). Parents' awareness of overweight in
themselves and their children: cross sectional study within a cohort (EarlyBird 21). BMJ, 330(7481),
23-24..
Jelenkovic, A., Sund, R., Hur, Y. M., Yokoyama, Y., Hjelmborg, J. V. B., Möller, S., ... & Silventoinen, K. (2016).
Genetic and environmental influences on height from infancy to early adulthood: An individual-based
pooled analysis of 45 twin cohorts. Scientific reports, 6(1), 1-13.
Kahlmeier S., Wijnhoven T.M.A., Alpiger, P. et al (2015). National physical activity recommendations:
systematic overview and analysis of the situation in European countries. BMC Public Health 15, 133.
https://doi.org/10.1186/s12889-015-1412-3.
Kerzner, B., Milano, K., MacLean Jr, W. C., Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach to
classifying and managing feeding difficulties. Pediatrics, 135(2), 344-353.
Khor, G.L., Cobiac, L., & Skrzypiec, G. (2002). Gender difference in eating behavior and social self concept
among Malaysian university students. Malaysian Journal of Nutrition, 8, 75-98.
109
Khor, G.L. (2003). Update on the prevalence of malnutrition among children in Asia. Nepal Medical College
Journal, 5 (2): 113-22.
Kim, K., Melough, M. M., Kim, D., Sakaki, J. R., Lee, J., Choi, K., & Chun, O. K. (2021). Nutritional Adequacy
and Diet Quality Are Associated with Standardized Height-for-Age among US Children. Nutrients,
13(5), 1689.
Kohl III, H. W., & Cook, H. D. (Eds.). (2013). Educating the student body: Taking physical activity and physical
education to school.
Krneta, Ž., Casals, C., Bala, G., Madić, D., Pavlović, S., & Drid, P. (2015). Can kinesiological activities change»
pure «motor development in preschool children during one school year?. Collegium antropologicum,
39(Supplement 1), 35-40.
Lai, W. K., Sidik, S. M., Lekhraj, R., Gan, W. Y., & Ismail, S. I. F. (2022). Prevalence and predictors of overweight
and obesity among adolescents in Seremban, Negeri Sembilan, Malaysia. Cureus, 14(1).
Law, L. S., Gan, W. Y., & Taib, M. N. M. (2020). Sociodemographic and psychological factors as predictors of
body mass index-for-age (BAZ) among adolescents in Sibu, Malaysia. Malaysian Journal of Medicine
and Health Sciences, 16(Suppl 6), 56-62.
Lee, J. S., Jin, M. H., & Lee, H. J. (2022). Global relationship between parent and child obesity: a systematic
KM4 review and meta-analysis. Clinical and experimental pediatrics, 65(1), 35–46.
https://doi.org/10.3345/cep.2020.01620
Lee, W. S., Jalaludin, M. Y., Khoh, K. M., Kok, J. L., Nadarajaw, T., Soosai, A. P., ... & Cheang, H. K. (2022).
Prevalence of undernutrition and associated factors in young children in Malaysia: A nationwide
survey. Frontiers in Pediatrics, 10.
Lee, S., & Lee, A. M. (2000). Disordered eating in three communities of China: A comparative study of female
high school students in Hong Kong, Shenzhen, and rural Hunan. International Journal of Eating
Disorders, 27(3), 317-327.
Llewellyn, A., Simmonds, M., Owen, C. G., & Woolacott, N. (2016). Childhood obesity as a predictor of
morbidity in adulthood: a systematic review and meta analysis. Obesity reviews, 17(1), 56-67.
Liao, J., Cao, C., Hur, J., Cohen, J., Chen, W., Zong, X., ... & Cao, Y. (2021). Association of sedentary patterns
with body fat distribution among US children and adolescents: a population-based study.
International Journal of Obesity, 45(9), 2048-2057.
Lifshitz, F., & Cervantes, C.D. (1996). Short stature. In: Pediatric Endocrinology, Lifshitz F (3rded.). Marcel
Dekker, NewYork.
Loomba-Albrecht, L. A., & Styne, D. M. (2009). Effect of puberty on body composition. Current Opinion in
Endocrinology, Diabetes and Obesity, 16(1), 10-15.
Makino, M., Tsuboi, K., & Dennerstein, L. (2004). Prevalence of eating disorders: a comparison of Western
and non-Western countries. Medscape general medicine, 6(3).
McCrindle, B. W. (2015). Cardiovascular consequences of childhood obesity. Canadian Journal of Cardiology,

31(2), 124-130.
Moehlecke, M., Blume, C. A., Cureau, F. V., Kieling, C., & Schaan, B. D. (2020). Self-perceived body image,
dissatisfaction with body weight and nutritional status of Brazilian adolescents: a nationwide study.
Jornal de Pediatria, 96, 76-83.
110
Shahril, M. R., Unal, T. I., Wong, J. E., Sharif, R., Koh, D., Lee, S. T., & Poh, B. K. (2022). Results from the Malaysia
2022 report card on physical activity for children and adolescents. Journal of Exercise Science &
Fitness, 21(1): Article in Press
MOH (2021). Nutrition Guidelines For Underweight Children, http://www.myhealth.gov.my/en/nutrition-

guidelines-for-underweight-children/
MyHEALTH Portal Rasmi Kementerian Kesihatan Malaysia. http://www.myhealth.gov.my/g-7/
Mondal, N., & Jaydip, S. (2016). Head circumference as an indicator of undernutrition among tribal pre-
school children aged 2-5 years of North Bengal, India. Human Biology Review, 5(1), pp17-33.
NCCFN (2013). Malaysian Dietary Guidelines for Children and Adolescents 2013, National Coordinating
National Cordinating Committee on Food and Nutrition (2016). National Plan of Action for Nutrition of
Malaysia 2016-2025. Ministry of Health Malaysia, Putrajaya.
NCCFN (National Coordinating Committee on Food and Nutrition) (2017). Recommended Nutrient Intakes
for Malaysia. A Report of the Technical Working Group on Nutritional Guidelines. Ministry of Health
Malaysia, Putrajaya.
Neufeld, L. M., Andrade, E. B., Suleiman, A. B., Barker, M., Beal, T., Blum, L. S., ... & Zou, Z. (2021). Food choice KM4
in transition: adolescent autonomy, agency, and the food environment. The lancet, 399(10320), 185-
197.

Neves, C. M., Cipriani, F. M., Meireles, J. F. F., Morgado, F. F. D. R., & Ferreira, M. E. C. (2017). Body image in
childhood: an integrative literature review. Revista Paulista de Pediatria, 35, 331-339.
NICE. (2013, October 23). Weight management: lifestyle services for overweight or obese children and young
people. https://www.nice.org.uk/guidance/ph47/chapter/1-recommendations#recommendation-1-
planning-lifestyle-weight-management-services-for-children-and-young-people
Nurjasmine, A.J., Abdul, H.S., Karimah, H.A.A., Mohd, A.A.R. (2019). A Review on Body Weight Perception
and Its Associated Factors Among Adolescents In Malaysia And Worldwide. World Journal of
Pharmaceutical And Medical Research, (4), 25-29.
Nur Nabilla, A.R., Chin, Y.S., and Norhasmah, S. (2019). Socio-Demographic Factors and Body Image
Perception Are Associated with BMI-For-Age among Children Living in Welfare Homes in Selangor,
Malaysia. Nutrients, 11, 142. Doi:10.3390/nu11010142.
Parry, L.L., Netuveli, G., Parry, J., & Saxena, S. (2008). A systematic review of parental perception of
overweight status in children. The Journal of ambulatory care management, 31(3), 253-268.
Paruthi, S., Brooks, L. J., D'Ambrosio, C., Hall, W. A., Kotagal, S., Lloyd, R. M., ... & Wise, M. S. (2016).
Recommended amount of sleep for pediatric populations: a consensus statement of the American
Academy of Sleep Medicine. Journal of clinical sleep medicine, 12(6), 785-786.
Poh, B. K., Ismail, M. N., Zawiah, H., & Henry, C. J. K. (1999). Predictive equations for the estimation of basal
metabolic rate of Malaysian adolescents. Malaysian journal of nutrition, 5(1 & 2), 1-14.
Poh BK, Ismail MN, Ong HF, Norimah AK & Safiah MY (2004). BMR predictive equations for Malaysian
adolescents aged 12-18 years. Final report for IRPA 06-02-02-0096 research project, Department of
Nutrition and Dietetics, Faculty of Allied Health Sciences, Universiti Kebangsaan Malaysia, Kuala
Lumpur
111
Pont, S. J., Puhl, R., Cook, S. R., & Slusser, W. (2017). Stigma experienced by children and adolescents with
obesity. Pediatrics, 140(6).
Prendergast, A. J., & Humphrey, J. H. (2014). The stunting syndrome in developing countries. Paediatrics
and international child health, 34(4), 250–265. https://doi.org/10.1179/2046905514Y.0000000158
Proia Patrizia, et al. (2021), The impact of diet and physical activity on bone health in children and adolescent.
Frontiers in Endocrinology, 12, 704647. https://doi.org/10.3389/fendo.2021.704647
Ramos, P., Moreno-Maldonado, C., Moreno, C., & Rivera, F. (2019). The role of body image in internalizing
mental health problems in Spanish adolescents: an analysis according to sex, age, and socioeconomic
status. Frontiers in psychology, 10, 1952.
Rivers (2016). Children: Stages of Growth and Development. In J. Payne-James, & R.W. Byard (Eds.),
Encyclopedia of Forensic and Legal Medicine (Second Edition) (pp. 539-557). Elsevier.
Relvas, G. R. B., Buccini, G. D. S., & Venancio, S. I. (2019). Ultra-processed food consumption among infants
in primary health care in a city of the metropolitan region of Sao Paulo, Brazil. Jornal de pediatria, 95,
584-592.
Rynders, C. A., Blanc, S., DeJong, N., Bessesen, D. H., & Bergouignan, A. (2018). Sedentary behaviour is a
key determinant of metabolic inflexibility. The Journal of physiology, 596(8), 1319-1330.
KM4
Schofield, W. N. (1985). Predicting basal metabolic rate, new standards and review of previous work. Human
nutrition. Clinical nutrition, 39, 5-41.
Schulzke, S. M., Kaempfen, S., Trachsel, D., & Patole, S. K. (2014). Physical activity programs for promoting
bone mineralization and growth in preterm infants. Cochrane Database of Systematic Reviews, (4).
Schwarzfischer, P., Gruszfeld, D., Socha, P., Luque, V., Closa-Monasterolo, R., Rousseaux, D., ... & Grote, V.
(2018). Longitudinal analysis of physical activity, sedentary behaviour and anthropometric measures
from ages 6 to 11 years. international journal of behavioral nutrition and physical activity, 15(1), 1-9.
Shakir, RM., Coates, AM., Olds, T., Rowland, A., Tsiros, MD. (2018). Not all sedentary behaviour is equal:
Children’s adiposity and edentary behaviour volumes, patterns and types. Obesity Research &
Clinical Practice; 12(6): 506-512.
Stevens, G. A., Beal, T., Mbuya, M. N., Luo, H., Neufeld, L. M., Addo, O. Y., ... & Young, M. F. (2022).
Micronutrient deficiencies among preschool-aged children and women of reproductive age
worldwide: a pooled analysis of individual-level data from population-representative surveys. The
Lancet Global Health, 10(11), e1590-e1599.
Sharif, R., Chong, K. H., Zakaria, N. H., Ong, M. L., Reilly, J. J., Wong, J. E., Saad, H. A., & Poh, B. K. (2016).
Results From Malaysia's 2016 Report Card on Physical Activity for Children and Adolescents. Journal
of physical activity & health, 13(11 Suppl 2), S201–S205. https://doi.org/10.1123/jpah.2016-0404
Shaw, S. C., Sankar, M. J., Thukral, A., Natarajan, C. K., Deorari, A. K., Paul, V. K., & Agarwal, R. (2018). Assisted
physical exercise for improving bone strength in preterm infants less than 35 weeks gestation: a
randomized controlled trial. Indian Pediatrics, 55(2), 115-120.
Stalnaker, K.A., Poskey, G.A. (2016). Osteopenia of prematurity: does physical activity improve bone
mineralization in preterm infants? Neonatal Network, 35, 95-104. https://doi.org/10.1891/0730-
0832.35.2.95
Striegel-Moore, R.H. & Smolak, L. (2001). Eating disorders: Innovative directions in research and practice
(1sted.). American Psychological Association, Washington DC.
112
Styne, D.M., Arslanian, S.A., Connor, E.L., Farooqi, I.S., Murad, M.H., Silverstein, J.H., Yanovski, J.A., 2017.
Pediatric Obesity—Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice
Guideline. The Journal of Clinical Endocrinology & Metabolism 102, 709–757. doi:10.1210/jc.2016-
2573
Tandon P.S., Tovar A., Jayasuriya AT, Welker E, Schober D. J, Copeland K., Dev D.A, Murriel A.L., Amso D.,
Ward D.S. (2016). The relationship between physical activity and diet and young children's cognitive
development: A Systematic Review. Preventive Medicine Reports, 3, 379-390.
https://doi.org/10.1016/j.pmedr.2016.04.003.
Tee, E. S., Nurliyana, A. R., Karim, N. A., Jan Mohamed, H. J. B., Tan, S. Y., Appukutty, M., Hopkins, S.,
Thielecke, F., Ong, M. K., Ning, C., & Mohd Nasir, M. T. (2018). Breakfast consumption among
Malaysian primary and secondary school children and relationship with body weight status-Findings
from the MyBreakfast Study. Asia Pacific Journal of Clinical Nutrition, 27(2), 421-432.
Tammelin, R., Yang, X., Leskinen, E., Kankaanpaa, A., Hirvensalo, M., Tammelin, T., & Raitakari, O. T. (2014).
Tracking of physical activity from early childhood through youth into adulthood. Medicine & Science
in Sports & Exercise, 46(5), 955-62.
Thompson, J.K., Heinberg, L.J., Altabe, M., & Tantleff-Dunn, S. (1999). Exacting beauty: Theory, assessment
and treatment of body image disturbance. American Psychological Association. Washington DC.
Tung, W.L. and Md, M.R. (2021). Perceived body image and its relationship with body mass index, self- KM4
esteem, body change strategy and social network usage among rural adolescents in Sarawak,
Malaysia. Malaysian Journal of Public Health Medicine, Vol. 21(1), 198-207.

Twisk, JW. (2001). Physical activity guidelines for children and adolescents: a critical review. Sports medicine
(Auckland, N.Z.), 31(8), 617–627. https://doi.org/10.2165/00007256-200131080-00006
Veldhuis, J. D., Roemmich, J. N., Richmond, E. J., Rogol, A. D., Lovejoy, J. C., Sheffield-Moore, M., ... & Bowers,
C. Y. (2005). Endocrine control of body composition in infancy, childhood, and puberty. Endocrine
reviews, 26(1), 114-146.
Voelker, D.K., Reel, J.J., and Greenleaf, C. (2015). Review: Weight status and body image perceptions in
adolescents: current perspectives. Adolescent Health, Medicine and Therapeutics, 6 149–158.
Warburton, D. E., & Bredin, S. S. (2017). Health benefits of physical activity: a systematic review of current
systematic reviews. Current opinion in cardiology, 32(5), 541-556.
White, D. A., Bethany, B. G., Gallagher, J. D., Jakicic, J. M., Rofey, D. L., & Venditti, E. M. (2016). The impact
of expressing concern for a child’s weight on the parents perception of child weight and the parents
concern for future weight problems. Journal of Childhood Obesity, 1, 04.
WHO/FAO (2003). Diet, Nutrition and the Prevention of Chronic diseases. Report of a joint WHO/FAO experts
Consultation. WHO Technical Report Series 916. World Health Organisation, Geneva.
WHO (2006). WHO Child Growth Standards: Length/height-for-age, weight-for- age, weight- for-length,
weight for-height and body mass index-for-age: Method and development. World Health
WHO Multicentre Growth Reference Study Group (2007). WHO Child Growth Standards: Length/height-
for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. World
Health Organization, Geneva.
World Health Organization. Adolescent Health. https://www.who.int/health-topics/adolescent-

health#tab=tab_1
113
World Health Organization. The WHO Child Growth Standards. http://www.who.int/

childgrowth/en/
Xanthopoulos, M. S., Borradaile, K. E., Hayes, S., Sherman, S., Vander Veur, S., Grundy, K. M., ... & Foster, G.
D. (2011). The impact of weight, sex, and race/ethnicity on body dissatisfaction among urban children.
Body Image, 8(4), 385-389.
Yang HR (2017). How to approach feeding difficulties in young children. Korean J Pediatr 2017;60(12):379-
384
Akta Pendidikan 1996 (Akta 550), memperuntukkan Pendidikan Prasekolah dalam Sistem Pendidikan
Kebangsaan. Melalui Dasar Pendidikan Prasekolah, KPM bertanggungjawab memberikan pendidikan
prasekolah kepada kanak-kanak yang berumur empat hingga enam tahun.
https://www.moe.gov.my/pendidikan/pendidikan-prasekolah/latar-belakang (Definition for
preschoolers@ prasekolah) https://globalnutritionreport.org/resources/nutrition-profiles/asia/south-
eastern-asia/malaysia/
UNICEF/WHO/World Bank Joint Child Malnutrition Estimates Expanded Database: Stunting,

Wasting and Overweight (July 2020, New York).
https://data.unicef.org/resources/dataset/malnutrition-data.
KM4
114
Appendices
A. BMI-for-age
Appendix 4.1: BMI-for-age growth chart from birth to 2 years old (boys)
BMI-for-age (Boys)
Birth to 2 years (z-score) Ministry of Health
Malaysia
Obesity
Overweight
Possible Risk
of Overweight
Normal
Wasted
KM4
Severely
Wasted

Birth 1 year 2 year
Age (Month and Year)
Appendix 4.2: BMI-for-age growth chart from 2 to 5 years old (boys)
BMI-for-age (Boys)
2 to 5 years (z-score) Ministry of Health
Malaysia
Obesity
Overweight
Possible Risk
of Overweight
Normal
Wasted
Severely
Wasted
2 year 3 year 4 year 5 year
Source: Ministry of Health Malaysia. Adapted from WHO, 2006
115
Appendix 4.3: BMI-for-age growth chart from birth to 2 years old (girls)
BMI-for-age (Girls)
Malaysia
Obesity
Overweight
Possible Risk
of Overweight
Normal
Wasted
Severely
Wasted
KM4
Birth 1 year 2 year

Appendix 4.4: BMI-for-age growth chart from 2 to 5 years old (girls)
BMI-for-age (Girls)
Malaysia
Obesity
Overweight
Possible Risk
of Overweight
Normal
Wasted
Severely
Wasted
116
Appendix 4.5: BMI-for-age Z-score table and interpretation for 5 to 19 years old (boys)
Age -3SD -2SD -1SD Median +1SD +2SD +3SD
5.1 12.1 13.0 14.1 15.3 16.6 18.3 20.2
6.0 12.1 13.0 14.1 15.3 16.8 18.5 20.7
7.0 12.3 13.1 14.2 15.5 17.0 19.0 21.6
8.0 12.4 13.3 14.4 15.7 17.4 19.7 22.8
9.0 12.6 13.5 14.6 16.0 17.9 20.5 24.3
10.0 12.8 13.7 14.9 16.4 18.5 21.4 26.1
11.0 13.1 14.1 15.3 16.9 19.2 22.5 28.0
12.0 13.4 14.5 15.8 17.5 19.9 23.6 30.0

KM4
13.0 13.8 14.9 16.4 18.2 20.8 24.8 31.7

14.0 14.3 15.5 17.0 19.0 21.8 25.9 33.1
15.0 14.7 16.0 17.6 19.8 22.7 27.0 34.1
16.0 15.1 16.5 18.2 20.5 23.5 27.9 34.8
17.0 15.4 16.9 18.8 21.1 24.3 28.6 35.2
18.0 15.7 17.3 19.2 21.7 24.9 29.2 35.4
19.0 15.9 17.6 19.6 22.2 25.4 29.7 35.5
Source: WHO (2007)
Z-score (SD) Interpretation
>2 Obesity
> 1 to < 2 Overweight
> - 2 to < 1 Normal
> - 3 to < - 2 Thinness
<-3 Severely Thinness
117
Appendix 4.6: BMI-for-age Z-score table and interpretation for 5 to 19 years old (girls)
Age -3SD -2SD -1SD Median +1SD +2SD +3SD
5.1 11.8 12.7 13.9 15.2 16.9 18.9 21.3
6.0 11.7 12.7 13.9 15.3 17.0 19.2 22.1
7.0 11.8 12.7 13.8 15.4 17.3 19.8 23.3
8.0 11.9 12.9 14.1 15.7 17.7 20.6 24.8
9.0 12.1 13.1 14.4 16.1 18.3 21.5 26.5
10.0 12.4 13.5 14.8 16.6 19.0 22.6 28.4
11.0 12.7 13.9 15.3 17.2 19.9 23.7 30.2
12.0 13.2 14.4 16.0 18.0 20.8 25.0 31.9

KM4
13.0 13.6 14.9 16.8 18.8 21.8 26.2 33.4

14.0 14.0 15.4 17.2 19.6 22.7 27.3 34.7
15.0 14.4 15.9 17.8 20.2 23.5 28.2 35.5
16.0 14.6 16.2 18.2 20.7 24.1 28.9 36.1
17.0 14.7 16.4 18.4 21.0 24.5 29.3 36.3
18.0 14.7 16.4 18.6 21.3 24.8 29.5 36.3
19.0 14.7 16.5 18.7 21.4 25.0 29.7 36.2
Source: WHO (2007)
Z-score (SD) Interpretation
>2 Obesity
> 1 to < 2 Overweight
> - 2 to < 1 Normal
> - 3 to < - 2 Thinness
<-3 Severely Thinness
118
B. Height-for-age
Appendix 4.7: Length-for-age growth chart from birth to 2 years old (boys)
Length-for-age (Boys)
Birth to 2 years (z-score)
Ministry of Health
Malaysia
Length (cm)
KM4

Birth 1 year 2 year
Appendix 4.8: Height-for-age growth chart from 2 to 5 years old (boys)
Height-for-age (Boys)
2 to 5 years (z-score)
Ministry of Health
Malaysia
Height (cm)
Source: Ministry of Health Malaysia. Adapted from WHO, 2006.
119
Appendix 4.9: Length-for-age growth chart from birth to 2 years old (girls)
Length-for-age (Girls)
Ministry of Health
Malaysia
Length (cm)
KM4
Birth 1 year 2 year

Appendix 4.10: Height-for-age growth chart from 2 to 5 years old (girls)
Height-for-age (Girls)
Ministry of Health
Malaysia
Height (cm)
120
Appendix 4.11: Height-for-age Z-score table Appendix 4.12: Height-for-age Z-score table
and interpretation from and interpretation from
5 to 19 years old (boys) 5 to 19 years old (girls)
Age < - 2SD ≥ - 2SD Age < - 2SD > - 2SD
5:1 < 101.1 ≥ 101.1 5: 1 < 100.1 ≥ 100.1
6:0 < 106.1 ≥ 106.1 6:0 < 104.9 ≥ 104.9
7:0 < 111.2 ≥ 111.2 7:0 < 109.9 ≥ 109.9
8:0 <116.0 ≥116.0 8:0 <115.0 ≥115.0
9:0 <120.5 ≥120.5 9:0 <120.3 ≥120.3
10:0 <125.0 ≥125.0 10:0 <125.8 ≥125.8

KM4
11:0 <129.7 ≥129.7 11:0 <131.7 ≥131.7

12:0 <134.9 ≥ 134.9 12:0 < 137.6 ≥137.6
13:0 <141.2 ≥141.2 13:0 < 142.5 ≥142.5
14:0 <147.8 ≥147.8 14:0 <145.9 ≥145.9
15:0 <153.4 ≥153.4 15:0 <147.9 ≥147.9
16:0 <157.4 ≥157.4 16:0 <148.9 ≥148.9
17:0 <159.9 ≥159.9 17:0 <149.5 ≥149.5
Z-score Interpretation Z-score Interpretation
≥-2SD Normal ≥-2SD Normal
<-2SD Stunting <-2SD Stunting
Source: WHO, 2007 Source: WHO, 2007
121
C. Weight-for-age
Appendix 4.13: Weight-for-age growth chart from birth to 2 years old (boys)
Weight-for-age (Boys)
Malaysia
Weight (kg)
KM4
Birth 1 year 2 year

Appendix 4.14: Weight-for-age growth chart from 2 to 5 years old (boys)
Weight-for-age (Boys)
Malaysia
Weight (kg)
122
Appendix 4.15: Weight-for-age growth chart from birth to 2 years old (girls)
Weight-for-age (Girls)
Ministry of Health
Malaysia
Weight (kg)
KM4

Birth 1 year 2 year
Appendix 4.16: Weight-for-age growth chart from 2 to 5 years old (girls)
Weight-for-age (Girls)
Ministry of Health
Malaysia
Weight (kg)
123
D. Head circumference-for-age
Appendix 4.17: Head circumference-for-age growth chart from birth to 3 years old (boys)
Head circumference-for-age (Boys)

Birth to 36 months (percentiles)
Ministry of Health
Malaysia
KM4
Birth
Age (Month)
Appendix 4.18: Head circumference-for-age growth chart from birth to 3 years old (girls)
Head circumference-for-age (Girls)

Birth to 36 months (percentiles) Ministry of Health
Malaysia
Birth
Age (Month)
Source: Ministry of Health Malaysia. Adapted from CDC, 2000.
124
Key Message 5
Be physically active everyday

KM5
Be Physically Active Everyday
Key Message 5
Be physically active everyday
Assoc. Prof. Dr. Hazizi Abu Saad, Assoc. Prof. Dr. Sharifah Wajihah Wafa Syed Saadun Tarek Wafa, Dr. Lee Yi Yi,
Mr. Wan Mohd Hakim Wan Ismail and Ms. Noor Junainah Masjuni
5.1 Terminology
Bone-strengthening activity Intensity

Bone-strengthening activity refers to the physical Intensity refers to the degree of overload an activity
activity planned to increase the strength of specific imposes on physiological systems compared to
sites of the skeletal system. These activities produce resting states. The intensity of physical activity can
an impact or tension force on the bones, promoting be described as light, moderate and vigorous. These
bone growth and strength (DHHS, 2008). Running, terms correlate to the absolute amount of energy
hopping, jumping rope, hopscotch and lifting expenditure or oxygen consumption associated
weights are examples of bone-strengthening with specific types of activity. Oxygen consumption
activities. is expressed in metabolic equivalents (METs), which
are multiples of the resting rates of oxygen
Duration consumption during physical activity (Ainsworth et
Duration represents the temporal length of an al., 2011). In general, light-intensity activity is
activity, often quantified in minutes. physical activity carried out at 1.0 to less than 3.0
METs; moderate-intensity activity is defined as 3.0
Frequency to 6.0 METs; and more than 6.0 METs is categorized
Frequency represents the number of times a person as vigorous-intensity activity.
engages in an activity over a predetermined period.
126
Interactive activities • Occupational work: Activities undertaken

Interactive exercises are exercises with a parent or during work or at school.
guardian that don't include screens as a method of
diversion. These can incorporate perusing, singing, • Household and other chores: Activities
narrating, shading, block building, riddles, and undertaken as part of day-today living.
games.
• Leisure-time physical activity: Activities
Moderate-to-vigorous intensity physical undertaken in the individual’s discretionary
activity (MVPA) or free time. Activities are selected based on
Moderate PA is equivalent to 4–7 METs in children personal needs and interests. They include
below 5 years, i.e., 4–7 times resting energy exercise and sports;
expenditure at rest for that child. Vigorous PA is
equivalent to >7 METs. For young children, this can • Exercise: A planned and organised category
include brisk walking, cycling, running, playing ball of leisure-time physical activity that is
games, swimming, dancing and energetic or active typically done to enhance or maintain
play, during which the child gets hot and breathless. physical fitness (WHO, 2010). Jogging,
Moderate PA is equivalent to 3–6 METs in children swimming, or going to the gym are some of
and adolescence 5 years and above, i.e., 3–6 times the examples.
resting energy expenditure at rest. Vigorous PA is
equivalent to >6 METs. (MacIntosh et al., 2021). • Sports: Sports include a variety of activities
carried out according to a set of rules for
Motor and skills development recreation or competition. Sports feature
The term "motor development" describes the teams or individuals engaging in physical KM5
growth of a child's musculoskeletal system as well activity and they may be supported by an
as the acquisition of large motor skills, sometimes institutional framework, like a sporting

known as "basic movement skills," and fine motor agency. Its definition varies around the world.
skills, such as object control. (Cech et al., 2012). It suggests a competitive form of physical
activity that encompasses both general
Muscle-strengthening activity exercise and a particular occupation (WHO,
This comprises physical activity and exercise to 2010). Examples of sports are playing
develop the strength, power, endurance, and volume badminton or other racquet sports, football,
of the skeletal muscles e.g., strength training, dancing, or juggling.
resistance training, or muscular strength and
endurance exercises (Bennie, 2020). Listed below are four types of physical activities
among infants and young children which are mainly
Physical activity categorised into structured and unstructured
Every skeletal muscle-driven movement that uses physical activities (NASPE, 2002):
energy is considered as physical activity. Exercise
is a multifaceted behaviour that incorporates several • Structured physical activity: Intentionally
factors. Four categories can be used to describe it: and planned physical activity that is guided
type, frequency, duration, and intensity. It is strongly by the caregiver.
aligned to exercise and physical fitness, but different
from both. Contrarily, the term "exercise" refers to • Unstructured physical activity: Child-
any controlled, structured, and repetitive body initiated physical activity that occurs as the
motions made with the intention of enhancing children explores their environment.
physical fitness (WHO, 2022). Among adults and
older children, the 5 components of physical activity • Aerobic physical activity is an endurance
are: activity that improves cardiorespiratory
fitness. Examples include running or jogging,
walking at a brisk pace, cycling, and
swimming.
• Anaerobic physical activity is an activity

aimed to build muscle mass. Examples
include weight lifting and sprints.
127
Play Sedentary screen time

Play is defined as being done voluntarily, for Sedentary screen time refers to the time spent
participants’ enjoyment, and without any particular watching screen-based entertainment such as TV,
end in mind. It can be done alone or with others, computer and mobile devices. This does not include
with or without objects. Through engaging in fun active screen-based games where physical activity
interactions with other people and things, young or movement is required.
children learn and solidify their developmental skills
(Smith & Pellegrini, 2013). Play can include: Physical fitness
In the context of this paper, the term physical fitness
• Floor-based play: refers to the supervised focuses on the health-related aspects of fitness.
play for infants, where children move on the Physical fitness is characterised by (i) an ability to
floor and develop motor skills. perform daily activities with vigour, and alertness,
without undue fatigue, and with ample energy to
• Interactive play: refers to play with a enjoy leisure-time pursuits, and (ii) demonstrations
parent or caregiver where the child and of traits and capacities that are associated with low
adult/older child interact and engage in play risk of premature development of diseases
for both cognitive and motor learning. associated with physical inactivity. The five
components of health- related physical fitness are
Physical inactivity cardiorespiratory endurance, muscular endurance,
Physical inactivity or being sedentary is defined as muscular strength, body composition and flexibility
‘a state when body movement is minimal and (Caspersen et al., 1985), which can all be assessed,
energy expenditure approximates resting metabolic quantified, and measured to provide an indication of
KM5 rate’. Examples include sitting or lying on the sofa an individual’s physical fitness level.
watching TV, sitting at a desk or computer, and
playing video games. Tummy time
Tummy time refers to the time an infant spends

Sedentary behaviour lying on their front (in prone position) while awake
Sedentary behaviour is defined as any waking with unrestricted movement of limbs (WHO, 2019).
behaviour characterised by an energy expenditure
≤1.5 metabolic equivalents (METs), while in a Age classification for children and adolescent
sitting, reclining, or lying posture. • Infant – birth to below 12 months
For children under 5 years of age, the sedentary • Toddlers – 1-3 years old
behaviours include time spent restrained in a car
• Pre-schoolers – 4-6 years old
seat, high-chair, stroller, pram or in a carrying device
or on a caregiver’s back. • Adolescents- 10-<18 years old
Recreational Screen Time According to the Ministry Education Malaysia:

Recreational screen time is defined as the time • Primary school children – school children
spent watching screens (television (TV), computer, aged 7-12 years
mobile devices) for purposes other than those • Secondary school children- school children
related to education/study or work. aged 13-17 years
5.2 Introduction
Regular physical activity is important for promoting of these include improved physical fitness
health and fitness in children and adolescents, (cardiorespiratory, muscular and adiposity), reduced
especially those who are inactive, to become more levels of depression, improved cognitive function
active and for those who are already active to (academic performance, executive function),
increase their cardiorespiratory fitness further. cardiometabolic health (blood pressure,
People of all ages should be physically active for dyslipidemia, glucose, and insulin resistance) and
their health and wellbeing. It has long been bone health (WHO, 2020).
acknowledged as a crucial element in improving
health and lowering the chance of developing In 2016, globally, around 80% of adolescents aged
several chronic diseases. Youth who are regularly 11-17 years were insufficiently active. Only 15% of
active also have a better chance of healthy girls and 22% of boys were active and met
adulthood. Physical activity is linked to various recommendations of at least 60 minutes of moderate
health outcomes in children and adolescents. Some to vigorous intensity physical activity per day.
128
Among Malaysian children aged 10 to 17 years old, activity than their younger counterparts (IPH, 2018).
the National Health and Morbidity Study (NHMS, Because epidemiologic data show that chronic and
2017) reported that 43.0% of primary school children degenerative diseases of adulthood begin in
and 62.3% of secondary school children were childhood, there has been concern that a lack of
physically inactive (IPH, 2018). While in 2022, about physical activity during childhood that persists into
21.4% and 66.7% of adolescents were categorised as sedentary during adulthood may be one of the major
active and inactive, respectively (IPH, 2022). causes leading to increased health problems in later
life. The bottom line is that physical activity reaps
Evidence shows that among children and health benefits far outweigh adverse events’ risks
adolescents, weight gain and adiposity (blood (DHHS, 2008). Hence it is vital to emphasise the
pressure, dyslipidemia, glucose, and insulin importance of physical activity and to provide
resistance), fitness, and behavioural conduct/pro- achievable strategies to encourage children and
social behavior are associated with sedentary adolescents, specifically and the nation in general,
behaviour (WHO, 2020). NHMS (2017) indicated that to become more physically active.
those in the older age groups had less physical
5.3.1 Physical activity and chronic disease are more likely to have high blood pressure and high
prevention cholesterol, which are risk factors for cardiovascular
disease (Cote et al., 2013), increased risk of impaired
Physical inactivity has been identified as a risk glucose tolerance, insulin resistance, and T2DM KM5
factor for chronic diseases. It is a contributor to the (Lloyd et al., 2012; Bacha & Gidding, 2016) breathing
rise in prevalence of overweight and obesity, problems, such as asthma (Mohanan et al., 2014) and

coronary heart disease (CHD), type 2 diabetes sleep apnea (Narang & Mathew, 2012) and joint
mellitus (T2DM), breast cancer, colon cancer and problems and musculoskeletal discomfort (Pollock,
reduced life expectancy (WHO, 2020). Individuals 2015). Obesity in children and adolescents is also
who are less active (600–3999 Metabolic equivalent associated with psychological problems such as
(MET)-minutes) have a 14%, 16% and 3% reduced anxiety and depression (Morrison et al., 2015), lower
risk of T2DM, CHD and breast cancer, respectively, self-reported quality of life and low self-esteem
compared to those who are inactive and further (Hamzaid et al., 2011) and social problems such as
decrease with higher levels of physical activity (PA) bullying and stigma.
(Kyu et al., 2016). It is expected that half a million
global deaths annually can be avoided with every It is postulated that the prevalence of low levels of
10% decrease in population-level inactivity. physical activity will increase with the current trend
of the increasing prevalence of obesity in the
5.3.2 Obesity, its related diseases and weight children population. Physical inactivity is a
management significant predictor and cause of obesity in
children, independent of nutritional habits with
Overweight and obesity are growing worldwide sedentary activities such as television viewing
health problems due to such lifestyle changes as having replaced recreational pursuits that involve
decreased physical activity (PA), increased more physical activity (Jago et al., 2005) and is
sedentary behaviour and unhealthy eating habits. In further emphasised when combined with the
Malaysia, obesity is one of the most significant risk consumption of unhealthy food (Utter et al., 2003).
factors for physical and psychological health Few studies conducted in Malaysia have shown that
problems, such as diabetes, hypertension, asthma, obese children (Wafa et al., 2017) and adolescents
thyroidism and lower quality of life (Mohd-Sidik et (Tan et al., 2019) are less physically active than their
al., 2021). Obesity in children and adolescents have normal-weight peers. Furthermore, several studies
received considerable attention from the scientific have documented that the increased risk of
community, particularly in response to the cardiovascular disease in children is associated with
concerning and growing trends in metabolic poor fitness (García-Hermoso et al., 2020). Hence,
syndrome among children. The latest National exercise interventions represent an effective clinical
Health and Morbidity Survey (NHMS, 2022) reported strategy for preventing obesity and co-morbidities
that the prevalence of childhood obesity (children in children and adolescents (Brown et al., 2019). A
under 18 years) increased from 11.9 to 14.2 percent systematic review reported that dose-response
between 2015 and 2022 (IPH, 2022). Obese children relations between physical activity and health
129
observed in several observational studies suggest strengthening physical activity at a moderately-

that the more physical activity in school-aged intense level can slow the loss of bone. Bone
children and youth, the greater the health benefits strengthening activities remain especially important
they will obtain. Furthermore, the review also for children and young adolescents because the
concluded that results from experimental studies greatest gains in bone mass occur during the years
indicate that even modest amounts of physical just before and during puberty. In addition, almost
activity can have health benefits in high-risk 90% of peak bone mass is acquired by the end of
youngsters (e.g., obese) (Janssen & Leblanc, 2010). adolescence (DHHS, 2008). Experimental studies
In particular, previous meta-analyses suggest that involving programmes of 10 to 60 minutes duration
aerobic exercise interventions have been shown to moderate to high-strain activity (impact, weight-
reduce fasting insulin levels significantly, insulin bearing) for 2 to 3 or more days per week have been
resistance (Marson et al., 2016; García Hermoso et shown to have beneficial effects on skeletal health.
al., 2014), adiposity (Kelley et al., 2019) and improving A systematic review indicates that 10 minutes of
blood lipid levels (Kelley & Kelley, 2007) in obese moderate-to-high impact activities performed on at
children and adolescents. least 2 or 3 days of the week combined with more
general weight-bearing aerobic activities would
Children today are more sedentary as they ride in have a modest effect on bone mineral density and
cars or buses to school, have less physical exercise, be beneficial for cardiovascular risk factors and
watch more television, play more sedentary games obesity prevention (Janssen & LeBlanc, 2010).
such as computer games, and do not have as much
freedom to play outside on their own. Several In both children and adolescents, participation in
systematic reviews reported that adolescents spend muscle-strengthening activities 2 to 3 times per
KM5 most of their time engaged in sedentary activities week significantly improves muscular strength.
(Biddle et al., 2010; Arundell et al., 2016; Stierlin et Muscle strengthening activities can be unstructured
al., 2015). In Malaysia, findings from the Southeast and part of play for this age group, such as running,
Asian Nutrition Survey (SEANUTS) study found that skipping with a rope, jumping, and lifting weights
most Malaysian children spent almost half of their (WHO, 2020). A recent global physical activity
sedentary time on screen-based activities, including guideline for children 5-17 years emphasise
playing video games, watching television, and using participation in high-intensity physical activity and
the computer (Lee et al., 2015). includes a recommendation to perform ‘muscle and
bone strengthening physical activities on at least 3
Observation and experimental evidence support the days per week (WHO, 2020). This muscular strength
hypothesis that maintaining high amounts and activity is important for protecting against chronic
intensities of physical activity starting in childhood diseases and all-cause mortality (Ruiz et al., 2008;
and continuing into adulthood will enable people to Ruiz et al., 2009).
maintain a favourable risk profile and lower
morbidity and mortality rates from cardiovascular 5.3.4 Mental health
disease and diabetes later in life. The research
suggests that moderate to vigorous-intensity Regular physical activity is not only important for
physical activity for at least 60 minutes per day optimal physical health, but it also gives benefits to
would help children and youth maintain a healthy mental health. Studies show that exercise can treat
cardiorespiratory and metabolic risk profile (Janssen mild to moderate depression as effectively as
& Leblanc, 2009). antidepressant medication—but without the side
effects. A recent study by Choi and colleagues found
5.3.3 Bone, joint and muscle health, and that running for 15 minutes a day or walking for an
performance hour reduces the risk of major depression by 26%
(Choi et al., 2019). In addition to relieving depression
Besides reducing the risk factors of non- symptoms, research shows that maintaining an
communicable diseases, other benefits associated exercise schedule can prevent individuals from
with physical activity include improved bone health relapsing. Research also suggests that physical
and strong muscles. Several studies have activity improves health-related quality of life (QoL)
demonstrated that exercise can enhance bone gains in children and adolescents (Marker et al., 2018).
in children and adolescents (Tan et al., 2014). Wafa et al. (2016) found a positive relationship
Keeping bones, joints, and muscles healthy can help between QoL and Moderate-to-vigorous intensity
ensure that children and adolescents are able to do physical activtiy (MVPA) in children indicating that
their daily activities and be physically active. Regular physically active children have a better quality of
participation in aerobic, muscle-strengthening and bone- life.
130
5.3.5 Asthma children aged 3-4 years of age should allocate 180
minutes to a variety of physical activities at any
Regular aerobic exercise has been shown to intensity, including 60 minutes of moderate to
improve asthma symptoms and, thus, asthma vigorous intensities and the more, the better (WHO,
control levels. A previous systematic review 2019). Children and youth aged 5 to 17 years should
reported that exercise can improve asthma control actively participate in at least 60 minutes of
but may not impact disease severity (Carson et al., moderate to vigorous-intensity physical activity
2013). The review also provided evidence that daily across the week, and most of this physical
regular physical exercise improves physical fitness activity consists of aerobic exercise. The activity
among adult asthmatics. Several studies show that related to muscle and bone strength should
a controlled aerobic programme (2 to 3 sessions/ incorporate vigorous-intensity aerobic activities for
week for at least 6 weeks) results in improved at least 3 days a week (WHO, 2020).
aerobic and anaerobic fitness in youth with asthma
(Council et al., 2003). Children who are physically active in running,
jumping, and other bone-strengthening activities
5.3.6 Academic performance have higher bone mass, improved bone structure
and greater bone strength. The Physical Activity
According to the US Centre for Disease Control and Guidelines for Americans 2nd edition also
Prevention (CDC), physical activity impacts recommends 60 minutes or more of physical
cognitive skills such as concentration and attention activity, including muscle and bone strengthening
and enhances classroom attitudes and behaviours, activity, in their key guidelines for children and
all of which are important components of improved adolescents aged 3 through 17 years and should be
academic performance. Several cross-sectional carried out at least 3 times a week. Activities that KM5
observations showed a positive association produce high physical stress on the bones, such as
between physical fitness level and academic running, jumping rope, basketball, tennis, and

achievement (Han, 2018; Dwyer, 2011; Knight, 2015). hopscotch, help to improve bone health (DHHS,
Furthermore, a systematic review on children’s 2019)
physical activity, fitness, cognitive function, and
academic achievement reported that physical Similarly, in the United Kingdom, Chief Medical
fitness, single bouts of PA, and PA interventions Officer Physical Activity Guidelines (2019) advocates
benefit children’s cognitive functioning (Donnelly et that children and young people should engage in
al., 2016). A systematic review of physical activity various types and intensities of physical activity
was reported to have a positive influence on across the week to develop movement skills,
cognitive and emotional functions (Bidzan-Bluma & muscular fitness, and bone strength.
Lipowska, 2018) and on classroom behaviour
(Watson et al., 2017). Mechanistic studies of Children and adolescents require an age-
cognitive function also suggest a positive effect of appropriate activity for muscle and bone
physical activity on intellectual performance strengthening because the greatest gains in bone
(Cotman & Berchtold, 2002). mass occur during the years just before puberty. In
addition, most of the peak bone mass is obtained by
5.3.7 Physical activity recommendations for the end of adolescence. Preschool-aged children
children and adolescents ages 3 to 5 should incorporate bone-strengthening
activities such as hopping, skipping, jumping, and
The World Health Organization (2019) suggests that tumbling. Although the specific amount of activity
infants who are under 1 year old ought to be active needed to improve bone health and avoid excessive
a few times each day in numerous ways through fat in young children is not well defined, a
floor-based play, for example, stomach times or reasonable target may be 3 hours per day of activity
inclined position for 30 minutes over the course of of all intensities, including light, moderate, or
the day while conscious. Infants under 1 year old, 30 vigorous intensity. This can be the normal sum of
minutes out of each day of inclined position were movement watched among children of this age and
ideally related with wellbeing pointers. Nonetheless, is steady with rules from Canada, the United
parents should organise and supervise active time Kingdom, and the Commonwealth of Australia
for infants. (Physical Activity Guidelines for Americans, 2019).
Children aged 1 -2 years of age ought to allocate 180 Infants and toddlers aged 0 to 3 years should get
minutes to a assortment of physical activities at more physical activity and avoid following their
progressively intensity from low to vigorous, while instinct to move as little as possible, while pre-
131
school children from 4 to 6 years old should or more, is better. Children aged 3 to 4 years old
accumulate a total of 180 minutes/day or more that should spend at least 180 minutes in various
can comprise instructed and non-instructed physical activities spread throughout the day, of
physical activity. Primary school children aged 6 to which at least 60 minutes is energetic play. Children
11 years should be moderate to vigorously active for aged 5-17 should accumulate at least 60 minutes
90 minutes or more a day, as well as children from per day of moderate to vigorous physical activity
age 12 to 18 years old. For primary school-aged involving various aerobic activities. Vigorous
children, the large muscle groups should be physical activities and muscle and bone
subjected to a higher-intensity load for two to three strengthening activities should be incorporated at
days a week to improve strength and endurance, least 3 days per week (CSEP, 2021).
considering respective developmental stages.
(German Federal Ministry of Health, 2016) Children below 1 year old should be physically
active a few times a day in multiple ways. This can
Allow the infants aged 1 year old and younger the be done through supervised interactive floor-based
opportunities to be active in daily life by maximising play – the more, the better for at least 30 minutes of
floor-based tummy time for infants whenever they tummy time over the day while awake, including
are awake. Make sure they are active in various moving their arms and legs and reaching and
ways and moving freely as much as possible with grasping for objects and some activities such as
activities such as baby swimming, rhythmic crawling, pulling, and walking in some cases.
gymnastics for infants, tumbling play, rolling, Toddlers aged 1 to 2 years should get at least 3
hopping, and bouncing on a parent's lap. Provide hours of physical activity each day, including
children aged 1 to 4 years old the opportunities to energetic play. This could be achieved by running,
KM5 be physically active in various ways during the day twirling, jumping, dancing, and skipping.
and ensure they can move freely as much as Preschoolers ages 3 to 5 should be active for at least
possible. Plan the activities they are interested in, 3 hours daily. This should include 1 hour of energetic
such as crawling, hopping, jumping, and swinging. play, like running, kicking, throwing, and jumping.
Alternatively, playing indoor and outdoor activities Children and adolescents aged 5 to 17 should have
that are appropriate and safe such as walking, at least 60 minutes each day of moderate to vigorous
scooting, and cycling with a balanced cycle with a physical activity that makes the heart beat faster.
pedal. (Danish Health Authority, 2021). The longer the duration, the better. It is
recommended for children and adolescents to
Children aged 0 to 4 should not be encouraged to include muscle and bone strengthening activities 3
passively stay in one place for a long time. They days per week, like running, swinging, push up,
should be moving from one place to another and climbing, lifting, sitting up and yoga as part of their
doing something. Children aged 4 to 18 should 60 minutes of daily activity (Physical activity and
engage in moderate to vigorous intensity physical exercise guidelines for all Australians, 2021).
activity for at least one hour a day. They can engage
in any activities including muscle and bone 5.3.8 Physical activity recommendations for
strengthening, at least 3 days a week, such as specific groups
running, jumping or other activities where the body
supports its weight (Health Council of the a. Inactive children
Netherlands, 2017).
Physical inactivity is a strong contributor to being
For infants, directed exercises may incorporate overweight. Reducing sedentary behaviours to less
tummy time, coming to and getting a handle on, than two hours per day is important to increase
pushing, and pulling, and slithering. The quality of physical activity and health. An incremental
inactive conducts such as non-screen-based approach to the 60 minutes goal is recommended
practices (e.g., perusing, narrating, singing) are (WHO, 2020). Increasing activity by 10% per week
empowered. For infants less than 1 year old, appears to be acceptable and achievable.
variation of plays, particularly through interactive Attempting to achieve too much too rapidly is often
floor-based play or more, is better. Infants might be counterproductive and may lead to injury. Children
scheduled for tummy times if they are unable to should be regularly encouraged to be active and
walk yet and their parents are pressed for time. For explore at home, day care, and pre-school. The
children aged 1 to 2 years old, at least 180 minutes amount of time they are restrained from being active
spent in various physical activities at any intensity, should be minimised (NASPE, 2004).
including energetic play, spread throughout the day
132
b. Disabled children d. Overweight and obese children
Disabled children and adolescents lead to more For overweight and obese children, they are
restrictive lives, and they tend to face an increased encouraged to embark on various aerobic activities
risk of becoming unfit and obese, as well as anti- with moderate to vigorous intensity and duration
social behaviour and mental health problems. (Strong et al., 2005). Obese and overweight children
Disabled children should be encouraged to engage and adolescents should also engage in muscle and
in physical activity with other children in pre-school bone-strengthening activities three times a week
settings, local playgrounds, school and extended (CDC, 2008). Clinical practice guidelines for
school settings, holiday clubs, and sports and leisure managing overweight and obesity in adults,
centres. Many disabled children and those with adolescents and children in Australia and the Boston
complex health requirements have to be content Children’s Hospital indicated that overweight and
with frequent hospital visits, and play can increase obese children should perform at least 60 minutes
a child’s ability to cope with medical procedures of moderate physical activity daily.
and hasten recovery (NICE, 1997). For children with
intellectual disability problems, the World Health 5.3.9 Physical activity in children and
Organization (2020) states that physical activity can adolescents – the role of schools,
help in improving the child’s physical function. In families, and communities
addition, physical activity has also been found to
provide positive benefits to children with cognitive a. The role of the school
function problems, such as attention-
deficit/hyperactivity disorder (ADHD). Schools play a vital role in encouraging children and
adolescents to participate in physical activity, KM5
c. Asthma and other medical conditions supporting them to achieve their potential, and
creating healthy, active habits for life. Most children

Strong et al. (2005) have tabulated the effects of and adolescents spend more of their waking hours
physical activity for asthmatic children and in schools than in any other locations during the
adolescents who encouraged aerobic fitness with school term (WHO, 2007), providing the time and
various activities for 2 to 3 days/ week for at least 6 space for physical activity opportunities during
weeks and intensity according to the aerobic lesson time, including Physical Education lessons,
programmes. For hypertensive children/ break times, active travel to and from school and
adolescents, aerobic physical activity for at least 12 providing opportunities outside school (PHE, 2020).
to 32 weeks, 3 days/ week with 30 min/ session and In this context, schools help develop positive
intensity to improve aerobic fitness was found to physical activity habits by raising the awareness of
have a positive, beneficial effect on blood pressure the importance of regular physical activity and by
control. increasing the children’s exposure to enjoyable and
varied activities and creating more active
Exercise will benefit children with asthma if they environments for students to move more during
take their medication as prescribed and manage their day (PHE, 2020). Schools provide opportunities
their asthma well. This should help them feel more for students to be physically active, and one of these
confident about their condition (Asthma+ Lung UK). is recess time (CDC, 2017). Recess is known to be
The recommendations for physical activity for an important segment of an active school
children with asthma are the same as for other environment by offering physical activity to
children, with at least 60 minutes of moderate to students during the school day, in class and physical
high-intensity daily activities. To minimize education sessions (CDC, 2013). Recess is a period
symptoms, modifications to the activity or sport may that provides students with chances to engage in
be helpful such as refraining from running during physical activity and to take a break from academic
warm-ups, and the child can engage in shorter work during the day, and children should be
lengths of track and field, long jump, or high jump. encouraged to be physically active and engaged
Warm-up activities before exercise can help with their peers in activities of their choice (CDC,
minimize the likelihood of exercise-induced asthma 2017).
in those with the condition (American Thoracic
Society Subcommittee on Exercise-induced
Bronchoconstriction, 2013).
133
Schools are strategically placed to allow the most and other lessons can improve physical, educational
inactive students and the wider school community outcomes and emotional development (Norris et al.,
to become more active (PHE, 2020). Schools helped 2015). In supporting this notion, WHO advised
children make healthy choices about physical stakeholders to partner and support the
activity and were found to impact physical activity implementation and evaluation of effective
levels outside the school positively. More than 50% evidence-based quality physical education to
of students reported that the physical activity they encourage physical activity and prevent sedentary
performed at home was because of what they behaviour in school children, especially those who
learned in school (Ofsted, 2018). Ofsted further are least active and living in low-to-middle income
recommends that “schools should provide adequate countries (LMICs) (WHO, 2018).
opportunities for children to take physical exercise
during the school day with opportunities to ‘get out A high-quality physical education curriculum
of breath.” The positive impact spans the life course, motivates all students to thrive and succeed in
starting from early years up to school-age and competitive sports and other physically demanding
adolescence and throughout life (PHE, 2020). activities. It also offers students the opportunity to
become physically confident, which is useful in
Schools should offer various physical activity supporting their health and fitness (PHE, 2020).
opportunities, including free play, that can increase Quality physical education and supportive school
physical activity participation because choice and environments can convey physical and health
variety can cater to the needs of all students. literacy for lifelong healthy, active lifestyles,
Children and adolescents should be given the preventing non-communicable diseases (NCDs) and
chance to try out a range of different physical mental health disorders, and better academic
KM5 activities to help them identify those activities they outcomes (WHO, 2018). For example, the curriculum
can enjoy, and the variety could maintain their for physical education in England aims to ensure
interest and motivation (HM Government, 2016). that all students develop competence to excel in a
Focusing on games, the enjoyable elements of broad range of physical activities, are physically
participation and the more traditional games, sports active for sustained periods, engage in competitive
or competitive activities can promote participation, sports and activities and lead healthy, active lives
especially among inactive children and adolescents (England Department of Education, 2013).
(PHE, 2020). Schools should also include safe, Opportunities to participate in competitive sports
inclusive, and accessible indoor as well as outdoor and other activities also build character and aid in
venues for children to be physically active and to embedding positive values such as fairness and
reduce sedentary behaviour to create improved respect (PHE, 2020).
learning environments for all children (UNESCO,
2017). Safe opportunities, facilities and equipment School-based policy initiatives are an important
should be made available to all children and component of endeavours to create a more active
adolescents to encourage physical activity. Schools society. Physical activity programmes in schools
are urged to make their facilities available at should offer education and advice to increase
different times, including early morning, late awareness of the benefits of physical activity (PHE,
afternoon, evenings and during the holidays (PHE, 2020). Studies have shown that PA interventions
2020). Policymakers are also urged to support and and initiatives based in schools are becoming more
strengthen the policy of shared use of school popular as evidence of their health benefits
facilities with an aim to increase the availability of continues to increase worldwide (Shah et al., 2017).
fields and other public spaces for utilisation by the
nearby community (WHO, 2018). b. The role of the family
The World Health Organization (WHO) indicates Parents are gatekeepers to children’s activity and
that quality physical education and physical activity play a strong role in increasing their child’s physical
opportunities in schools promotes physical activity activity (Patrick et al., 2013; Davison et al., 2013).
participation. Physical activity programs invest in Parents can influence their child’s activity by being
better child development and educational active with them, role-modelling of active behaviour
outcomes, encouraging the attainment of the 4th and facilitating physical activity by providing
Sustainable Development Goal on ‘Quality encouragement and logistic support for their
Education’ (WHO, 2018). Physical activity can be children (Jago et al., 2010; Lindqvist et al., 2015;
embedded in the curriculum, teaching, and learning, Rhodes & Lim, 2017). A growing body of evidence
and expanding the amount of time spent being has shown that providing logistic support is
physically active during physical education sessions associated with increased physical activity and
134
could be the most important source of parental Motivational signs or point-of-decision prompts
influence on children’s physical activity (Solomon- placed near the stairs, escalators, or elevators can
Moore et al., 2018; Tate et al., 2015; Hennessy et al., encourage people to take the stairs (CPSTF, 2021).
2010). These signs can be strategically placed in different
settings, including those frequented by children and
Parents’ moderate-to-vigorous intensity physical adolescents, shopping malls, light rail transit, or train
activtiy (MVPA) level was positively associated with stations.
the child’s physical activity (Tate et al., 2015). Active
parents were more likely to facilitate their child’s Combined built environment approaches to
participation in various activities, specially increase physical activity create or modify
organised sports, and their children were less likely environmental characteristics in a community to
to be overweight and obese (Erkelenz et al., 2014). make physical activity easier or more accessible
Children were found to be more active with higher (Omura et al., 2020). For instance, pedestrian and
MVPA if both parents share and have equal roles in bicycle transportation system interventions as well
supporting their child’s activity (Solomon-Moore et as land use and environment design intervention are
al., 2018). Despite a weak positive relationship two components of effective built environment
between the level of parent and child physical interventions. Designs and connectivity of streets
activity regardless of the age of the child, sex of the and infrastructure and access for pedestrian, biking
parent or child and the type of physical activity and public transportation are parts of the
observed in a systematic review, parents still play transportation system interventions. Meanwhile,
important roles in influencing their children’s mixed land use, increased residential density,
physical activity by encouragement and support accessibility to various destinations, parks and
(Petersen et al., 2020). recreational facilities are parts of the land use and KM5
environment design interventions (CPSTF, 2016).
Physical activity parenting practices include Implementation of this community preventive

planning and leading family activities involving services task force (CPSTF) recommendation in
physical activity, enrolling children in organised communities could encourage active living, increase
physical activity, taking children to recreational physical activity, and eventually improve health
venues where children can be active, helping (Omura et al., 2020).
children acquire skills for physical activity and
providing physical activity-related equipment The implementation plan highlighted by the
(Davison et al., 2013). Research shows that parents’ National Strategic Plan for Active Living (NASPAL)
perceptions of physical activity, including being to promote active living among all Malaysians
more active, valuing and enjoying physical activity, includes: i) increasing the availability of resources
and perceiving that their child enjoys physical and facilities in the community to encourage
activity and is athletically competent, had higher physical activity and exercise in safe environments,
levels of positive physical activity parenting ii) local authorities providing billboards to encourage
practices (Dowda et al., 2011; Davison et al., 2013). physical activity at strategic sites, iii) organising
monthly “Car Free Campaigns” to create a
c. The role of the community supportive environment for physical activity, iv)
encouraging local authority to provide pedestrian
Environmental and policy approaches can be and cyclist with safe and accessible sidewalks,
applied to change the community’s physical walking paths and cycling paths, and v) providing
environment to provide opportunities and support parking space for bicycles in every station of public
to help the community be more active by making it transportation. (Ministry of Health Malaysia, 2018).
easier and safer (CPSTF, 2021). The improved built NASPAL also recommends introducing active
environment with enhanced land use design and transportation policies to provide safe and equitable
transportation system can make physical activity access to recreation and physical activity, ensuring
easier and more accessible. Policies, projects, or regular physical activity in kindergartens and
designs include street connectivity, sidewalks, schools and promoting “sport for all” to promote
bicycle lanes, infrastructure for public active living. These strategies would benefit
transportation, and access to parks and other Malaysians from all walks of life.
recreational facilities to support physical activity
participation. Access to places for physical activity The WHO promotes walking and biking to school
can be created or enhanced by developing walking programmes which include actions to improve
trails, building more physical activity facilities, or access by walking, cycling and public transport, and
providing access to existing exercise facilities. to intensify the promotion of walking, cycle training,
135
and teaching road safety skills to children of all ages Early childhood development and sleep have a
and abilities (WHO, 2018). The CPSTF also complex relationship. Because some children may
recommended interventions to increase active display worse developmental outcomes in the
travel to school based on the evidence that they setting of poor sleep and better outcomes in the
increase walking among students. Active travel context of sufficient sleep, Mindell and Moore (2018)
interventions will make it less challenging for advocated day-to-day functioning and skill
children and adolescents to travel to school actively development as better indicators of sleep
(e.g., walking or biking) by improving the physical development in early childhood. Added to that,
and social safety of common school routes or Seehagen et al. (2015) found that sleep in infants is
promoting safe pedestrian behaviours (CPSTF, important for consolidation of memory and language
2021). learning.
The community can organise community-wide Children who frequently get less sleep than is
campaigns about the benefits of being active, teach advised are more likely to struggle with behaviour
people how to change behaviours, and develop and learning issues as well as physical and mental
supportive social environments (Baker et al., 2015; health conditions such as obesity, diabetes,
CPSTF, 2021). Activities can be combined with depression, or injuries (Quist et al., 2016; Paruthi et
health education to build family support, increase al., 2016; Paavonen et al., 2009). Insufficient sleep in
children’s physical activity, and make community children and adults could impair mental and
design changes that support physical activity physical being, causing an alteration in cognitive
(CPSTF, 2021). Programmes tailored to a person’s functions or metabolic disorders, for example, an
interests and needs and teach skills like goal-setting increase in obesity and overweight, dysfunctional
KM5 and problem-solving help older children and eating behaviours, decreased physical activity, and
adolescents incorporate and maintain physical metabolic changes (Bonanno et al., 2019). According
activity in their lives (Baker et al., 2015). to a study by Leornado et al. (2018), getting the
recommended amount of sleep per night lowers the

5.3.10 Sleep, health, and wellbeing risk of elevated fasting blood sugar levels in boys,
and sleep issues are linked to lower HDL-c in girls
The biological process of sleep is homeostatically and higher triglyceride levels in boys. These findings
regulated, and it is universally perceived as a state highlight the clinical significance of improving sleep
of unconsciousness (Mukherjee et al., 2015). It is hygiene to lower metabolic risk factors in children
understood to be a condition that incorporates high and adolescents.
brain activity rather than just being in a resting state
(Carskadon & Dement, 2005). Sleep is essential to The amount of sleep a person needs changes with
human beings and involves both physiological and age, where children and adolescents require more
behavioural processes. Many psychological sleeping time than adults. During infancy, human
processes, such as immune system activity, body beings spend most of their time in the sleeping state
metabolism and hormonal balance, emotional and (Ednick et al., 2009). Sleep needs decrease from 12-
mental health, learning, and mnemonic processes, 16 hours of sleep per 24 hours (including naps) for
occur during sleep (Bonanno et al., 2019). To have infants aged 4-12 months to 8-10 hours for
healthy sleep, sufficient duration, appropriate timing, adolescents aged 13-18 (Paruthi et al., 2016).
a conducive environment free of disturbances and
disorders, and regularity are required. The term used The multidisciplinary expert panel of the United
to explain the recommendations intended to States National Sleep Foundation recommended 8
maximize the ability and opportunity for sleep is to 10 hours of sleep per day for adolescents upon
known as sleep hygiene (Ellis & Allen, 2019). consideration of scientific evidence based on all
components of health (Hirschkowitz et al., 2015).
Healthy sleep habits such as getting 1 to 4 naps, Short sleep duration among adolescents was
ranging from 30 minutes to 2 hours for infants (NLM, associated with adverse physical and mental health
2020), establishing a calming bedtime routine that outcomes and potentially led to decreased alertness,
is consistent and predictable (CPS, 2004) or turning poor health, depressed mood, obesity, automobile
off screen-based devices 30 minutes prior to accidents and poorer academic performance
bedtime (Bates et al., 2020) are some of the (Hirschkowitz et al., 2015; Chaput et al., 2016).
recommendations to improve sleep and maintain a Meanwhile, longer sleep duration was associated
regular sleep schedule. with lower adiposity indicators, better emotional
regulation, and better quality of life (Chaput et al.,
2016).
136
Data from across the world also indicate that Adolescents face many challenges with sleep, and
adolescents sleep too late or too little; showing its relevance is increasingly recognised. Poor sleep
similar patterns of sleep in the Western and Eastern among adolescents can result in longer-term sleep
societies with later sleep onset on weekdays and disturbances, which may affect them into adulthood
weekends as the adolescent age (Carskadon, 2011; (Dregan & Armstrong, 2010; Bruce et al., 2017). A
Gariepy et al., 2020; Ong et al., 2019). A systematic systematic review found that reduced sleep
review and analysis of adolescent sleep patterns and duration, sleep quality and problems are associated
problems showed that sleep length among with changes in social behaviour (including
adolescents across the world range from 7.4 to 8.4 aggression, anxiety, and depression) among children
hours, and Asian adolescents go to bed later, obtain and adolescents, which may contribute to later
less sleep and report higher rates of daytime illnesses in adulthood (da Silva et al., 2022).
sleepiness than adolescents from other regions
(Gradisar et al., 2011). A systematic review found Consistent bedtime and wake up times, along with
that later sleep time is generally associated with the required amount of sleep are associated with
poorer health outcomes, including poorer emotional better health outcomes, including enhanced focus,
regulation, lower academic achievement or behaviour, learning memory, emotional control and
cognitive function, poorer sleep quality, poorer mental as well as physical well-being. As a result,
eating behaviours, lower physical activity and more parents and other caregivers need to make sure that
sedentary behaviours, in children and adolescents infants, children, and adolescents get enough time
between 5 and 18 years old (Dutil et al., 2022). to sleep soundly. Public health messages about the
value of sleep patterns and sleep quality for children
and adolescents can be disseminated at the policy
level, and sleep promotion strategies be made KM5
accessible to the population.
137
5.4 Current Status
In Malaysia, several surveys have been conducted 43.0% of primary school children and 62.3% of
that evaluated its population’s physical activity level secondary school children were physically inactive.
and/ or physical activity pattern. A study among The prevalence of moderate to active individuals
children aged 4 to 6 years in 22 pre-schools in Kuala was higher among rural (46.4%) compared to urban
Lumpur found that 48.7% complied with physical (43.2%) children and among boys (54.1%) compared
activity guidelines (Lee et al., 2021). A study in to girls (35.2%). In 2022, National Health and
Kuantan found that 35.3% of adolescents aged 13 Morbidity Survey reported that 21.4% and 66.7% of
years old had low physical activity, while 61.5% had adolescents were active and in active, respectively
moderate and only 3.0% had high physical activity (IPH, 2022).
levels based on the Physical Activity Questionnaire
for Older Children (PAQ-C) (Dan et al., 2007). Among Several studies in Malaysia also reported sedentary
15 years old adolescents, about two-thirds (69.2%) and screen time among children. In a study by Lee
of the females had a low physical activity score, et al. (2021), only 25.2% of children aged 4 to 6 years
whereas almost half of the males (44.8%) had a low met the screen time recommendation that is not
physical activity score, and the overall prevalence of more than two hours a day. Among children aged
low physical activity was (59.7%) (Ng et al., 2019). four-to-six years in Kuantan Pahang, 89.8% of them
recorded more than two hours a day of total screen
A result of the study by using the number of steps time duration ((Mohd Shukri et al., 2020). Among
as an indicator of physical activity showed that Malaysian children aged 7 to 12, approximately
among children aged 7 to 12 years, only 15.2% of 68.4% of the primary school children did not meet
KM5 them (14.9% boys; 15.6% girls) met the the screen time recommendation (Lee et al., 2016).
recommended daily step counts (boys:13000 steps; Another study in Kelantan reported that adolescents
girls: 11000 steps). Another study using pedometers aged 12-19 years spent, on average, 3.5 hours a day
among children and adolescents aged between 9 to on screen-based sedentary behaviours (Teo et al.,
18 years old in urban Selangor found that among 9 2014).
to 12 years old children, only 43% of males and 34%
of females meeting the international guidelines for The GSHS 2012 study revealed that 52.7% of
the minimum number of steps/day (males 15,000; Malaysian children and adolescents spent two
females 12,000); while in the older age group (13 to hours or less per day doing sitting activities, which
18 years), only 12% females and 55% males achieved included sitting and watching television, playing
the ‘expected minimum steps/ day’ (males 12,000; computer games, and talking with friends. The latest
females 10,000) (Wilson, 2008). nationwide study in Malaysia showed that 53.6
adolescents watched television, used computers,
There were several nationwide school-based and played video games for less than 2 hours per
surveys conducted in Malaysia. Findings from the day over the weekend. About 69.8% of adolescents
Malaysian School-Based Nutrition Survey 2012 in school engaged in these activities for less than 2
showed that 42.7% of Malaysian school children hours per day (IPH,2018).
aged 10 to 17 years were inactive (Baharudin et al.,
2014), and MyBreakfast Study 2013 showed that Given the low levels of physical activity among
34.8% of children and adolescents aged 6-17 years Malaysians in general, particularly among children
were categorized as having low physical activity and adolescents, it is therefore important to include
levels (Appukutty et al., 2015). The nationwide and highlight physical activity in the Malaysian
school-based surveys were conducted in 2017 Dietary Guidelines (MDG) (Figure 5.1) for children
involving 10-17 years school children. The NHMS and adolescents as a measure to promote physical
study among children and adolescents reported that activity amongst our young population.
138
LIMIT
Limit Physical
Inactivity & Sedentary
Behavior
Example : Watching TV,
Playing video game,
Surfing internet,
Playing computer
3 TIMES IN A WEEK
Participate at least 3 times in a week in activities.
That increase muscle and bone strength
Muscle:
KM5
Climbing trees/ walls,Resistance band, Playing on monkey bars
Bone:
Running, Jumping jack, Jump rope, Hopscotch

60 MINUTES DAILY
Accumulate at least 60 minutes of moderate-to-vigorous intensity
Physical Activity Daily
Playing actively outdoors, running and chasing,

cycling, swimming, football, badminton
EVERYDAY
Be active everyday in as many ways as you can
Walking, climbing stairs, be active during PE class, doing household chores
Note:
Adequate sleep for optimal health and well-being.
Uninterrupted 9-11 hours of sleep every night for those aged 5-13 years and 8-10 hours every night for those aged 14-17 years
with consistent bed wake-up times
Figure 5.1: Physical activity pyramid for children and adolescents. Adapted from NCCFN (2013)
139
Key Recommendation (KR) 1: Be active every day in as many ways as you can.
General Parents/ Caregiver Health Professional


For children and adolescents Try to incorporate more physical Advise parents and caregivers
(5 to 17 years), accumulate a activities in daily life, as a form how to encourage children to
minimum of 60 minutes of of exercise every day. be active every day as many
moderate-to-vigorous intensity as they can.
physical activities daily.

Do these activities whenever Try not to restrict children from Encourage the involvement of
possible for children and being naturally active. parents and family members
adolescents to be more active. to help children be more
active.
KM5 a. Walk or cycle to the school.
b. Engage in some physical

activity during school and

recess.
c. Participate actively during

physical education classes.
d. Help with household chores

such as sweeping and
mopping the floor.
e. Walk up the stairs, instead

of taking the lift or escalator.
f. Take a walk or engage in

outdoor activities with family
or friends.
- KR1: HTA3: -
Allow infants (less than 1 year) to
be physically active several times
a day in as many ways as
possible, especially through
supervised interactive floor-
based activities/ play (e.g.,
tummy time).
- KR1: HTA4: -
Encourage toddlers (aged 1 to 3
years) to move often once the
toddler is walking.
140
Key Recommendation (KR) 1: Be active every day in as many ways as you can. (cont.)

- KR1: HTA5: -
Spend more time looking for
activities that encourage toddlers
to move (e.g., climbing a slide at
the playground).
- KR1: HTA6: -
Encourage pre-schoolers
(aged 3 to 4 years) to spend at
least 180 minutes in a variety of
types of physical activity in safe,
and different environments.
- KR1: HTA7: -
Emphasise fun and enjoyment,
KM5
over winning and competition
when conducting structured
sports programmes for children

and adolescents.
141
Key Recommendation (KR) 2: For toddlers, pre-schoolers, children, and adolescents 3-17 years
old, achieve at least 60 minutes of moderate-to-vigorous intensity physical activity daily.
General Parents/ Caregiver/

Health Professional
(to children and adolescents) Teacher

Accumulate a minimum of 60 Encourage pre-schoolers (aged Advise parents and caregivers
minutes of moderate-to-vigorous 3 to 4 years) to participate in to encourage moderate-to-
intensity physical activities daily moderate-to-vigorous intensity vigorous intensity physical
as part of transportation physical activity, such as active activity for their children.
(travelling from one place to play and walking.
another), physical education,
sport, free play, and planned
exercises.

Activities should be diverse Allow them to help with Provide examples of physical
according to level of physical household chores like sweeping activity that is developmentally
development and enjoyable and putting away their toys. appropriate and enjoyable.
KM5 based on physical activity needs,
benefits, and characteristics.

For children who are not Encourage children and Encourage the involvement of
physically active, gradually adolescents (aged 5 to 17 years) parents and family members
increase the duration and to engage in moderate-intensity in moderate-to-vigorous
frequency of physical activity to aerobic physical activity, such as intensity physical activity to
achieve at least 60 minutes riding a bicycle and brisk walking. help children be more active
daily. (refer physical activity
in appendices).
- KR2: HTA4: -
Accompany children for longer
walks, visits to recreational parks
or swimming pools and bike
rides during leisure time.
142
Key Recommendation (KR) 3: For children and adolescents (5-17 years), participate at least 3
times a week, in activities that increase muscle and bone strength.

Health Professional

Incorporate muscle and bone Encourage and supervise the Encourage parents and
strength training or activities that activities that enhance the caregivers to take part and
make muscles work harder than muscles and bones. supervise the activities based
usual as part of 60 minutes daily on the limit and ability of their
physical activities at least 3 days children.
a week (sport, free play, and
planned exercises).

Utilising the playground Ensure that the activities and Advise the activities that are
equipment such as monkey bar, exercises are based on the limit appropriate for the children's
wall climbing and exercise and abilities of their children. age, ensuring it is safe,
facilities are some examples of enjoyable and has variety
muscle-strengthening activities (Refer Table 5.2: Examples of KM5
that can be unstructured, fun, physical activity for children
and enjoyable. and adolescent a day in

appendices).

Children as early as 7-8 years Encourage children and
can include weightlifting or adolescents (aged 5 to 17 years)
resistance band work as part of to engage in activities that
their strength training. strengthen the muscles and
bones for at least 3 days in a
week.

Participate in activities such as Encourage traditional games and
climbing and skipping. fitness activities that require
participants to run fast, jump high,
change direction, and maintain
balance.

Enjoy every activity and increase Design a simple progressive
time spent in physical activity activity or training that
involving muscle mass and involves hopping, jumping,
bone strength. kicking, skipping, and running.
KR3: HTA6: - -
Primary school children and
adolescents (7-17 years old)
are encouraged to take part in
supervised strength and
resistance training programmes.
143
Key Recommendation (KR) 4: Limit physical inactivity and sedentary behaviors

Health Professional
KR4: HTA1: KR4: HT1: KR4: HTA1:

Children and adolescents Monitor children’s screen time Communicate and advise
(5-17 years) should be and sedentary behaviors. parents and caregivers to
discouraged from extended monitor their child’s physical
periods of sedentary time. activity, screen time and
sedentary behaviors.

Children and adolescents Encourage children to replace Advise the activities that are
(5-17 years) should limit sedentary activities with activities appropriate for the children's
recreational screen time (not that involve active movement age, ensuring it is safe,
including educational activities) and play. enjoyable and has variety
for example playing video (Refer Table 5.2: Examples of
games and surfing the internet. physical activity for children
and adolescent a day in
KM5
appendices).
- KR4: HTA3: -
Infants (less than 1 year) and

children 1-year-old do not need
screen time but avoid being
restrained for more than an hour
at a time.
- KR4: HTA4: -
Children aged 2-4 years old
should avoid being restrained for
more than an hour at a time and
limit sedentary screen time no
more than 1 hour per day.
- KR4: HTA5: -
If children are into electronic
games, encourage them to play
active video games (e.g.
basketball video exergames).
- KR4: HTA6: -
Encourage children to play
actively (e.g., jogging, futsal, and
table tennis) as much as
possible.
- KR4: HTA7: -
Increase accessibility of
equipment (e.g., racket and ball),
space (gym, playground, and
futsal court) and time (specific
time on weekend or weekdays)
for children and adolescents to
participate in active activities.
144
Key Recommendation (KR) 5: Have adequate amounts of sleep for optimal health and wellbeing.

Health Professional

Ensure infants, children and Monitor and observe children's Educate parents/ parents
adolescents have sufficient sleeping behaviour. to be, creche, preschool
time of good quality sleep as operators, and teachers on
recommended in Table 5.1. sleep importance and ways
to achieve them.
- KR5: HTA2: -
Learn to recognise the sign of sleep
readiness of babies (e.g., rubbing eyes,
yawning, looking away or fussing).
- KR5: HTA3: -
Establish a calming, consistent and
predictable bedtime routine (e.g:
KM5
having a bath, changing into night
clothes and a fresh nappy, or a good
swaddle).

- KR5: HTA4: -
Provide a calm (e.g., dimmed light,
quiet room, suitable temperature, and
good ventilation) and safe environment.
- KR5: HTA5: -
Place the infants on his or her back on
a firm, flat surface in a child’s own crib.
- KR5: HTA6: -
Establish a nap routine for infants (up
to one year) ranging from 1 to 4 naps
about 30 minutes to 2 hours daily.
- KR5: HTA7: -
Read a soothing bedtime story or
recite zikir or prayers for Muslim.
- KR5: HTA8: -
Screen-based devices should not be
allowed in children’s bedrooms and
should be turned off 30 minutes before
bedtime.
- KR5: HTA9: -
Encourage mindfulness practices for
children and adolescents (e.g., setting
aside 10-30 minutes for quiet talk with
parents or families, quiet play or
reading).
145
Table 5.1: Sleep behaviour recommendation in 24-hour by age for infants, children and adolescents.
Age Sleep behaviour recommendation in 24-hour day
0-3 months 14-17 hours of good quality sleep including naps.

4-11 months 12-16 hours of good quality sleep including naps.
1-2 years 11-14 hours of good quality sleep including naps, with regular sleep and wake-up times.
3-4 years 10-13 hours of good quality sleep including naps, with regular sleep and wake-up times.
5-13 years 9-11 hours of uninterrupted sleep per night, with consistent bed and wake-up times.
14-17 years 8-10 hours of uninterrupted sleep per night, with consistent bed and wake up times.
Sources: WHO (2019) for ages below 5 years & CSEP (2021) for 5-17 years.
5.5.1 Additional Recommendations
5.5.1.1 Children who are inactive as lack of access, transportation, and information.
Many physical activities can be adapted so that
Children who are inactive should be regularly everyone can participate. For example, sports that
encouraged to be active. To achieve the goal of 60 can be played in a wheelchair include tennis,
KM5 minutes per day of moderate-intensity physical basketball, track, dance, riding horses or swimming.
activity, an incremental approach is recommended. Children with special needs require adaptation and
Increasing physical activity by 10% per week is an extra support to perform physical activity. Consult
achievable target. Young children, on the other hand, with a medical doctor or health professionals before
should be encouraged to explore their environment starting an exercise routine with your child, to
to stay active. understand the risk (if any) and to be familiar with
proper safety precautions.
5.5.1.2 Children living with physical
disability Children with asthma can and should be physically
active. Parents and school teachers should
The recommendations of 60 minutes per day of encourage children with asthma to participate in
moderate- to vigorous intensity per day and 3 days physical activity. It is important for each child with
a week of strengthening muscle and bone activity asthma to recognise his own asthma triggers (e.g.,
is applicable for all children aged 5-17 years old. dust, chemical sprays, heavy exercise) and to avoid
Time spent being sedentary should be limited and or control these triggers. An asthma management
monitored, especially the amount of recreational plan should be developed for each child by the child
screen time. Health conditions such as multiple himself, parent/ guardian, and health care provider.
sclerosis, intellectual disability, Parkinson’s disease, Lastly, the child should have convenient access to
spinal cord injury, stroke, depression, schizophrenia, asthma medications.
and attention-deficit/hyperactivity disorder (ADHD)
could affect the ability of individuals to perform Children who are overweight or obese should
physical activity. Children living with physical embark on a physical activity program which
disabilities including children with special needs comprise of moderate to vigorous-intensity physical
should be encouraged to play and be involved in activity. Barriers to physical activity should be
physical activity wherever possible following their considered and programmes can be designed to
own abilities. This includes settings such as at help children create realistic goals (e.g., exercise for
community playgrounds, preschools, and schools. 10 minutes) that they can build on over time (e.g.,
Parents and teachers should help the child identify increase to 15 minutes).
ways to overcome barriers to physical activity, such
146
5.6 References
Ainsworth, B.E., Haskell, W.L., Meckes, N, Bassett, D.R., Tudor-Locke, C., Greer, J.L., Vezina, J., Whitt-Glover.
M.C., & Leon, A.S. (2011). Compendium of physical activities: A second update of codes and MET
values. Medicine and Science in Sports & Exercise 43 (8): 1575-1581.
American Thoracic Society Subcommittee on Exercise-induced Bronchoconstriction (2013). An official

American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J
Respir Crit Care Med. May 1;187(9):1016-27.
Appukutty, M., Tee, E.S., Mohd Nasir, M.T., et al. (2015). Breakfast intake, body weight status and association
with physical activity level. Symposium on MyBreakfast Study of School Children: Findings,
Implications & Solutions – Programme & Abstracts. 2015;21.
Arundell, L., Fletcher, E., Salmon, J., Veitch, J., & Hinkley, T. (2016). A systematic review of the prevalence of
sedentary behaviour during the after-school period among children aged 5–18 years. International
Journal of Behavioural Medicine 13(93).
Asthma + Lung UK. Asthma facts and statistics [Online]. Available at:
https://www.asthma.org.uk/about/media/facts-and-statistics (Accessed on 14 December 2021)
Bacha, F., & Gidding, S.S. (2016). Cardiac abnormalities in youth with obesity and type 2 diabetes. Current
Diabetes Report 16(7):62. KM5
Baharudin, A., Zainuddin, A.A., Manickam, M.A., et al. (2014). Factors associated with physical inactivity

among school-going adolescents: data from the Malaysian School-Based Nutrition Survey 2012. Asia
Pacific Journal of Public Health 26(5): 27S-35S.
Baker, P.R.A., Francis, D.P., Soares, J., Weightman, A.L., & Foster, C. (2015). Community wide interventions
for increasing physical activity. Cochrane Database of Systematic Reviews: issue 1. Art. No.:
CD008366.
Bates, L. C., Zieff, G., Stanford, K., Moore, J. B., Kerr, Z. Y., Hanson, E. D., Barone Gibbs, B., Kline, C. E., & Stoner,
L. (2020). Covid-19 Impact on Behaviours across the 24-Hour Day in Children and Adolescents:
Physical Activity, Sedentary Behaviour, and Sleep. Children 7(9):138.
Bennie, J. A. (2020). Muscle-strengthening Exercise Epidemiology: A New Frontier in Chronic Disease

Prevention. Sport Medicine. https://doi.org/10.1186%2Fs40798-020-00271-w
Biddle, S.J., Pearson, N., Ross, G.M., & Braithwaite, R. (2010). Tracking of sedentary behaviours of young
people: A systematic review. Preventive Medicine (51): 345–351.
Bidzan-Bluma, I., & Lipowska, M. (2018). Physical Activity and Cognitive Functioning of Children: A
Systematic Review. Int J Environ Res Public Health. 19;15(4):800.
Bonanno, L., Metro, D., Papa, M., Finzi, G., Maviglia, A., Sottile, F., Corallo, F., & Manasseri, L. (2019).
Assessment of sleep and obesity in adults and children: Observational study. Medicine (Baltimore).
Nov; 98(46): e17642.
Brown, T., Moore, T.H., Hooper, L., Gao, Y., Zayegh, A., Ijaz, S., Elwenspoek, M., Foxen, S.C., Magee, L,
O'Malley, C., Waters, E., & Summerbell, C.D. (2019). Interventions for preventing obesity in children.
Cochrane Database Systematic Review 23;7(7):CD001871.
Bruce, E.S., Lunt, L., & McDonagh, J.E. (2017). Sleep in adolescents and young adults. Clinical Medicine
(London) 17(5), 424–428.
147
Carskadon, M.A., & Dement, W.C. (2005). Normal human sleep: an overview. Principles and practice of sleep
medicine. (4th ed.). Kryger MH, Roth T, Dement WC eds. Elsevier Saunders: Philadelphia 13–23.
Carskadon, M.A. (2011). Sleep in adolescents: the perfect storm. Pediatric Clinics of North America 58(3),
637–647.
Carson, K.V., Chandratilleke, M.G., Picot, J., Brinn, M.P., Esterman, A.J., & Smith, B.J. (2013). Physical training
for asthma. Cochrane Database Systematic Review Sep 30:(9).
Caspersen, C.J., Powell,K.E., & Christenson, G.M. (1985). Physical activity, exercise and physical fitness:
Definition and distinctions for health-related research. Public Health Reports 100 (2): 126-131.
Cech, D.J., Suzanne, P.C.S., & Martin. T. (2012). Motor Development in Functional Movement Development
Across the Life Span (Third Edition) Pg. 45-67. Elsevier Inc. https://doi.org/10.1016/B978-1-4160-
4978-4.00003-X
Chaput, J., Gray, C.E., Poitras, V.J., et al. (2016). Systematic review of the relationships between sleep duration
and health indicators in school-aged children and youth. Applied Physiology, Nutrition, and
Metabolism 41, 6 (Suppl. 3): S266-S282.
Choi, K.W., Chen, C., Stein, M.B., et al. (2019). Assessment of Bidirectional Relationships Between Physical
Activity and Depression Among Adults: A 2-Sample Mendelian Randomization Study. JAMA
KM5 Psychiatry 76(4):399–408.
CPSTF (2021). What Works – Increasing Physical Activity. Community Preventive Services Task Force
[Online] Available at:

https://www.thecommunityguide.org/sites/default/files/assets/What-Works-Factsheet-
PhysicalActivity.pdf (Accessed on 13 January 2022).
CPSTF (2016). Physical activity: built environment approaches combining transportation system
interventions with land use and environmental design. Community Preventive Services Task Force
[Online] Available at: https://www.thecommunityguide.org/findings/physical-activity-built-
environment-approaches (Accessed on 13 February 2022).
CDC (2017). Strategies for Recess in Schools. Centers for Disease Control and Prevention and SHAPE
America—Society of Health and Physical Educators, US Dept of Health and Human Services, Atlanta.
Cote, A.T., Harris, K.C., Panagiotopoulos. C, et al. (2013). Childhood obesity and cardiovascular dysfunction.
Journal of the American College of Cardiology 62(15):1309–1319.
Cotman, C.W., & Berchtold, N.C. (2002). Exercise: A behavioural intervention to enhance brain health and
plasticity. Trends in Neurosciences 25: 295-301.
Counil, F.P., Varray, A., Matecki, S., Beurey, A., Marchal, P., & Voisin, M. (2003). Training of aerobic and
anaerobic fitness in children with asthma. Journal of Pediatrics 142: 179-184.
CPS (2004) Canadian Paediatric Society. Creating a Safe Sleep Environment for Your Baby. Paediatrics &
Child Health 9(9): 665-674.
CSEP (2021). Canadian 24-hour movement guidelines for the children and youth (5-17 years): An integration
of physical activity, sedentary behaviour, and sleep. Canadian Society for Exercise Physiology
[Online] Available at: https://csepguidelines.ca/guidelines/children-youth/ (Accessed on 13
December 2021)
Dan, S.P., Mohd Nasir, M.T., & Zalilah, M.S. (2007). Sex and ethnic differences in physical activity levels of
adolescents in Kuantan. Malaysian Journal of Nutrition. 13 (2): 109-120.
148
Danish Health Authority (2021). Recommendations for physical activity: Children 1-4 years old. [Online].
Available at: https://www.sst.dk/-/media/English/Publications/2021/Prevention-Physical-
activity/Onepager-physical_activity_1-4_years_old.ashx (Accessed on 12 January 2022).
Danish Health Authority (2021). Recommendations for physical activity: Infants younger than 1 year old.
Online]. Available at: https://www.sst.dk/-/media/English/Publications/2021/Prevention-Physical-
activity/Onepager-physical_activity_0-1_years_old.ashx . (Accessed on 12 January 2022).
da Silva, A.C., do Carmo, A.S., & dos Santos, L.C. (2022). Associations between sleep practices and social
behavior of children and adolescents: a systematic review. J Public Health (Berl.) 30, 1101–1112.
DHHS (2008). Physical activity guidelines for Americans. US Department of Health and Human Services
[Online] Available at: https://health.gov/sites/default/files/2019-09/paguide.pdf (Accessed 8 March
2012).
DHHS (2019). Physical Activity Guidelines for Americans, 2nd edition, 2018. U.S. Department of Health and
Human Service [Online]. Available at: https://health.gov/sites/default/files/2019-
09/Physical_Activity_Guidelines_2nd_edition.pdf (Accessed on 12 January 2022).
Davison, K.K., Mâsse, L.C., Timperio, A., et al. (2013). Physical activity parenting measurement and research:
challenges, explanations, and solutions. Department for Education. National curriculum in England;
physical education programmes of study. Childhood Obesity 2013(9):S-103–9.
KM5
Donnelly, J.E., Hillman, C.H., Castelli, D., Etnier, J.L., Lee, S., Tomporowski, P., Lambourne, K., & Szabo-Reed,
A.N. (2016). Physical Activity, Fitness, Cognitive Function, and Academic Achievement in Children:

A Systematic Review. Medicine & Science in Sports & Exercise 48(6):1197-222.
Dowda, M., Pfeiffer, K.A., Brown, W.H., Mitchell, J.A., Byun, W., & Pate, R.R. (2011). Parental and
environmental correlates of physical activity of children attending preschool. Archives of Pediatric
and Adolescent Medicine 165(10):939-44.
Dregan, A., & Armstrong, D. (2010). Adolescence sleep disturbances as predictors of adulthood sleep
disturbances—a cohort study. J Adolesc Health 46: 482-487.
Dutil, C., Podinic, I., Sadler, C.M., et al. (2022). Sleep timing and health indicators in children and adolescents:
a systematic review. Health Promot Chronic Dis Prev Can 42(4):150-169.
Dwyer, T., Sallis, J.F., Blizzard, L., et al. (2011). Relation of academic performance to physical activity and
fitness in children. Pediatric Exercise Science 13: 225–237.
Ednick, M., Cohen, A.P., McPhail, G.L., Beebe, D., Simakajornboon, N., & Amin. R.S. (2009). A review of the
effects of sleep during the first year of life on cognitive, psychomotor, and temperament development.
Sleep 32(11):1449–1458.
Ellis, J. G. & Allen, S. F. (2019). Sleep Hygiene and the Prevention of Chronic Insomnia. Sleep and Health:
137-145.
England Department of Education (2013). National curriculum in England: physical education programmes
of study. [Online] Accessed on 15 November 2021. Available
at:https://www.gov.uk/government/publications/national-curriculum-in-england-physical-
education-programmes-of-study/national-curriculum-in-england-physical-education-programmes-
of-study (Accessed on 13 December 2021)
Erkelenz, N., Kobel, S., Kettner, S et al. (2014). Parental activity as influence on children’s BMI percentiles
and physical activity. Journal of Sports Science and Medicine 13: 645-650.
149
García Hermoso, A., Saavedra, J.M., Escalante, Y., Sánchez López, M., & Martínez Vizcaíno V (2014).
Endocrinology and Adolescence: aerobic exercise reduces insulin resistance markers in obese youth:
a metaanalysis of randomized controlled trials. European Journal of Endocrinology 171:R16371.
García-Hermoso, A, Ramírez-Vélez, R., García-Alonso, Y., Alonso-Martínez, A.M., Izquierdo, M. (2020).

Association of Cardiorespiratory Fitness Levels During Youth with Health Risk
Later in Life: A Systematic Review and Meta-analysis. JAMA Pediatr. 2020 Oct1;174(10):952-960.
Gariepy, G., Danna, S., Gobina, I., et al. (2020). How are adolescents sleeping? Adolescent sleep patterns
and sociodemographic differences in 24 European and North American countries. J. Adolesc. Health
66, S81–S88.
German Federal Ministry of Health (2016) National Recommendations for Physical Activity and Physical
Activity Promotion [Online] Available at: https://www.sport.fau.de/files/2015/05/National-
Recommendations-for-Physical-Activity-and-Physical-Activity-Promotion.pdf (Accessed on 12
January 2022).
Gradisar, M., Gardner, G., & Dohnt, H. (2011). Recent worldwide sleep patterns and problems during
adolescence: A review and meta-analysis of age, region, and sleep. Sleep Medicine Vol 12 (2): 110-
118.
KM5 Hamzaid, H., Talib, R.A., Azizi, N.H., Maamor, N., Reilly, J.J., & Wafa, S.W. (2011). Quality of life of obese
children in Malaysia. International Journal of Pediatric Obesity 6 (5-6):450-4.
Han, G.S. (2018). The relationship between physical fitness and academic achievement among adolescents
in South Korea. Journal of Physical Therapy Science 30(4):605-608.
Health Council of the Netherlands (2017). Dutch Physical Activity Guidelines 2017. The Hague: Health
Council of the Netherlands Publication no. 2018/08e. [Online]. Available at
h t t p s : / / w w w. g e z o n d h e i d s r a a d . n l / s i t e s / d e f a u l t / fi l e s / g r p u b l i c a t i o n /
physical_activity_guidelines_2017_0.pdf. (Accessed on 12 January 2022).
Hennessy, E., Hughes, S.O., Goldberg, J.P., et al. (2010). Parent-child interactions and objectively measured
child physical activity: a cross-sectional study. International Journal of Behavioural Nutrition and
Physical Activity 7:71-xx.
Hirshkowitz, M., Whiton, K., Albert, S.M., et al. (2015). National Sleep Foundation’s updated sleep duration
recommendations: final report, Sleep Health 1(4): 233-24.
HM Government United Kingdom (2016). Childhood Obesity, A Plan for Action. [Online] Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/
546588/Childhood_obesity_2016__2__acc.pdf (Accessed on 13 January 2022)
IPH (2018). National Health and Morbidity Survey (NHMS) 2017. (NMRR-16-698-30042). Adolescent Health
and Nutrition Survey; Infographic Booklet. Institute for Public Health Malaysia, Ministry of Health,
Putrajaya.
IPH (2020). National Health and Morbidity Survey (NHMS) 2019. Institute for Public Health Malaysia:
Ministry of Health, Putrajaya.
Jago, R., Baranowski, T., Baranowski, J.C., Thompson, D., & Greaves, K.A. (2005). BMI from 3-6 years of age
is predicted by TV viewing and physical activity, not diet. International Journal of Obesity 29 (6): 557-
564.
Jago, R., Fox, K.R., Page, A.S., et al. (2010). Parent and child physical activity and sedentary time: do active
parents foster active children? BMC Public Health 10:194.
150
Janssen, I., & Leblanc, A. (2009). Systematic review of the health benefits of physical activity in school-aged
children and youth. International Journal of Behavioural Nutrition and Physical Activity 7: 40.
Janssen, I., & Leblanc, A.G. (2010). Systematic review of the health benefits of physical activity and fitness
in school-aged children and youth. International Journal of Behavioral Nutrition and Physical Activity
7:40.
Kelley, G.A., & Kelley, K.S. (2007). Aerobic exercise and lipids and lipoproteins in children and adolescents:
a meta analysis of randomized controlled trials. Atherosclerosis 191:44753.
Kelley, G. A., Kelley, K. S., & Pate, R. R. (2019). Exercise and adiposity in overweight and obese children and
adolescents: a systematic review with network meta-analysis of randomised trials. BMJ open 9 (11)
e031220
Knight, Noelle A. (2015). Effects of a before school physical activity program on physical activity,
musculoskeletal fitness, and cognitive function (Master's Thesis, East Carolina University).
Kyu, H.H., Bachman, V.F., Alexander, L.T., Mumford, J.E., Afshin, A., Estep, K, Veerman, J.L., Delwiche, K.,
Iannarone, M.L., Moyer, M.L., Cercy, K., Vos, T., Murray, C.J., & Forouzanfar, M.H. (2016). Physical
activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke
events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study
2013. BMJ 9 (354): i3857
KM5
Lee, S.T., Wong, J.E., Nik Shanita S, Ismail, M.N., Deurenberg, P., & Poh, B.K. (2015). Daily physical activity
and screen time, but not other sedentary activities, are associated with measures of obesity during

childhood. International Journal of Environmental Research and Public Health 12:146-161.
Lee, S.T.;Wong, J.E.; Chan, G.K.L., & Poh, B.K. (2021). Association between Compliance with Movement
Behavior Guidelines and Obesity among Malaysian Preschoolers. International Journal of
Environmental Research and Public Health 18: 4611-xxx.
Leornado, P.A., Jorge Enrique, C.B., Cesar, A.S., Jorge, M., Rute, S, María, C.R., Antonio, G.H., & Ramírez, V.
(2018). Role of sleep duration and sleep-related problems in the metabolic syndrome among children
and adolescents. Italian Journal of Paediatrician 44(1).
Lindqvist, A., Kostenius, C., Gard, G., et al. (2015). Parenting participation plays an important part in
promoting physical activity. International Journal of Qualitative Studies on Health and Well-being
10: 27397.
Lloyd. L.J., Langley-Evans, S.C., McMullen, S. (2012). Childhood obesity and risk of adult metabolic
syndrome: a systematic review. International Journal of Obesity 36(1):1–11
MacIntosh, B.R., Murias, J.M., Keir, D.A., & Weir, J.M. (2021). What Is Moderate to Vigorous Exercise
Intensity?. Front. Physiol. 12:682233. doi: 10.3389/fphys.2021.682233
Marker, A.M., Steele, R.G., & Noser, A.E. (2018). Physical activity and health-related quality of life in children
and adolescents: A systematic review and meta-analysis. Health Psychology 37(10):893-903.
Marson, E.C., Delevatti, R.S., Prado, A.K., Netto, N.& Kruel, L.F. (2016). Effects of aerobic, resistance, and
combined exercise training on insulin resistance markers in overweight or obese children and
adolescents: a systematic review and meta analysis. Preventive Medicine 93:2118
Mindell, J.A., & Moore M. (2018). Does Sleep Matter? Impact on Development and Functioning in Infants.
Pediatrics, 142(6), e20182589. https://doi.org/10.1542/peds.2018-2589
MOH (2018). National Strategic Plan for Active Living (NASPAL) 2017-2025, Ministry of Health Malaysia,
Putrajaya.
151
Mohanan, S., Tapp, H., McWilliams, A., & Dulin, M. (2014). Obesity and asthma: pathophysiology and
implications for diagnosis and management in primary care. Experimental Biology and Medicine 239
(11):1531–40.
Mohd-Sidik, S., Lekhraj, R., & Foo, C.N. (2021). Prevalence, Associated Factors and Psychological
Determinants of Obesity among Adults in Selangor, Malaysia. International Journal of Environmental
Research and Public Health 18(3): 868.
Mohd Shukri, N. A., Mustafa, N., Rusali, R., A. Ramos, A., & Ghazali, J (2020). The Gadget Generation: Body
Mass Index and Duration Of Physical Activity And Screen-Viewing Among Preschoolers In Kuantan,
Pahang. Malaysian Journal of Public Health Medicine 20(2): 116-122.
Morrison, K.M., Shin, S., Tarnopolsky, M., et al. (2015). Association of depression and health related quality
of life with body composition in children and youth with obesity. Journal of Affective Disorders
172:18–23.
Mukherjee, S., Patel, S.R., Kales, S.N., Ayas, N.T., Strohl, K.P., Gozal, D., & Malhotra, A. (2015). An Official
American Thoracic Society Statement: The importance of healthy sleep: Recommendation and future
priorities. The American Thoracic Society Ad Hoc Committee on Healthy Sleep. Am J Respir Crit
Care Med Jun 15;191(12):1450-8.
Narang, I., Mathew, J.L. (2012). Childhood obesity and obstructive sleep apnea. Journal of Nutrition and
KM5 Metabolism 134202. doi: 10.1155/2012/134202. Epub 2012 Aug 22.
NASPE (2002). Active Start: A statement of physical activity guidelines for children birth to five years.
National Association for Sport and Physical Education pp. 17-18.
NASPE (2004). Physical activity for children: a statement of guidelines. (2nd ed.). National Association for
Sport and Physical Education. Reston, Virginia.
NCCFN (2013). Malaysian Dietary Guidelines for Children and Adolescents 2013, National Coordinating
Ng, A.K., Hairi, N.N., Jalaludin, M.Y., et al.(2019). Dietary intake, physical activity and muscle strength among
adolescents: the Malaysian Health and Adolescents Longitudinal Research Team (MyHeART) study.
BMJ Open 9:e026275.
NICE (1997) (National Institute for Health and Clinical Excellence). Guidelines for promoting physical
activity with people with disabilities. [Online] Available at: www.nice.org.uk. (Accessed 25 February
2012).
NLM (2020) (National Library of Medicine). Bedtime habits for infants and children. [Online] Available at
https://medlineplus.gov/ency/article/002392.htm (Accessed 25 February 2022).
Norris, E., Shelton., N., Dunsmuir, S, Duke-Williams, O, & Stamatakis, E. (2015). Physically active lessons as
physical activity and educational interventions: A systematic review of methods and results.
Preventive Medicine 72:116-25.
Ofsted (2018). (Office for Standards in Education, Children's Services and Skills). Obesity, healthy eating
and physical activity in primary schools. Manchester, United Kingdom.
Omura, J.D., Carlson, S.A., Brown, D.R., Hopkins, D.P., Kraus, W.E., Staffileno, B.A., Thomas, R.J., Lobelo, F., &
Fulton, J.E. (2020) on behalf of the American Heart Association Physical Activity Committee of the
Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; and
Council on Clinical Cardiology. Built environment approaches to increase physical activity: a science
advisory from the American Heart Association. Circulation. 2020: 142:e160– e166.
152
Ong, J.L., Tandi, J., Patanaik, A., et al. (2019). Large-scale data from wearables reveal regional disparities in
sleep patterns that persist across age and sex. Sci. Rep. 9, 3415.
Paavonen, E. J., Räikkönen, K., Lahti, J., Komsi, N., Heinonen, K., Pesonen, A.-K., Järvenpää, A.-L., Strandberg,
T., Kajantie, E. & Porkka-Heiskanen, T (2009). Short Sleep Duration and Behavioral Symptoms of
Attention-Deficit/Hyperactivity Disorder in Healthy 7- to 8-Year-Old Children. Pediatrics 123(5): e857.
Physical activity and exercise guidelines for all Australians (2021).[Online]. Available at:
https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-
exercise-guidelines-for-all-australians (Accessed on 12 January 2022).
Paruthi, S., Brooks, L.J., D’Ambrosio, C., Hall, W.A., Kotagal, S., Lloyd, R.M. Malow, B.A., Maski, K., Nicholas,
C., Qu an, S.F., Rosen, C.L., Troester. M.M., & Wise, M.S. (2016). Consensus statement of the American
academy of sleep medicine on the recommended amount of sleep for healthy children: methodology
and discussion. Journal of Clinical Sleep Medicine 12(11):1549-61.
Patrick, H., Hennessy, E., McSpadden, K, et al. (2013). Parenting styles and practices in children's obesogenic
behaviours: scientific gaps and future research directions. Childhood Obesity 9:73–86
Petersen, T., Moller, L., Brond, et al. (2020). Association between parent and child physical activity: a
systematic review. International Journal of Behavioral Nutrition and Physical Activity 17:67-xx
PHE (2020). What works in schools and colleges to increase physical activity? Public Health England, KM5
London, United Kingdom.

Pollock, N.K. (2015). Childhood obesity, bone development, and cardiometabolic risk factors. Molecular and
Cellular Endocrinology 410:52-63.
Quist, J.S., Sjödin, A., Chaput, J.P., & Hjorth, M.F. (2016). Sleep and cardiometabolic risk in children and
adolescents. Sleep Medicine Reviews 29:76–100.
Rhodes, R., & Lim, C. (2017). Promoting Parent and Child Physical Activity Together: Elicitation of Potential
Intervention Targets and Preferences. Health Education & Behaviour 1-12.
Ruiz, J.R., Sui, X., Lobelo, F., Morrow, J.R. Jr, Jackson, A.W., Sjöström, M, et al. (2008). Association between
muscular strength and mortality in men: prospective cohort study.BMJ 337:a439
Ruiz, J.R., Sui, X., Lobelo, F., Lee, D.C., Morrow, J.R. Jr., Jackson, A.W., et al. (2009). Muscular strength and
adiposity as predictors of adulthood cancer mortality in men. Cancer Epidemiology Biomarkers and
Prevention 18:1468-76.
Seehagen, S., Konrad, C., Herbert, J.S., & Schneider, S. (2015). Timely sleep facilitates declarative memory
consolidation in infants. Proceedings of the National Academy of Sciences of The United States of
America 112(5):1625–1629.
Shah, S., Allison, K.R., Schoueri-Mychasiw, N., Pach, B., Manson, H., & Vu-Nguyen, K. (2017). A review of
implementation outcome measures of school-based physical activity interventions. Journal of School
Health 87: 474-486
Smith, P.K., & Pellegrini, A,. (2013). Learning Through Play. Encyclopedia on Early Childhood Development.
[Online] Available at: https://www.child-encyclopedia.com/play/according-experts/learning-through-
play. (Accessed on October 15, 2022).
Solomon-Moore, E,Toumpakari, Z, Sebire, S.J., et al. (2018). Roles of mothers and fathers in supporting child
physical activity: a cross-sectional mixed methods study. BMJ Open 8:e019732.
153
Stierlin, A.S., De Lepeleere, S., Cardon, G., Dargent-Molina, P., Hoffmann, B., Murphy, M.H., Kennedy, A.,
O’donoghue, G., Chastin, S.F., & De Craemer, M. (2015). A systematic review of determinants of
sedentary behaviour in youth: A DEDIPAC-study. International Journal of Behavioral Medicine 12:133
Strong, W.B., Malina, R.M., Blimkie, C.J.R., Daniels, S.R., Dishman, R.K., Gutin, B., & Trudeau, F. (2005).
Evidence based physical activity for school-age youth. Journal of Pediatrics 146: 732-7.
Tan, V.P., Macdonald, H.M., Kim, S., Nettlefold, L., Gabel, L., Ashe, M.C., & McKay, HA (2014). Influence of
physical activity on bone strength in children and adolescents: a systematic review and narrative
synthesis. Journal of Bone and Mineral Research 29(10):2161-81.
Tan, A., Yen, S. T., Fang, X., & Chiang, F. S. (2019). Body weight and physical activity of adolescents in
Malaysia. International Health, 11(2), 150–158.
Tate, E.B., Shah, A., Jones, M., et al. (2015). Toward a better understanding of the link between parent and
child physical activity levels: the moderating role of parental encouragement. Journal of Physical
Activity and Health 12:1238–44.
Teo, P.S., Nurul-Fadhilah, A., Aziz, M.E., Hills, A.P., & Foo, L.H (2014). Lifestyle practices and obesity in
Malaysian adolescents. International Journal of Environmental Research and Public Health 11:5828-
5838.
KM5 UNESCO (2017). Report of the Sixth international conference of ministers and senior officials responsible
for physical education and sport (MINEPS VI). Annex 1 Kazan Action Plan. SHS/2017/5 REV Paris,
September 2017; adopted on 14–15 July 2017[Online] Available at: http://unesdoc.
unesco.org/images/0025/002527 /252725E.pdf (Accessed 25 February 2022).
UK Chief Medical Officers' Physical Activity Guidelines (2019) [Online]. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/
832868/uk-chief-medical-officers-physical-activity-guidelines.pdf (Accessed on 12 January 2022).
US Department of Health and Human Services: Office of Disease Prevention & Health Promotion (2008).
2008 Physical Activity Guidelines for Americans. [Online] Available at: www.health.gov/paguidelines.
(Accessed on 14 October 2022)
Utter, J., Neumark-Sztainer, D., Jeffery, R. & Story, M. (2003). Couch potatoes or french fries: Are sedentary
behaviours associated with body mass index, physical activity and dietary behaviours among
adolescents? Journal of American Dietetic Association 103 (10): 1298-1305
Wafa, S.W., Nur Nadzirah, A., Shahril, M.R., Halib, H., Rahim, M. & Janssen, X. (2017). Measuring the Daily
Activity of Lying Down, Sitting, Standing and Stepping of Obese Children Using the ActivPALTM
Activity Monitor. Journal of Tropical Pediatrics 63(2)
Wafa, S.W., Shahril, M.R., Ahmad, A.B., Zainuddin, L.R., Ismail, K.F., Aung, M.M., & Mohd Yusoff, N.A. (2016).
Association between physical activity and health-related quality of life in children: a cross-sectional
study. Health and Quality of Life Outcomes 4 (14) :71
Watson, A., Timperio, A., Brown, H. et al. (2017) Effect of classroom-based physical activity interventions on
academic and physical activity outcomes: a systematic review and meta-analysis. Int J Behav Nutr
Phys Act 14, 114-xxx.
WHO (2007). The WHO Reference 2007. World Health Organization, Geneva. [Online] Available at:
http://www.who. int/growthref/en/ (Accessed on 1 May 2012).
WHO (2007). Promoting Physical Activity in Schools: An Important Element of a Health-Promoting School.
World Health Organization, Geneva.
154
WHO (2010). Global Recommendations on Physical Activity for Health: Appendix 5 Glossary. World
Health Organization, Geneva. [Online]. Available at:
https://www.ncbi.nlm.nih.gov/books/NBK305048/?report=reader. Accessed on October 15, 2022)
WHO (World Health Organization) (2018). WHO Global Action Plan on Physical Activity 2018-2030. 2018.
Global action plan on physical activity 2018–2030: more active people for a healthier world. World
WHO (2019). Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of
age. World Health Organization, Geneva.
WHO (2020). WHO Guidelines on physical activity and sedentary behaviour 2020. World Health
Organization, Geneva
WHO (2022). Physical activity. World Health Organisation, Geneva. Available at: https://www.who.int/news-
room/fact-sheets/detail/physical-activity (Accessed on 12 January 2022).
Wilson, N. (2008). Pilot study report for survey of physical activity and sport in Malaysian children. National
Sports Institute of Malaysia, Bukit Jalil, Kuala Lumpur.
KM5
155
Appendices
Appendix 5.1: Examples of moderate and vigorous activities defined by level of intensity
For the second level of the physical activity pyramid, examples of moderate and vigorous activities defined
by level of intensity are as follows:
Moderate activity • Handball

3.0 to 6.0 METs • Football
(3.5 to 7 kcal/min) • Hockey at a moderate or hard effort
• Hopscotch with a hard effort
Aerobic exercise (transport): • Horseback riding at a hard effort
• Climbing stairs at a light effort • Ice skating at a moderate or hard effort
• Walking at a moderate or hard effort • Kayaking at a hard effort
• Walking carrying a load • Martial arts (karate/ judo/ kick boxing)
• Race walking at a light or moderate effort • Netball
• Cycling at a light effort • Playing active video games (e.g. dance mat,
arcade games) at a hard effort
Aerobic exercise (play/ sports): • Riding a scooter/ rollerblading/ roller skating at
• Aerobics at a light effort a moderate or hard effort
• Archery • Rock climbing at a moderate or hard effort
• Athletics- jumping at a light or moderate effort • Rugby
• Athletics – throwing
KM5 • Badminton Moderate activity
• Ballet at a light or moderate effort 3.0 to 6.0 METs
• Baseball at a light or moderate effort (3.5 to 7 kcal/min)
• Cricket at a moderate or hard effort • Playing the drums/ trombone

• Dancing (general) at a light or moderate effort • Playing frisbee at a moderate or hard effort
• Fishing • Playing with animals or young children at a
• Golf moderate or hard effort (walk/ run)
• Gymnastics • Playing with playground equipment (e.g., monkey bars)
• Hide and seek, poison ball • Riding a scooter/ rollerblading/ roller skating at
• Hockey at a light effort a light effort
• Hopscotch at a light or moderate effort • Riding a skateboard
• Horseback riding at a moderate effort • Rock climbing at a light effort
• Ice skating at a light effort • Squash with a light effort
• Juggling • Swimming
• Kayaking at a light or moderate effort • Table tennis
• Playing active video games (e.g. dance mat, • Tennis (court) at a light effort
arcade games) at a moderate effort • Tenpin bowling
• Unstructured indoor or outdoor play (walk/ run)
Vigorous activity • Volleyball (court)
Greater than 6.0 METs
(more than 7 kcal/min) Aerobic exercise (chores):
• Carrying small children
Aerobic exercise (transport): • Carrying very heavy items (e.g., moving furniture)
• Climbing stairs at a moderate or hard effort • Childcare (dressing)
• Race walking at a hard effort • Dusting
• Cycling at a moderate or hard effort • Gardening
• Making the bed, tidying/ cleaning room
Aerobic exercise (play/ sports): • Mopping
• Aerobics at a moderate or hard effort • Mowing lawn
• Athletics- hurdles steeplechase • Pulling up weeds, raking leaves
• Athletics- jumping at a hard effort • Scrubbing floors
• Ballet at a hard effort • Shovelling/ digging
• Baseball at a hard effort • Sweeping
• Basketball • Vacuuming
• Climbing trees • Washing car/ windows
• Dancing (general) at a hard effort • Wheel barrowing
156
Vigorous activity
Greater than 6.0 METs
(more than 7 kcal/min)
• Running/ jogging • Squash with a moderate or • Trampoline
• Skipping/ jump rope hard effort • Volleyball (beach)
• Tennis (court) at a moderate or
hard effort
Source: Ridley, Ainsworth & Olds (2008)
Appendix 5.2:Examples of muscle strengthening and bone strengthening activities defined

by level of intensity
For the third level of the physical activity pyramid, examples of muscle strengthening and bone-
strengthening activities defined by level of intensity are as follows:
Muscle-strengthening activities Bone-strengthening activities
• Lifting weights • Basketball
• Climbing trees/walls • Hopping, skipping, jumping
• Playing on playground equipment (e.g., monkey • Jumping rope
bars) • Running
• Push-ups, pull-ups, sit-ups • Hopscotch
• Tug of war • Gymnastics
• Working with resistance bands • Volleyball
KM5
• Tennis
Source: Ridley, Ainsworth & Olds (2008)

Appendix 5.3:Examples of structured and unstructured physical activities
Some examples of structured and unstructured physical activities as additional recommendations for
children are as follows:
Structured Physical Activity1 Unstructured Physical Activity2

• Playing instruments • Playing at school playground
• Playing in a marching band • Moving about, swinging, or climbing
• Playing guitar or drums in a rock band • Walking
• Twirling a baton in a marching band • Helping around the house
• Singing and dancing as a co-curricular activity • Taking the stairs
in school • Tidy up room
• Playing a musical instrument while actively • Skateboarding
running in a marching band • Roller-skating or in-line skating
• Badminton • Running
• Football • Skipping
• Swimming • Jumping rope
• Basketball • Performing jumping jacks
• Netball • Bike riding
• Futsal
• Volleyball
• Table tennis
• Karate, taekwondo, silat, or other martial arts
1Activities done in a structured or organized environment (such as playing in a league, sports club, private facility)
2Activities done in free play
157
Table 5.2: Examples of physical activity for children and adolescent per day
Age Examples
1-3 months Tummy time (30 minutes per day) (opportunities for your baby to move their legs,
kicking, move their arms and lifting their head)
Let your baby to grip your fingers or grip toys
Encourage the infant to roll over, move its body and reach out toys or grasping the
objects.
3-6 months Let you baby to rolling over, and reaching the objects/ toys
Hold your baby, provide support and encourage your baby to sit.
Hold your baby, provide support and encourage your baby to stand.
Teach your baby how to clap its hands.
Encourage your baby to move to music and sing songs
6-9 months Encourage movements such as reaching out, grabbing and transferring objects/toys.
KM5
Encourage your infant to learn self-feed.
Creeping and crawling on a clean and safe floor.
Support the infant in a standing position
Encourage dance /move their body to music.
9-12 months Assist and encourage infants to stand and practice walking
Encourage the infant to pull themselves up reaching a toy/ object.
Encourage the infant to pick up toys/objects on the floor
Encourage and help the infant to push-and-pull toys / objects.
Toddler and Unstructured “free” play:

young child ● Utilising the playground equipment such as monkey bars
(1-5 years) ● Dancing to tunes and music, Climbing tree
● Tug of war, Hopscotch, bicycle riding
● Skipping with a rope, running
Structured play: Active transport (with adult supervision)

● Singing while dancing ● Walking to a destination with parents
● Active games ● Bicycle riding
● Puzzles ● Play scooter
● Soccer
● Drawing Everyday physical tasks
● Card games ● Helping to set up meal areas
● Tidying up their toys, play areas or their bed
● Helping with gardening or simple household
chores
158
Table 5.2: Examples of physical activity for children and adolescent per day (cont.)
Age Examples
Older Focus: muscle and bone strengthening activities:

children - ● Running
adolescents ● Rock climbing
● Jumping rope
● Brisk walking
● Bicycle riding
● Hopscotch
● Hiking
● Gymnastics
● Sit-ups
● Press-ups
● Resistance training (weights, exercise bands)
● Netball, basketball
● Hockey, badminton, football
● Tennis and table tennis.
● Hiking,
● Kayaking or swimming
● House and yard work, such as sweeping or pushing a lawn mower
KM5
159
KM5
160
Key Message 6
Eat adequate vegetables and fruits every day

KM6
Eat adequate vegetables and

fruits every day
Dr Yasmin Ooi Beng Houi, Ms. Ain Hanani Budiono, Ms. Ainan Nasrina Ismail, Ms. Catherine Mering,
Dr. Megan Hueh Zan Chong and Ms. Sarina Sariman
6.1 Terminology
Adequate unripe fruits are used in cooking or added into

Adequate is defined as the daily intake level that salads which can offer a tasty alternative. Fruits can
meets the recommended amount for specific age also be consumed as canned fruits, dried fruits, and
groups. It implies at least three servings of fruit juice, preferably without added sugar, salt, and
vegetables and two servings of fruits everyday for preservatives. Fruits are generally high in fibre and
children and adolescents aged 7 to 18 years. In micronutrients including vitamins and minerals as
practice, it means having vegetables and fruits well as phytonutrients.
during mealtimes as well as snacks.
Phytonutrients
Fruit Phytonutrients refer to naturally occurring
The term fruit is generally used to describe the chemicals or compounds in plant foods that are
sweet, fleshy edible portion of a plant that arises believed to provide a wide range of health benefits
from the base of the flower and surrounds the seeds. to humans. Phytochemicals offer protection against
Most fruits are not cooked and are eaten fresh when infections, help to prevent diseases, and have
they are ripe which give a sweet taste. In some antioxidant, detoxification and anti-inflammatory
cases, fruits are consumed before they ripen, usually functions. There are various categories of
with a spicy or savoury sauce or dip. Some ripe and phytonutrients that have been identified in plants,
162
the most common are carotenoids (such as beta (kacang buncis) and winged beans or four-angled
carotene, lutein, lycopene, and zeaxanthin), beans (kacang botor), cruciferous vegetables (such
flavonoids (such as flavonols, isoflavones, as cabbages and broccoli) and edible plant stems
anthocyanins), ellagic acid, resveratrols, (such as celery and asparagus). There are also local
phytoestrogens and glucosinolates. Vegetables and vegetables that are commonly consumed as ulam
fruits are good sources of phytonutrients. (such as pennywort (pegaga) and ulam raja) and
traditional vegetables (such as cekur manis, terung
Vegetables pipit and midin). Vegetables are also available as
Vegetables are the edible parts of plants that include canned or frozen vegetables. Some vegetables are
leaves, roots, stalks, bulbs and flowers but do not eaten raw while others are cooked to make them
include tubers (potato, tapioca and yam). more palatable and digestible, sometimes in
Commonly consumed vegetables are green leafy combination with other food groups (such as egg,
vegetables (such as spinach, mustard leaves and meat, fish, or legumes). Vegetables can also be
lettuce), coloured vegetables (such as red spinach), consumed as juice, preferably without added sugar
fruit vegetables (also known as gourds or melons, and / or salt. Like fruits, vegetables are also high in
such as pumpkin, loofah and cucumber), bean fibre and micronutrients including vitamins and
vegetables (such as long beans, French beans minerals as well as phytochemicals.
6.2 Introduction
Consuming an adequate intake of vegetables and al., 2020). Vegetables and fruits have been
fruits is one of the strategies to address lifetime risks recognized as the key components of a healthy diet KM6
of diet related NCDs and achievement of because of their high levels of health-promoting
micronutrient recommendations. However, the nutrients and bioactive compounds, including fibres,
consumption is inadequate including among phytochemicals, vitamins, and minerals. There is

children and adolescents. This will contribute to a evidence that fruits contain anti-inflammatory and
poor diet quality that may affect their growth and antioxidant properties which contribute towards
development. Vegetables and fruits have been maintaining health and reducing risk of diseases
recognised to be generally low in calories and such as cardiovascular diseases, atherosclerosis,
contain nutrients and bioactive compounds diabetes, asthma, and cancer (Majdan &
including vitamins, minerals, fibre and Bobrowska-Korczak, 2022).
phytonutrients that are essential to the body.
Children are encouraged to eat fruits and vegetables The essential nutrients found in vegetables and
of various colours to get benefits from vitamins and fruits are especially important and beneficial to
minerals (such as vitamin C, thiamine, riboflavin, B- ensure optimum growth and development of
6, niacin, folate, vitamin A, and vitamin E) as well as children. They strengthen children’s immune
phytonutrients and antioxidants (Blumfield et al., system to help fight illnesses and protect against
2022). Thus, it is crucial to incorporate a variety of diseases. Phytonutrients enhance immunity by
vegetables and fruits in their diet. Proper handling possessing antioxidant properties which provide
and preparation of vegetables and fruits are central protection against free radicals, and anti-
to reducing nutrient loss and ensuring children get inflammatory properties that can maintain eye,
optimum benefit from the foods. These are covered cardiovascular and bone health as well as protection
in the Additional Recommendations at the end of against diabetes mellitus and cancers. There is
this chapter. compelling evidence that a diet rich in vegetables
and fruits can lower the risk of cardiovascular
Vegetables and fruits have potential health- disease, cancer, and all-cause mortality (Aune, 2019).
promoting effects beyond providing basic nutrition The high fibre content in vegetables and fruits is
needs in humans, including their role in reducing also good to prevent constipation and improve
inflammation and their potential preventive effects digestive system. In addition, the fibre content
on various chronic disease states leading to enhances satiety and consequently helps in
decreases in years lost due to premature mortality maintaining healthy body weight as they are
and years lived with disability/morbidity (Wallace et relatively low in energy.
163
The association of low intake of vegetables and Various actions have been taken to encourage and
fruits with micronutrient deficiencies and various improve the consumption of vegetables and fruits
diseases is well established. Deficiency in specific especially among children. The government
vitamins and minerals increase the risk of diseases together with the private sector have also
such as night blindness (lack of vitamin A), scurvy endeavoured to improve food and nutrition security
(lack of vitamin C), osteoporosis (lack of calcium) by ensuring the availability, accessibility, utilization,
and iron-deficiency anaemia (lack of iron and folate). and stability of food supply especially vegetables
Poor nutrition interferes with children’s health and and fruits. Exposure, availability and accessibility to
growth from infancy to adulthood. Insufficient healthy foods especially vegetables and fruits at
intake of folate among pregnant mothers has home, schools, childcare centres and in the
significantly increased risk of neural tube defects in community could affect food choices, taste
new-borns. preference and intake of children. Creating and
maintaining a supportive and conducive
Despite the established benefits of vegetable and environment for healthy food requires collective
fruit consumption, intake is relatively low in children efforts from parents, caregivers, and teachers.
worldwide. UNICEF’s Global Database on Infant and Children and adolescents must have continuous
Young Child Feeding demonstrated poor diets in access to vegetables and fruits at home, in schools
early childhood. Only 59% of children aged 6 to 23 and any facilities where they spend a considerable
months were fed vegetables and/or fruits (UNICEF, amount of time like creches and transit care centres
2021). In Malaysia, it is not uncommon for children between school and religious or extra classes.
and adolescents to not achieve their daily These efforts will help to establish lifelong
recommendations for vegetable and fruit intake. preferences for vegetables and fruits early in life.
KM6

6.3.1 Immunity and infection
Children are more susceptible to infections due to of ultra-processed foods, can negatively affect a
their underdeveloped immune system and their healthy immune system (Myles, 2014). Diet high in
high exposure to microorganisms at schools and refined carbohydrates and low in vegetables and
childcare facilities. Infectious diseases that are fruits could disrupt the intestinal microorganisms
common among children include upper respiratory balance, resulting in chronic inflammation of the
tract infections (URTI) or ‘the common cold’ and gastro-intestinal system, and associated suppressed
gastrointestinal conditions such as diarrhoea. immunity (Olmo et al., 2021). Additionally, diet that
Common cold is reported to be the most frequent is low in vegetables and fruits may also be low in a
infection in children. Preschool-aged children may wide range of phytonutrients which play essential
have an average of 6 to 10 episodes of cold a year roles as antioxidants and anti-inflammation (Serafini
(Cotton et al., 2008), while 10% to 15% of school- & Peluso, 2016). The immune system needs a myriad
aged children have at least 12 infections per year of micronutrients including vitamin A, vitamin C,
(Loo, 2009). Infectious diarrhoea is also reported to vitamin Bs and trace mineral such as selenium to
be prevalent among children where 1.7 billion function well. Nevertheless, these essential nutrients
diarrhoea episodes occurred among children aged cannot be synthesised by the human body and need
under 5 years worldwide every year (WHO, 2017). to be sourced exogenously from the diet. Vitamins
The prevalence of diarrhoea among children under A, C, folate, B6, B12 and selenium are present
5 years in Malaysia was 4.4% with the Other naturally in vegetables and fruits. These nutrients
Bumiputera children reported to be having the often work synergistically to build and support a
highest risk (Aziz et al., 2018). healthy immune system.
Having a strong immune function can help to prime Vitamin A is important for cell differentiation,
the body to fight against childhood infections. immune cell maturation and regulatory roles in
Nutrition plays a major role in building a strong immune responses and processes (Raverdeau &
immune function. Consuming a balanced diet Mills, 2014). Vitamin A deficiency is associated with
consisting of a variety of vegetables and fruits on a impaired mucosal barrier function, altered immune
regular basis is crucial to promote immunity and responses, and increased susceptibility to a range of
fight off infections in children. On the other hand, infections (Huang et al., 2018). Children with lower
diets that are limited in variety and lower in serum vitamin A level were reported to have a
nutrients, such as those consisting predominantly higher incidence of diarrhoea and influenza
164
infections, compared to children with higher serum in supporting immune function and protecting host
retinol level (Thornton et al., 2014). Yellow- and susceptibility to infection is widely documented.
orange-coloured vegetables and fruits such as red Selenium plays essential roles in regulating the
capsicum, carrot, tomato, mango and papaya proliferation, differentiation, activation, and optimal
contain significant amounts of carotenoids, the function of B-cells and T-cells (Avery & Hoffmann,
precursors for vitamin A. Dark green coloured 2018). Selenium deficiency impairs both the humoral
vegetable such as green spinach (Zuwariah et al., and cell-mediated immune response, diminishes
2021), and cekur manis also contain carotenoids, natural killer cell activity, therefore increasing one’s
though yellow-to-red pigments are masked by the susceptibility to infections. Selenium deficiency also
green pigment of chlorophyll (Tee et al., 1997; USDA, appears to enhance the virulence or progression of
2016). some viral infections (Guillin et al., 2019). Selenium
content in vegetables and fruits can vary depending
Vitamin C has excellent antioxidant properties. on the selenium content in soil. Vegetables and fruits
Vitamin C supports immunity and protects the body containing a good amount of selenium are green
against infections by stimulating production and beans, radish, carrots, cabbage, and oranges (Rai et
function of leukocytes (white blood cells) and al., 2019).
antibody production (Hemilä, 2017; Schwager et al.,
2015). Vitamin C deficiency is associated with 6.3.2 Childhood obesity
decreased mononuclear cell vitamin C content and
T lymphocyte-mediated immune responses, thus Obesity is a long-term risk factor for many non-
increases one’s susceptibility to a variety of communicable diseases in later life. Poor dietary
infections including respiratory infections such as habits developed during childhood and adolescence
pneumonia (Carr & Maggini, 2017). During episodes contribute towards obesity. The National Health and KM6
of URTI, vitamin C supplementation has also been Morbidity Survey (NHMS) 2019 showed that
shown to support recovery, with a greater benefit prevalence of overweight and obesity (BMI-for-age

seen in children than in adults. A Cochrane review > +2SD) was 5.6% (95% CI: 4.13 – 7.55) for children
showed that the duration and severity of infections aged below 5 years. The same survey showed that
were reduced by 14% in children and 8% in adults. the prevalence of overweight for children and
In children, 1 to 2 g/day vitamin C shortened colds adolescents aged 5 to 17 years was 15.0% (95% CI:
by 18% (Hemilä & Chalker, 2013). Where possible, 13.31 – 16.82) and obesity was 14.8% (95%CI: 13.06
vitamins should be derived from foods because – 16.70) based on their BMI-for-age status (IPH,
foods contain nutrients and non-nutrients that 2020). A later cross-sectional study of 2,221
together contribute towards overall health. Leafy adolescents aged 13 – 17 years from randomly
vegetables such as red amaranth, green spinach selected secondary schools in Seremban, Negeri
(Zuwariah et al., 2021), tapioca shoots, cekur manis, Sembilan showed that prevalence of overweight
kai-lan and fruits such as guava, longan, papaya, was 17.0% and obesity was 14.9% (Lai et al., 2022).
lime and tangerines are good sources of vitamin C
(Tee et al., 1997). Results from meta-analyses of randomised control
trials involving dietary component in weight
The B vitamins are involved in intestinal immune management interventions in children and
regulation, thus contributing to gut barrier function. adolescents with overweight or obesity published
Deficiency of B vitamins lead to compromised between 1975 and 2020 showed that intervention
immune responses and processes. Folate deficiency groups achieved significantly greater reductions in
is associated with decreased circulating T mean total energy intake at < 6 months (-194
lymphocyte while B6 deficiency impairs lymphocyte kcal/day, 95% CI: -275.80 to – 112.90) and increases
proliferation and T lymphocyte-mediated immune in fruit and/or vegetable intakes over 2 – 12 months
responses (Yoshii et al., 2019). Vegetables such as (range +0.6 to +1.5 servings/day) (Duncanson et al.,
red amaranth, green spinach (Zuwariah et al., 2021), 2021). In a longitudinal study, low vegetable intake
capsicum, banana and jackfruit contain good was associated with higher body mass index (BMI)
amount of vitamin B6 (USDA, 2016). Fruits such as in women whose vegetable consumption was
papaya, ciku and kiwi are good sources of folate tracked from adolescence into adulthood (te Velde
(Chew et al., 2012). et al., 2007). Fruits and vegetables contain a high
proportion of water, fibre and are low in calories and
Selenium acts in synergy with the antioxidant energy density. As water has the ability to reduce
vitamins, vitamin C and vitamin E to promote energy density (Grunwald et al., 2001) and fibre
cellular redox balance (Huang et al., 2012; Zoidis et provides non-energy containing mass, it is plausible
al., 2018). The roles of selenium and selenoproteins that components of vegetables and fruits may
165
prevent weight gain and facilitate weight loss, micronutrients including vitamin C, folate and
within the context of a reduced energy diet. It is magnesium in constipated children as compared to
likely that fibre content of vegetables and fruits, their non-constipated counterparts with adequate
particularly whole, structurally intact plant foods intake of plant foods (Lee et al., 2008).
attenuate the glycaemic impact of energy intake
and contribute to satiety and consequently weight Case-control studies showed that vegetable and
management (Greger, 2020). Therefore, replacing fruit consumption in children and adolescents were
high energy dense foods with high fibre foods that significant risk factors for constipation. A case-
are lower in energy density, such as vegetables and control study comparing 221 children with
fruits, can be an important part of a weight functional constipation (cases) and 230 children
management strategy for children. without constipation (control), aged 6 to 18 years in
Antalya, Turkey showed that good adherence to the
Children (aged 2 – 5 years) of women who were Mediterranean diet was associated with a lower risk
recruited at 24 – 34 weeks of gestation into the of functional constipation, but unfortunately
longitudinal Healthy Beginnings Trial in Sydney, adherence to the Mediterranean diet decreased
Australia (n = 667) showed that consumption of with age. This diet is characterised by high
vegetables and milk decreased whilst discretionary consumption of cereals, olive oil, fruits and
food intake (sweet and salty snacks, fast foods, vegetables, and water and milk products (Akbulut
processed meats, confectionary) and screen time et al., 2021). Another case-control study in Thailand
decreased over an intervention period which began also showed that limited fruit or vegetable
at 30 – 36 weeks of gestation to 24 months after consumption (adjusted odds ratio [OR] 11.07, 95%
birth. The Trial was a home-based intervention to CI: 3.82 – 38.08) is a significant independent risk for
KM6 reduce childhood obesity. Child BMI at 2 years constipation in children. Water intake was the other
predicted overweight / obesity at 3.5 years, and independent risk (adjusted OR 5.47, 95% CI: 1.73 –
child BMI at 3.5 years predicted obesity at 5 years. 17.34). For the first year of life, daily vegetable or fruit
Poor dietary and lifestyle behaviours in early consumption of less than one ladle (OR 9.63, 95% CI:
childhood, and high maternal and child BMI at 2 3.67 – 25.25), daily fruit juice intake of <250ml (OR
years predicted earlier obesity onset (Kunaratnam et 2.58, 95% CI: 0.62 – 10.69) and daily water intake of
al., 2020). As most countries including Malaysia have <250 ml (OR 4.42, 95% CI: 1.69 – 11.58) were
a majority of children and adolescents who do not significant risk factors. The Thai study was
consume the recommended amounts of vegetables conducted on pre-school children aged 1 – 4 years
and fruits, which leads to early onset of chronic with 45 constipated (cases) and 45 non-constipated
diseases or increased risk for chronic diseases in (control) attending an outpatient department in
adulthood, there is a pressing need to change the Bangkok (Wanichsetakul & Wongteerasut, 2021). In
obesogenic environment to one of a healthogenic Sri Lanka, a case-control study of 165 children and
environment. Strategies should be formulated to adolescents aged from early infancy to 17 years with
reduce the marketing of energy-dense snacks to functional constipation were matched with healthy
children, and instead to increase the promotion of controls. Fibre content of their current diet (OR
vegetables and fruits to children (Folvord et al., 27.50, 95% CI: 14.88 – 50.87) was a significant risk
2021). for constipation. A low fibre diet was one where the
habitual diet was lacking in vegetables, fruits, and
6.3.3 Bowel movement whole grains. Price of vegetables and fruits was
prohibitive for low-income patients (Edan & Yahya,
A systematic review and meta-analysis showed that 2022).
pooled prevalence of constipation in children was
9.5% (95% CI: 7.5 – 12.1) based on the Rome III/IV In Japan, the Toyoma Birth Cohort Study with 7,998
criteria (Koppen et al., 2018). Low consumption of children aged 9 – 10 years showed that 319 children
dietary fibre, vegetables and fruits could disrupt (3.9%) experienced constipation. Infrequent fruit
bowel movements, particularly in children. A cross- intake (OR 1.94, 95% CI: 1.42 – 2.66) and infrequent
sectional study of Brazilian children aged 4 – 7 years vegetable consumption (OR 1.46, 95% CI: 1.03 –
(n=152) found that prevalence of constipation was 2.05) were significantly associated with constipation
32.2%, and there was a statistically significant (Yamada et al., 2019). The same Toyoma Birth Cohort
association between constipation and non- Study on adolescents aged 12 – 13 years (n = 5540)
consumption of fruits (p = 0.003) and greens showed 261 adolescents (4.7%) developed
(excluding starchy roots and tubers) (p = 0.007) constipation during the three-year observation
(Andreoli et al., 2018). In addition, low intake of plant period. Infrequent intake of fruits at baseline (0 – 2
foods contributed to significantly lower intakes of times / week) (OR 1.50, 95% CI: 1.08 – 2.09) was
166
associated with the incidence of constipation. 6.3.4 Cancer

Frequency of vegetable consumption was not a
predictor of constipation for these adolescents, The American Cancer Society (Rock et al., 2020)
possibly because most adolescents might have recommends consumption of a variety of vegetables
consumed vegetables almost every day at the – dark green, red, and orange, fibre-rich legumes
follow-up survey, hence the research questionnaire (beans and peas), fruits – especially whole fruits with
did not produce variance in analysis (Yamada et al., a variety of colours, and whole grains for cancer
2021). However, recent evidence from the Avon prevention at all ages. These intakes, together with
Longitudinal Study of Parents and Children lower intake of processed meats and red meats,
(ALSPAC) showed that increasing fibre was not an lower intake of added sugar, saturated and/or trans
effective treatment for constipation in children fats, higher intake of legumes and/or fish and/or
(Tappin et al., 2020). Tappin et al. (2020) compared poultry, inclusion of unsaturated fats, and no
hard stool data at age 4 weeks, 6 months and 2.5 excessive energy intake, have been associated with
years, constipation data at age 4 – 10 years, and fibre a lower risk of colorectal cancer and total cancer
intake at 2 years from ALSPAC. They found that hard incidence in meta-analyses of observational studies.
stools at 4 weeks predated fibre. At that time, the The World Cancer Research Fund International
diet was milk with no fibre intake. At 6 months of recommends a diet which includes at least 30g of
age, hard stools predicted lower fibre intake at 2 fibre from food, and at least 400g of a variety of non-
years (p=0.003). When the data was collected in the starchy vegetables and fruits every day (WCRF,
early 1990s, weaning children to solids containing 2018). There is evidence to show that dietary fibre
fibre was recommended at 4 months of age. They probably decreases risk of colorectal cancer and risk
showed that heredity explained 59% of constipation of weight gain, overweight or obesity. There is also
from US, Japanese and UK twin data. evidence that non-starchy vegetables or fruits KM6
probably decrease risk of aerodigestive cancers
Fruit juices have been widely promoted as a solution (WCRF, 2018). An umbrella review showed that

for constipation in children because the taste is consumption of cruciferous vegetables was
readily acceptable to children. They are a source of associated with a reduced risk of all-cause mortality
vitamin C and fluid. However, the evidence so far and various cancers (Li et al., 2022). However, Li et
has been based on expert opinion rather than al cautioned that warfarin resistance caused by
scientific studies. The presence of sugar in fruit vitamin K-rich broccoli was reported. Aune et al.
juices increase energy intake which predisposes (2017) reported a dose-response of 100g/d
inappropriate weight gain and dental caries increment of cruciferous vegetables was associated
(Heyman & Abrams, 2017). There are limited studies with a 10% decrease in the risk of all-cause mortality
conducted to compare the sugar content of fruit- (RR = 0.90, 95% CI: 0.85 – 0.95). Aune et al, also
based drinks. Walker et al. (2014) assessed sugar reported cruciferous vegetable intake could reduce
profiles of ten popular beverages in the USA and the risk of all-cause mortality by 12% (RR=0.99,
found varying concentrations of sugar across 95%CI: 0.80 – 0.97) for the highest vs. lowest group
different types of sugar-sweetened beverages of intakes. Sulphur compounds in cruciferous
(SSBs). In juices sweetened with high-fructose corn vegetables, such as sulforaphane may be a cancer
syrup (HFCS), fructose accounted for 52.1% ± 5.9% chemopreventive agent as demonstrated in cell-line
of sugar content, although in some juices made from studies (Farag & Motaal, 2010). They also contain
100% fruit, fructose concentration reached 65.35 g/L antioxidants that could potentially induce
accounting for 67% of sugars. A recent study antioxidant enzymes, which may protect against
conducted in Slovenia analysed 51 best-selling carcinogenesis (Williamson et al., 1996).
products in the market to determine the specific
types of sugars in sugar-sweetened beverages. The WCRF (2018) stated that evidence comes
Findings showed that the amount of sugar deviated mostly from studies of adults but, unless there is
within + 10% of the amount listed on the label. evidence to the contrary, also apply to children aged
Sucrose was the most commonly used sweetener 5 years and over. Primary prevention of adult
(71%), with higher fructose content observed in cancers, such as colorectal cancer, should
beverages with fructose–glucose syrup or a higher commence early in childhood because of the long
content of fruit juice (Hafner et al., 2022). gestation of nutritionally related cancers (Rogers &
Barr, 2020). A sufficient intake of vegetables and
fruits during childhood may possibly have a long-
term protective effect on cancer risk in adults. The
Boyd Orr cohort, which is a longitudinal study with
a 60 year follow up showed that increased childhood
167
fruit consumption reduced risk of incident of cancer While cardiovascular disease (CVD) is typically not
in adulthood (Maynard et al., 2003). diagnosed until adulthood, atheromatous lesions
have been discovered in children and young adults
The protective effects of vegetables and fruits (McMahan et al,, 2006; Strong et al., 2001). The
against risk of cancer are probably mediated presence of atherosclerosis in youth has been linked
through micronutrients, phytochemicals and fibre in to CVD risk factors such as obesity, abnormal
vegetables and fruits. While phytochemicals and plasma lipoprotein levels, elevated blood pressure
micronutrients may prevent and interrupt the and insulin resistance. The Muscatine Study (Lauer
development of cancer cells, fibre may prevent et al., 1975), the Bogalusa study (Berenson et al.,
carcinogens from becoming active. Diet and dietary 1998), and the Pathobiological Determinants of
components could alter the risk of developing Atherosclerosis in Youth (PDAY) study (Zieske, et al.,
cancers by modulating various processes involved 2002), all confirmed the origin of atherosclerosis in
with onset, incidence, progression, and/or severity childhood. A recent study on school children aged
of diseases. They could also directly or indirectly 8 – 12 years in Madrid, Spain (n=365) showed that
alter expression of genes and gene products children with a more pro-inflammatory diet had
therefore modifying expression of cancer risks (Rock higher risks of developing hypertension in childhood
et al., 2020; Stan et al., 2008). (OR 2.805, 95% CI: 1.107 – 3.927), obesity (OR 2.3), or
developing obesity and hypertension
6.3.5 Cardiovascular diseases simultaneously (OR 1.290, 95% CI: 1.316 – 3.985)
(Mora-Urda et al., 2022). An anti-inflammatory diet
Ischaemic heart diseases remained as the principal is associated with high levels of anti-inflammatory
causes of death, 15.0% of medically certified deaths markers such as interleukins (IL-10) and tumour
KM6 in Malaysia in 2019 (Department of Statistics necrosis factor beta (TNF-β). In-vitro and animal
Malaysia, 2020). Daily consumption of vegetables model studies showed that vegetables, fruits, and
and fruits in sufficient amounts could help prevent legumes have high concentrations of bioactive
major diseases such as cardiovascular diseases and compounds including antioxidants and anti-
certain cancers (Aune et al., 2017). There are many inflammatory properties (Zhu et al., 2018) which are
mechanisms by which vegetables and fruits confer associated with reduced risk of cardiovascular
protective effects against such diseases. Vegetables diseases (CVD). Efforts should be made to ensure
and fruits contain phytochemicals, antioxidants and children and adolescents develop a habit of
vitamins such as bioflavonoids, carotenoids, vitamin consuming vegetables and fruits if they have not
E and C. These components could reduce the risk of already done so. These could be combined with
cancer, coronary heart disease, stroke, and high screening of vascular health for children and
blood pressure. adolescents so that dietary and exercise
interventions could be started to reverse the process
of early vascular ageing (Hanssen, 2022).
168
6.3.6 Diabetes analysis of prospective studies with a follow-up

period of 10 years or more, did show pooled
Diabetes is a strong independent risk factor for maximum-adjusted relative risk of diabetes mellitus
cardiovascular disease and often these conditions for the highest vs the lowest intakes were 0.91 (95%
exist together, sharing common modifiable risk CI: 0.87-0.96) for total fruits, 0.87 (95%CI: 0.81-0.93)
factors (Carter et al., 2010; Leon & Maddox, 2015). A for green leafy vegetables, 0.72 (95%CI: 0.57-0.90) for
systematic review and meta-analysis of cohort yellow vegetables, and 0.82 (95%CI: 0.67-0.99) for
studies found a weak inverse association between cruciferous vegetables (Wang et al., 2016).
vegetable and fruit intake and risk of diabetes
mellitus. The summary Relative Risk (RR) for high At present, there is no firm conclusion as to whether
vs. low intakes of vegetables and fruits combined increasing intake of vegetables and fruits in
was 0.93 (95%CI: 0.89 – 0.98, I2 = 0%, Pheterogeneity childhood can decrease the risk of diabetes mellitus
= 0.37) (Halvorsen et al., 2021). In a linear dose- later in life. Inadequate consumption of vegetables
response analysis, they reported that summary RR and fruits was detected in children with risk factor
per 200 g/ day was 0.98 (95% CI: 0.95 – 1.01, I2 = for diabetes mellitus. A Canadian study on youths
37.8%, Pheterogeneity = 0.14). Halvorsen et al. aged 11 – 23 years (n=529) showed that youths
found inverse associations for apples, apples and identified with risk factors for type 2 diabetes did not
pears, blueberries, grapefruit and grapes and raisins, consume sufficient amounts of vegetables and fruits
while positive associations were observed for on a daily basis (n=94, 17.8%) (Kolahdooz et al.,
intakes of cantaloupe, fruit drinks, fruit juice, brussels 2019). The relationship between intake of vegetables
sprouts, cauliflower, and potatoes. However, they and fruits in childhood and risk of diabetes mellitus
cautioned that these associations were based on should be investigated further.
few studies and further investigations in additional KM6
studies were necessary. A 7-year prospective study Although the mechanism for this association is
of 0.5 million Chinese adults showed that among uncertain, it is plausible that a combination of

participants without diabetes at baseline, higher antioxidants and phytochemicals in vegetables and
daily fruit consumption was associated with fruits might reduce the markers of oxidative stress
significantly lower risk of developing diabetes which cause chronic inflammation and production
(adjusted HR = 0.88, 95%CI: 0.83-0.93) versus non- of cytokines through suppressing secretion of
consumers (p<0.001) (Du et al., 2017). insulin and promoting cell dysfunction (He et al.,
2023; Leiter & Lewanczuk, 2005). Evidence also
Data from a 10-year follow-up of the ATTICA study suggests that green leafy vegetables might
population (n=1485) in Greece showed that intake contribute to lower risk of diabetes mellitus due to
of at least 4 servings / day of vegetables was their magnesium content (Rodriguez-Moran et al.,
associated with a 0.42 times lower risk of developing 2011). Vegetables are likely to be beneficial in the
diabetes mellitus (Hazard Ratio, HR = 0.42, 95%CI: management of diabetes mellitus due to their fibre
0.29 – 0.61) (Kosti et al., 2022). In a study conducted content, low energy density and association with
in Singapore, Odegaard et al. (2011) reported that insulin sensitivity (Wang et al., 2016).
dietary pattern with higher intake of vegetables,
fruits, and soya foods was inversely associated with A systematic review and meta-analysis of 17
risk of incident diabetes mellitus in adults who have cohorts involving 38,254 cases/10,126,754 person
never smoked. Data was derived from the Singapore years, showed that consumption of fruit juice was
Chinese Healthy Study which included 43,176 associated with 7% greater incidence of diabetes
Chinese men and women who were followed from mellitus after adjustment for adiposity (Imamura et
1993 through 2004. Participants from the same study al., 2015). However, consumption of fruit juice had a
were followed-up again between 2006 to 2010 for lower association with incidence of diabetes
physician-diagnosed incident diabetes. After mellitus compared to consumption of sugar
adjustment for potential confounders, Chen et al. sweetened beverages, which was reported to be at
(2018) reported that total intake of vegetables (top 13% per one serving/day and artificially sweetened
vs. bottom quintile, HR = 1.08, 95%CI: 0.98 – 1.18, beverages at 8%, both after adjustment for adiposity
Ptrend = 0.66) was substantially associated with risk (Imamura et al., 2015). Fruit juice refers to the
of diabetes mellitus. They did not find associations product or preparation containing 100% fruit juice.
when dark green leafy vegetables and cruciferous Any beverage that is less than 100% fruit juice must
vegetables were analysed separately. They list the percentage of the product that is fruit juice,
concluded that beneficial effect of vegetable and the beverage must include a descriptive term,
consumption on diabetes mellitus in an Asian such as “drink,” “beverage,” or “cocktail.” In general,
population was not convincing. However, a meta- juice drinks contain between 10% and 99% juice and
169
added sweeteners, flavours, and sometimes 1.74-5.48) and refusal to eat specific foods (OR: 1.68,
fortifiers, such as vitamin C or calcium (Heyman & 95%CI: 1.10-2.58) (Cole et al., 2018). Cole et al. also
Abram, 2017). The Malaysian Dietary Guideline for reported that family mealtime routine (OR: 0.66,
adults limits unsweetened fruit juice to one serving 95%CI: 0.48-0.91), balance and variety of food
per day as part of the ‘five per day’ recommendation (OR:0.60, 95%CI: 0.40-0.88), and involvement in meal
for vegetable and fruit intake (NCCFN, 2021). planning or food preparation (OR: 0.68, 95%CI: 0.52-
0.90) were associated with lower odds of food
6.3.7 Establishing, maintaining, and refusal. Chilman et al. (2021) also found that these
increasing intake of vegetables and extrinsic features decrease the likelihood of picky
fruits eating: family meals, responsive parents, and
involvement of children in the food preparation.
It is crucial to establish a healthy eating pattern
during childhood since these eating habits are likely Children often spend time in childcare locations,
to be maintained throughout adolescence and later which may be a home-based childcare or a centre-
into adulthood. Increasing the variety of foods based childcare. There was observable difference in
consumed is also important to ensure a sufficient child picky eating behaviour based on choice of
intake of nutrients in one’s meals (Koo et al., 2016). childcare arrangements. A US study comparing a
Adequate consumption of vegetables and fruits is a centre-based childcare within a university campus
key component of a health promoting diet for and 12 home-based childcares (n=50 child-parent
chronic disease prevention due to the low energy pairs, where at least one child was aged 3 – 5 years)
and high nutrient density, and high level of bioactive showed that children in centre-based childcare
compounds of these food items, which are crucial displayed more picky eating behaviours when at
KM6 for cardiovascular disease and obesity prevention home than at childcare. Home-based childcare
(Kähkönen et al., 2021). children displayed picky eating behaviours more
similarly between their home and their childcare
Picky eating, particularly refusing vegetables or locations (Luchini et al., 2017). When comparison
fruits, is common among children and adolescents was made on picky eating behaviour of centre- and
and often causes distress and concern for caregivers home-based childcares, children in the home-based
(Dahlsgaard & Bodie, 2019). Research or intervention childcares expressed significantly more physical
for picky eaters varies, conducted either at the refusals when an unpopular meal was served
clinical setting or home setting. Avoidance of new (p<0.01), and significantly more physical refusals
food and rejection of foods are common among (p<0.001), physical avoidances for the popular
picky eaters, resulting in failure to meet nutritional (p<0.001) and non-popular meal (p<0.001), and
requirements, thus impairing physical growth of significantly more verbal avoidances for the popular
children, and interfering with psychosocial meal (p<0.001) than children at centre-based
functioning within the household. When presented childcare. Luchini et al. (2017) found that the centre-
with picky eaters, parents might do one of these: based caregivers were very systematic regarding
require children to keep trying the food, allow them lunchtime and followed the feeding protocol set by
to eat / make separate meals, allow them to not eat, the centre. The protocol ensured that no other food
or allow them to choose only food that they like, all options were available for children if they did not
of which indirectly reinforce food neophobia and like what was served, and guided caregivers
refusal behaviours (Trofholz et al., 2017). Chilman et towards suitable feeding strategies such as serving
al. (2021) reported that intrinsic factors such as the food family style, and having children try a bite
increased sensitivity particularly to taste and smell of all foods on their plate before receiving a second
and the child’s personality were commonly reported helping of any food. It is worthwhile to note the
among picky eaters. Common extrinsic features important role played by centre-based childcares in
which appear to increase the likelihood of picky shaping healthy eaters by balancing children’s
eating are unstructured / uninvolved parenting, preferences with a healthy diet; research shows this
rewards for eating, and pressuring children to eat type of authoritative feeding style achieves this.
(Chilman et al., 2021). A prospective study involving
parents of preschool-aged children on home feeding The success of children consuming more vegetables
environment (n=497) in the USA found watching and fruits through a structured way of providing
television during meals (OR: 3.24, 95%CI: 1.29-8.17), vegetables and fruits was reported in an
food refusals (OR: 2.61, 95%CI: 1.11-6.13), and observational study in the Netherlands (n=569
parents that allowed child control over feeding were children aged 6 – 9 years). Schools with a 5-day-a-
more likely to perceive their child as being a picky week fruit and vegetable policy had children eating
eater in terms of limited variety (OR: 3.09, 95%CI: 130g of vegetables and fruits. Schools with free
170
provision of vegetables and fruits presented in an 25% of children achieved the daily recommendation
attractive fruit bowl had children consuming 250g of 400g (Illić et al., 2022). Among children aged 9 –
of vegetables and fruits. Schools without a school 12 years who are digital natives, multimedia
food policy had children eating 60g of vegetables interventions which comprised of vegetable and
and fruits. The proportion of children eating fruit related messages during an English lesson
vegetables and fruits was significantly higher for the before lunchtime, managed to increase their fruit
5-day-policy (97-98%) and fruit bowl situation (87- consumption compared to children who were given
97%) compared to no-policy situation (50-60%) generic messages (Wongprawmas et al., 2022).
(p<0.001) (Zeinstra et al., 2021). This shows that a
feasible and effective intervention at school setting There is variation in rejection rates within vegetable
is possible. A nationwide school intervention to and fruit categories among Malaysian children
cultivate healthy minds and bodies in children in (Ismail et al., 2009). A decade ago, most of the
Japan was enabled by legislation, known as the children aged 5 – 6 years who attended
Basic Law on Shokuiku, which was enacted in 2005. kindergartens that participated in the Bright Start
The legislation targets all age groups and is a whole- Nutrition programme in the Klang Valley, Malaysia
country approach. One of the reaches of this (n=992) was found to like fruits (95.1%) and to a
legislation is shokuiku promotion in schools and lesser extent, liked vegetables (65.1%) (Poh et al.,
nursery schools, where parents, educators and 2012). Most ethnic Chinese pre-schoolers in Subang
daycare providers were expected to be particularly Jaya, Selangor (n=91) preferred fruits (70%), which
active in promoting shokuiku among childrenn were provided as snacks by parents, but vegetables
(Kurotani et al., 2020). School-aged children in Japan were least liked by them; only about 40% expressed
receive shokuiku (food and nutrition education) to that they like vegetables (Norimah & Lau, 2000).
encourage them to eat well-balanced diets, which Preferences for vegetables and fruits remained KM6
includes cereal grains, protein, and vegetables. A almost the same for the past decade. Most ethnic
study on eating and lifestyle behaviours of Japanese Malay children (n=134 aged 10.3 + 1.0 years) in

female university students who went through the Kuala Lumpur stated that their most preferred fruit
shokuiku programme in their childhood suggested was bananas (91.9%) and most preferred vegetable
that their well-balanced dietary habits may have was carrots (71.4%). The most recognised fruit was
been a result of school shokuiku. However, late- oranges (100.0%) and the most recognised
night snacking due to late bedtime and home-meal vegetable was tomatoes (96.3%). Preferences and
replacements when living alone were also observed recognition of fruits were higher compared to
(Kibayashi, 2022). vegetables. More than 80% of participants preferred
bananas, watermelon, apples, oranges, grapes, and
Interventions to get children to try a new fruit can mangoes. Carrots (71.4%), cucumbers (63.2%),
be successful. A British cluster-randomised broccoli (56.8%) were the most preferred vegetables,
controlled trial compared two mindfulness exercise while string beans (25.3%), and capsicums (21.9%)
intervention (mindful breathing and mindful raisin- were the least preferred. Unfortunately, most
eating) and a non-mindful control task on children (53.0%) were not aware of the daily
anticipated liking and intake of a novel fruit (n=71 recommended servings of vegetables and fruits, and
children aged 10-12 years engaged at school over 5 40.0% expressed a low attitude towards eating a
days) showed that children in the mindful raisin- variety of vegetables and fruits. Willingness to try a
eating arm reported greater anticipated liking of a new type of vegetable and consume more
novel fruit. Children in both mindfulness vegetables was lower (68.7%) compared to fruits
interventions consumed greater amounts of a novel (75.4%) (Ali et al., 2020).
fruit than children in the control group (Bennet et al.,
2020). A three-year school-based intervention to Each vegetable and fruit type are unique in terms of
increase vegetable and fruit intake among primary its flavour, texture, and appearance, which provide
school children in Zagreb, Croatia, that included challenges in encouraging children’s preference for
interactive classroom workshops, cross-curricular them (Kahkonen et al., 2021). A study conducted in
activities, homework challenges, visual exposure Uruguay reported that colour and taste of the
with educational poster in classrooms, parent vegetable and family consumption habits play a
education via website, and the implementation of major role in school-aged children’s acceptance or
new dishes into the school food system, showed rejection of vegetables (Raggio & Gambaro, 2018).
that children in the intervention group increased In a randomized control trial among children aged 2
their total daily vegetable and fruit intake compared – 4 years, increased consumption was reported after
to the control group. This increase in vegetable and repeated exposure of different vegetables’
fruit intake was observed in 89% of children, and preparation. Study findings however were
171
influenced by child’s neophobia status and pre receiving vegetables, and vegetable purchase at
intervention vegetable consumption, with children farmers' markets which was higher in the rural area
with neophobia being less responsive to the than in the suburban and urban areas in Japan
intervention and with children who ate more (Machida & Yoshida, 2018). A systematic review of
vegetables before the intervention being more 53 studies demonstrated that vegetable and fruit
responsive to the intervention (de Wild et al., 2015). intake improved with community gardeners
Appearance alteration of vegetables and fruits was compared to non-gardeners, or with higher
also successful to improve willingness to try disliked frequency of gardening. Vegetable and fruit intake
vegetables and fruits thus increasing their were not different between community gardeners
consumption, as reported by a study among 7-10 and home gardeners. Most of the studies were
years old children in Hong Kong (Chung & Fong, conducted in the USA and were cross-sectional.
2018). Malaysia is trying to encourage more There were two studies from France, and one each
vegetables and fruits to be sold in school canteens from Canada, Japan, the Netherlands, South Africa,
by expanding on the Program Hidangan Berkhasiat and the UK. However, the evidence quality overall
di Sekolah (HiTS). This programme ensures was low (Hume et al., 2022). Recent and early
balanced meals, which ensures carbohydrate and gardening experience during childhood improved
protein, vegetables and fruits are served in school mean intake of vegetables and fruits compared to
meals (MOH, 2022). those without gardening experience among
university students in USA (Loso et al., 2018). In
Children tend to eat a particular food that is familiar Malaysia, urban farming is increasingly proposed as
to them, thus early exposure to vegetables and fruits a sustainable solution for food security. Urban
in the family environment may influence the community farming comes under the Ministry of
KM6 preference and consumption of vegetables and Housing and Local Government which introduced
fruits among children. In a study conducted among the Urban Community Farm Policy in August 2021
school children in Finland, mothers’ and fathers’ (KPKT, 2021). Nutrition component could be
preference on vegetable and fruit intake influenced integrated into local community garden projects
their children differently. Both parents’ preference which involved children at childcare centres and
was positively associated with strong-tasting kindergarten. This is one of the possible learning
vegetables and berries and sweet tasting fruits, methods used to expose them to the environment
while only mothers’ preference was associated with outside the classroom. Evidence from randomized
children’s preference for common vegetables controlled trials showed that intervention involving
(Kähkönen et al., 2021). Similar findings were nutrition education, gardening experience in school
reported in Polish and Romanian respondents, in gardens, and cooking or food preparation has the
which the quantity and variety of vegetables potential to enhance dietary behaviours specifically
consumed by children were significantly influenced on vegetables and fruits (Landry et al., 2021; Wells et
by their parents (Groele et al., 2019). Besides, al., 2022).
children of parents who tend to put stronger
pressure on their children to eat vegetables or who Consumption of free sugars from foods and drinks
act as negative role models more often ate fewer are common risk factors for tooth decay, obesity, and
vegetables; suggesting an enjoyable eating cardiovascular disease in children (Chi & Scott,
environment may encourage vegetables intake 2019; Paglia et al., 2019). Free sugars are mono- and
(Raggio & Gambaro, 2018). disaccharides added to food or drinks; or sugars
naturally present in honey, syrups and fruit juices
Most Malaysians live in an urban setting; 24.4 excluding sugars in milk. Sweet products (e.g.,
million (75.1%) of Malaysians live in urban areas confectionery, chocolates, cakes, biscuits, sugar, and
compared to 8.1 million (24.9%) in rural areas jam) were major contributors to total sugar intake in
(Department of Statistics Malaysia, 2022). all countries, genders and age groups, followed by
Household participation in urban community fruits, beverages and dairy products (Azaïs-Braesco
gardens may improve vegetable and fruit intake et al., 2017). A study conducted among Saudi
among members in the household. Adults with a children aged 6 – 12 years showed that higher
household member who participated in a intake of free sugar predicted lower intake of many
community garden consumed vegetables and fruits essential nutrients including vitamins, minerals and
1.4 times more per day than those who did not fibre which can be contributed by vegetables and
participate, and they were 3.5 times more likely to fruits (Mumena, 2021).
consume vegetables and fruits at least 5 times daily
(Alaimo et al., 2008). Vegetable intake frequency was Cruciferous vegetables such as those belonging to
associated with practices of vegetable cultivation, the Brassicaceae family, which include cabbage,
172
Chinese cabbage (bok choy), cauliflower, broccoli, total glucosinolate content by 57% and 51%,
collard greens, kale and Brussels sprouts, have been respectively (Hwang & Kim, 2013). Boiling for up to
shown to reduce risk of all-cause mortality and 30 minutes decreased glucosinolates by 58 – 77%.
various cancers because dietary ingestion of Common home preparation methods, such as
glucosinolates found in these vegetables are cutting, chopping, or shredding cruciferous
associated with anti-cancer properties (Jeffrey & vegetables, followed by leaving them exposed for an
Araya, 2009). Glucosinolates are metabolised to hour before cooking, expose them to myrosinase
cancer preventive isothiocyanates. However, which is naturally present in the vegetable and
glucosinolates are also goitrogens, which may stored compartmentalised from glucosinolates in
decrease iodine uptake and interfere with thyroid the plant tissue. Myrosinase converts glucosinolates
functions, thus increasing the risk of goitre and other to corresponding isothiocyanates (Song &
thyroid diseases. In healthy individuals, Thornalley, 2007). Oxalates occur naturally in plants;
concentration of glucosinolates is far below those vegetables with higher oxalate content include
likely to cause a physiological effect; and should not spinach, chard, and carrots. Soluble (unbound)
be a reason to exclude cruciferous vegetables from oxalates can chelate minerals, reducing their
part of a diet containing a variety of vegetables absorption. Therefore, oxalates are referred to as
(Petroski & Minich, 2020). Cooking with iodised salt ‘antinutrients’. Home cooking methods are suitable
is another precaution to avoid reduced iodine to significantly reduce oxalate content. Boiling and
uptake. Home cooking methods can remove a discarding that water is the most efficient method
considerable amount of glucosinolates. Steaming of decreasing oxalate content because oxalate is
broccoli for 5 minutes reduced glucoraphanin and leached into the water (Chai & Liebman, 2005).
KM6
6.4 Current Status
Despite their well-documented health benefits, a Malaysian adolescents aged 10 – 17 years

high prevalence of inadequate consumption of consumed less than the recommended 3 servings of
vegetables and fruits was reported among children vegetables per day, and 68.5% consumed less than
and adolescents globally. A meta-analysis of Global 2 servings of fruits per day. There were no
School-based Student Health Surveys (GSHS) differences in consumption rates of adolescents in
conducted from 2004 to 2013 showed that rural and urban areas, and between girls and boys;
adolescents consumed vegetables 1.75 (95% CI: 1.58 90.8% of urban adolescents, 93.9% of rural
– 1.92) times per day and fruit 1.43 times per day adolescents, 92.4% of boys and 91.9% of girls
(95% CI: 1.26 – 1.60). Worryingly, 20.6% (95% CI: 15.8 consumed less than 3 servings of vegetables per
– 25.9) of adolescents consumed vegetables less day; 69.4% of urban adolescents, 67.5% of rural
than once per day, and 34.5% (95% CI: 29.4 – 39.7) adolescents, 67.7% of boys and 69.3% of girls
of them consumed fruits less than once per day consumed less than 2 servings of fruits per day (IPH,
(Beal et al., 2019). A meta-analysis of the GSHS also 2017).
found that 74% of adolescents aged 12 – 15 years ate
vegetables and fruits less than 5 times per day The SEANUTS Malaysia data (n=1773) showed that
(Caleyachetty et al., 2015). Overall frequencies of older children aged 10 – 12 years consumed
vegetable and fruit consumption in all countries that significantly more vegetables (1.58 servings per day)
participated in the study showed that consumption and fruits (1.33 servings per day) compared to
was far below the minimum amount recommended younger children aged 7 – 9 years who consumed
by the WHO (at least 400g)/ day) (Darfour-Oduro et 1.17 servings of vegetables per day and 1.06
al., 2018). The GSHS data also showed that more servings of fruits per day. Among children aged 7 –
than half of Malaysian adolescents, 68.5% of boys 9 years, girls had significantly higher intake of fruits
and 72.0% of girls, OR 0.85 (95%CI: 0.78 – 0.91) (1.14 servings per day) compared to boys (0.99
consumed less than the recommended 3 servings servings per day (Koo et al., 2016). Among younger
per day of vegetables. For fruits, 56.1% of boys and Malaysian children aged 1 – 6 years, an earlier
55.9% of girls, OR 1.01 (95%CI: 0.93 – 1.09), nationally representative survey, the SEANUTS
consumed less than the recommended 2 servings Malaysia, which was conducted from 2010 – 2011
per day. showed that children were consuming 1.07 servings
of vegetables and 0.91 servings of fruits per day.
Consumption of vegetables and fruits among Only 15.8% of children achieved the recommended
Malaysian adolescents were further reduced by two servings of vegetables per day. Only 11.7% of
2017. The nationally representative Adolescent children achieved the recommended two servings
Nutrition Survey, ANS 2017 showed that 92.2% of of fruits per day. Only 3.4% of children consumed
173
two servings of vegetables and two servings of fruits cauliflower (34.4%), kale (kalian) (34.1%), lady’s finger
per day. More children aged 5 – 6 years achieved the (33.0%), eggplant (26.7%), string beans (French
fruit intake recommendation of two servings per day beans, kacang buncis) (25.3%), and capsicum
(16.3%), compared to only 6.6% of children aged 1 – (21.9%). Their most preferred fruits were banana
2 years achieving the recommendation (Chong et al., (91.9%), watermelon (89.7%), apple (88.3%), orange
2017). It is a concern that a majority of children were (87.0%), grapes (87.0%), mango (86.2%), pineapple
not achieving their vegetable and fruit (72.4%), papaya (72.1%), pear (68.6%), guava (54.2%),
recommendations from very early in life. The and kiwi (45.8%) (Ali et al., 2020). These commonly
SEANUTS Malaysia study showed that vegetable consumed vegetables and fruits are used as
intake was associated with ethnicity and examples in the recommendations in this Dietary
geographical region, and fruit intake was associated Guideline.
with age, parental educational level, and
geographical region (Chong et al., 2017). Chong et There is limited study reported in Malaysia on fruit
al. (2017) and Koo et al. (2016) showed that age was juice consumption among children. As fruit juice
a significant determinant of fruit intake, but not contains intrinsic sugar, it has often been grouped
vegetable intake. Among urban Malaysians, toddlers together with sugar-sweetened beverages. Sugar
(n = 181, 1 – 3 years) and pre-schoolers (n = 252, 4 – increases palatability and preference towards fruit
6 years) from low- and middle-income households juice but reduced fibre in juice is associated in
consumed significantly less fruits than children from reducing satiety (Benton & Young, 2019).
high income households; nevertheless children from Consumption of fruit juice has been associated with
all income groups did not achieve their dental problems in several studies, but the findings
recommended servings. There was no significant were not conclusive (Liska et al., 2019). In a study
KM6 difference in vegetable intake for children from all among representative samples of children in USA,
income groups, and all groups did not achieve their drinking 100% fruit juice regularly at age 2 years is
recommended servings (Zalilah et al., 2015). associated with higher odds of becoming
overweight between 2 and 4 years (Shefferly et al.,

The top five most commonly consumed vegetables 2016). In a meta-analysis study, consumption of
among Malaysian adolescents were green leafy 100% fruit juice was also associated with a small
vegetables (82.7% from the total population), amount of weight gain in children aged 1 – 6 years
flowered / flower bud vegetables (65.7%), carrot but not in children aged 7 – 18 years suggesting
(60.0%), podded vegetables (57.4%), cucumber more research to be conducted to confirm these
(54.8%) and tomato (29.9%). Example of flowered / associations (Auerbach et al., 2017). In this Dietary
flower bud vegetables are cauliflower, cabbage, and Guideline, whole fruit consumption is recommended
broccoli, which are also cruciferous vegetables. over fruit juice, and fruit juice if chosen, should not
Examples of podded vegetables are green beans or exceed one per day.
French beans (kacang buncis), and okras or lady’s
fingers (kacang bendi). The top five most commonly Traditional vegetables and fruits are also referred to
consumed fruits among Malaysian adolescents as wild edible plants. These vegetables and fruits are
were apple (81.0%), banana (72.2%), orange (61.9%), consumed by groups of Malaysians but might not
watermelon (61.6%) and mango (56.4%) (IPH, 2017). be familiar to a majority of the population. They are
The preference for these vegetables and fruits were usually collected from areas where consumers live,
also observed among ethnic Malay children (n = 134, or are cultivated in the area they live in. They could
aged 10.3 + 1.0 years) in Kuala Lumpur; most of usually be found in night markets (pasar malam), or
these children (70.9%) lived in households with community markets (tamu in Sabah). Sometimes
income below RM3,900 per month. Their most these vegetables may be found in shops and
preferred vegetables were carrot (71.4%), cucumber supermarkets situated where consumers of
(63.2%), broccoli (56.8%), cabbage (50.0%), tomato traditional vegetables live. These vegetables add to
(45.1%), spinach (44.0%), long beans (43.3%), the variety of vegetable intake, and provide
mustard leaf (sawi) (42.8%), lettuce (36.8%), considerable amount of calcium, iron, potassium,
174
magnesium, and antioxidants, other than In comparison, only 7.9% of Australian children and
carbohydrate and protein. Examples are sayur adolescents aged 2 – 18 years in the Australian 2011
manis / pucuk manis, tapioca leaves (pucuk ubi), – 2012 National Nutrition and Physical Activity
pecah beling / pecah kaca / saya / aying Survey (n=2812) were achieving the Australian
(Strobilanthes crispa Blume) and vegetable fern Dietary Guidelines (ADG) recommendations for
(pakis / pucuk paku / snegoh) (Diplazium vegetables (Flayet-Moore et al., 2019). The ADG
esculentum(Retz.) Sw), (Tharmabalan, 2023), recommends 2 – 3 servings of vegetables & legumes
moringa leaves and pods (drumstick leaves, kelor, and beans for toddlers aged 1 – 2 years, 2.5 servings
Moringa oleifera) (Liliwirianis et al., 2011; Sudha et for children aged 2 – 3 years, 4.5 servings for 4 – 8
al., 2021), terung pipit (Solanum torvum), ulam raja years, 5 servings for 9 – 11 years, 5 servings for girls
(Cosmos cuadatus) (Liliwiranis et al., 2011), midin aged 12 – 18 years, and 5.5 servings for boys aged
(Chai, 2016), akar ulan putih (Aniseia martinicensis), 12 – 18 years (Eat For Health, 2022). The standard
fruit of ampas tebu / medang (Gironniera hirta), serving for vegetables in the ADG is about 75 g (100
tunjuk langit (Helminthostachys zeylanica) (Wong – 350 kJ), which are given as ½ cup cooked green or
et al., 2013; Wong et al., 2014), and wild pepper as orange vegetables, 1 cup green leafy or raw salad
leafy vegetables (Piper umbellatum, O. borneense, P. vegetables, or 1 medium tomato (Nutrition Australia,
auritifolium and P. rueckeri) (Alan et al., 2022). 2021), which is the same as the Malaysian standard
serving.
Food neophobia might explain some, but not all the
possible reasons for such low consumption of In Indonesia, based on a systematic review of 15
vegetables and fruits. An earlier study conducted in studies on people aged 10 – 24 years, Rachmi et al.,
Hulu Selangor, Selangor on children aged 7 – 9 years (2021) found that adolescents there consumed
(n = 882) showed that children with food neophobia inadequate vegetables and fruits. An estimated KM6
consumed 0.22 ± 0.18 servings of vegetables per day 98.4% of adolescents aged 13 – 18 years were
compared to neophilic children who consumed 0.35 considered to have inadequate intake of fruits and

± 0.34 servings per day. Neophobic children vegetables; 94.7% in this age group stated that they
consumed 0.27 ± 0.42 servings of fruits per day consumed vegetables every day and 28.9% stated
compared to neophilic children who consumed 0.41 they consumed fruits every day. Vegetable intake
± 0.72 servings per day. Food neophobia was was 62.1g/day and fruit intake was 106.6g/day
identified with a validated Food Neophobia Scale. (Hermina & Prihatini, 2016). The Indonesian
However, there was no significant difference in Balanced Nutrition Guidelines (Pedoman Gizi
intake between neophobic and neophilic children Seimbang) recommends a minimum of 400g/day
(Zalilah et al., 2005). A recent study among ethnic (250g vegetables and 150g fruits) (Direktorat
Malay children in Kuala Lumpur aged 9 – 12 years Jenderal Bina Kesehatan Masyarakat DKR, 2003),
(n = 134) showed that willingness to try a new type which is the same as the Malaysian Dietary
of vegetable and consume more vegetables was Guidelines as both refer to the WHO guidelines for
lower (68.7%) compared to fruits (75.4%) (Ali et al., vegetable and fruit intake.
2020). Preference for sweeter vegetables and fruits
such as carrot, cucumber, banana, watermelon, and In Thailand, the 5th National Health Examination
apple might be a possible reason. Dressler et al. Survey (NHES V) showed that over 70% of
(2017) reported that children in New Zealand adolescents aged 10 – 16 years had only few
preferred mild and sweet vegetables such as carrot, portions of vegetables and fruits per day and less
corn, potato, broccoli, and cauliflower. An earlier than 5% of them met the national daily
study among ethnic Malay pre-schoolers aged 6 recommendations (Siwarom et al., 2021). In
years in Muar, Johor (n-68) showed that a minimum Singapore, more than 80% of children consumed less
of three exposures to vegetables increased the liking than 2 servings of vegetables per day and 2 servings
and consumption (Nordilah & Zahara, 2012). The of fruits per day, as recommended by the Singapore
bitter taste of vegetables might be a reason for lower Health Board (Lim et al., 2020). Lim et al., also
preference for other vegetables. Younger children reported that primary school children’s eating
with greater sensitivity to the bitter taste of behaviour were correlated with mother’s perceived
phenylthiocarbamide (PTC) and 6-n-propylthiouracil behavioural control. They found that mother and
(PROP) reported lower preferences for and child’s lack of motivation, lack of satiety, difficulty in
consumption of bitter foods such as vegetables. changing child’s eating habits, and lack of family
However, there were also other studies which found support significantly reduced children’s healthy food
no association between PTC or PROP sensitivity and intake.
food preferences and intake (Ventura & Worobey,
2013).
175
Key Recommendation (KR) 1: Eat adequate amount of vegetables and fruits every day.

Health Professional

For children and adolescents Educate parents to give 2 Purchase enough vegetables
aged 7 to 18 years, eat at least servings of vegetables and 2 and fruits for children and
3 servings of vegetables and servings of fruit daily to children adolescents to meet their daily
2 servings of fruits daily. below 7 years old. Meanwhile, requirements and make it
for children and adolescents always available and
aged 7 to 18 years, educate accessible at home.
parents, children and
adolescents to eat at least 3
servings of vegetables and 2
servings of fruits daily.
KM6 KR1: HTA2: KR1: HTA2: KR1: HTA2:

Ensure that vegetables and Educate parents, children and Involve children and
fruits fill up half the plate adolescents to fill up half their adolescents in meal planning,
according to the Quarter Quarter plate with vegetables and fruits purchasing and preparation of
Half concept in the Malaysian according to the Quarter Quarter foods particularly vegetables
Healthy Plate for all main meals. Half concept in the Malaysian and fruits.
Healthy Plate for all main meals.

Eat at least one serving of Educate children and Serve children with vegetables
vegetables at every main meal. adolescents to eat at least one and fruits which fill half the
serving of vegetables at every plate according to the Quarter
main meal. Quarter Half concept in the
Malaysian Healthy Plate for all
main meals.

Choose fresh fruits as healthy Educate parents, children and Eat vegetables and fruits with
snacks in between main meals. adolescents to choose fresh children to encourage them to
fruits as healthy snacks in eat.
between main meals.

Choose fresh fruits over fruit Educate parents, children and Serve vegetables and fruits
juices. Fruit juices should not adolescents to limit fruit juices to creatively to encourage
replace more than 1 serving of not more than one serving per consumption.
fruit. day if choosing to serve/
consume fruit juices.
- - KR1: HTA6:
Expose children to the tastes
of vegetables and fruits as
early as 6 months through the
introduction to complementary
food. Introduce it repeatedly.
176
Key Recommendation (KR) 1: Eat adequate amount of vegetables and fruits every day. (cont.)

Health Professional
- - KR1: HTA7:
Educate children and
adolescents on the benefit
and importance of eating
vegetables and fruits for a
healthy body.
- - KR1: HTA8:
Guide children to order well-
balanced meals including
adequate portions of
vegetables and fruits when
eating out. KM6
- - KR1: HTA9:

At school, ensure vegetables
and fruits are served in the
menu for school events such
as parent-teacher association
meetings, training, prize-
giving, teachers’ and
children’s day celebrations,
and sports day, whether for
children, teaching staff or
parents.
- - KR1: HTA10:
Carry out regular inspections
of the food sold in the canteen
to ensure that vegetables and
fruits are included in the
menu. Provide advice on how
to include them in the menu.
- - KR1: HTA11:
Make classroom lessons or
co-curricular activities
regarding healthy eating
especially vegetables and
fruits interesting. E.g., carry
out hands-on food
demonstration and tasting,
plant edible gardens.
177
Key Recommendation (KR) 2: Eat a variety of vegetables every day.

Health Professional

Eat green leafy vegetables such Educate parents, children and Provide a variety of
as mustard leaf (sawi) and adolescents to eat green leafy vegetables as part of regular
spinach (bayam) and their vegetables including their edible meals and snacks.
edible stems every day. stems every day.

Eat different coloured Suggest to include different Add vegetables into every
vegetables for lunch and dinner. coloured vegetables for lunch dish. For example, add water
and dinner. spinach (kangkung) as side
dish in nasi lemak, carrot and
brinjal into curry, and peas into
ayam masak merah.

KM6
Eat fruit vegetables such as Educate children and Prepare vegetable juices such
cucumber, tomato, brinjal adolescents to include fruit as cucumber juice without
(eggplant), pumpkin (labu vegetables several times a week. added sugar and seasonings.
kuning) and petola several Vegetables can be mixed with

times a week. fruits to enhance flavour and
encourage intake.

Eat vegetables such as fresh Educate parents, children and Cut vegetables into smaller
green leafy vegetables, other adolescents to eat fresh green sizes and incorporate into
fresh vegetables including leafy vegetables, other fresh meals to encourage picky
various coloured vegetables, vegetables including various eaters to consume
fruit vegetables, bean coloured vegetables, fruit vegetables. For example,e
vegetables, ulam, canned and vegetables, bean vegetables, shrimp/ anchovies fritters with
frozen vegetables. ulam, canned and frozen chives or bean sprout, burger
vegetables. patties or dumplings with
carrots and green vegetables.

Choose a variety of vegetables Educate children and Consider planting some
as snacks such as cucumber adolescents to include a variety vegetables around the house,
slices, tomatoes, carrot sticks of vegetables as snacks. preschools and schools.
and vegetables tempura. Engage children and students
in gardening vegetables and
fruits where possible.

Eat traditional vegetables such Suggest traditional vegetables Introduce traditional
as sayur manis, terung pipit, suitable to the local culture and vegetables to children
terung asam, midin, drumstick availability when conducting whenever there are
(moringa) leaves and tapioca nutrition education. opportunities
shoots (pucuk ubi).
KR2: HTA7: - -
Drain and rinse canned
vegetables to reduce salt.
178
Figure 6.1: Traditional vegetables
Tapioca shoots (Pucuk ubi) Terung pipit Terung asam
KM6

Drumstick/ moringa leaves
Midin Sayur Manis
(Daun kelor)
Key Recommendation (KR) 3: Eat a variety of fruits every day.

Health Professional

Eat different types of fruits Educate parents, children and Educate children and
including seasonal fruits when adolescents to eat different types adolescents to eat different
available, at every main meal. of fruits at every main meal. types of fruits at every main
meal.

Choose a variety of fresh Suggest to children and Serve to children and
fruits as snacks over pickled adolescents a variety of fruits adolescents a variety of fruits
fruits. Consume fruits such as as snacks. as snacks.
bananas and guava, without
added sugar, salt or seasonings.

If you choose dried fruits, select Advise children and adolescents to choose unsweetened or
unsweetened or unsalted unsalted variety if dried fruits are chosen.
varieties such as raisins, dates
and mangoes.
179
Key Recommendation (KR) 3: Eat a variety of fruits every day. (cont.)

Health Professional

If you choose canned fruits, Advise that canned fruits if If canned fruits are chosen,
serve without its syrup. chosen, should be consumed serve without its syrup.
without its syrup.

Read food labels to identify fruit Educate children and adolescents to read food labels to identify
juices, which are different from fruit juices, which are different from fruit juice drink and fruit drink.
fruit juice drink and fruit drink. If If fruit juices (without added sugar) were chosen, limit to once a
you choose fruit juices (without day. Mention that fresh whole fruits are preferable over fruit juices.
added sugar), limit to once a day.
Fresh whole fruits are preferable
over fruit juices.
KM6 6.5.1 Additional Recommendations:
Prevention of choking in young children

• For children aged below 7 years, vegetables and fruits could be a potential choking hazard if they
are not prepared or served appropriately to children. To prevent choking, vegetables and fruits should
be cut into small pieces and seeds should be removed from fruits.
• Children should also be monitored by adults when they are served with vegetables and fruits that
could potentially cause choking.
Preparations of vegetables and fruits
• To ensure children get the many nutrients from vegetables and fruits, proper selection, storage, and
preparation are required. Choose only fresh vegetables and fruits and avoid those that are bruised,
over-ripe and shrivelled.
• Refrigerate perishable vegetables and fruits to maintain quality and safety while some others such
as melons, mangoes, bananas, papayas, may require room temperature for quality and ripening.
• Wash vegetables and fruits (with skin and without skin) before use with cool tap water to remove
dirt, pesticide residues, insects, and harmful microbes.
• Cooking vegetables and fruits will make certain nutrients more available. It is advisable to minimize
the time, temperature and amount of water used when cooking vegetables and fruits to retain their
nutrients. To avoid choking hazards in children, cut cooked vegetables into appropriate sizes before
serving.
• If iodine deficiency is a concern, prepare cruciferous vegetables such as cabbage, tapioca shoots and
broccoli in the correct way to allow for optimum iodine uptake from the diet. For example, boil tapioca
shoots, press and drain the water before further cooking; cut cabbage and expose for about an hour
before cooking.
180
6.6 References
Akbulut, U., Isik, I., Atalay, A., & Topal, I. (2021). Adherence to the Mediterranean diet and risk of functional
constipation in children in Turkey: case-control study. Eastern Mediterranean Health Journal, 27(6),
587-594. https://apps.who.int/iris/handle/10665/352824
Alaimo, K., Packnett, E., Miles, R. A., & Kruger, D. J. (2008). Fruit and vegetable intake among urban
community gardeners. Journal of Nutrition Education and Behavior, 40(2): 94-101.
https://doi.org/10.1016/j.jneb.2006.12.003
Alan, R., Tunung, R., Saupi, N., & Lepun, P. (2022). Wild pepper species consumed as green leafy vegetables
among Orang Ulu groups in Asap-Koyan Belaga, Sarawak. Food Research, 6(2):166-171.
https://doi.org/10.26656/fr.2017.6(2).246
Ali, M. S. A, Nazir, N. A. M., & Manaf, Z. A. (2020). Preference, attitude, recognition and knowledge of fruits
and vegetables intake among Malay children. Malaysian Journal of Medical Sciences, 27(2), 101-111.
https://doi.org/10.21315/mjms2020.27.2.11
Andreoli, C. S., Vieira-Ribeiro, S. A., Fonseca, P. C. A., Moreira, A. V. B., Ribeiro, S. M. R., de Morais, M. B., &
Franceschini, S. d. C. C. (2018). Eating habits, lifestyle and intestinal constipation in children aged
four to seven years. Nutricion Hospitalaria, 36(1), 25-31. https://doi.org/10.20960/nh.02059
Auerbach, B. J., Wolf, F. M., Hikida, A., Vallila-Buchman, P., Littman, A., Thompson, D., Louden, D., Taber, D.R., KM6
& Krieger, J. (2017). Fruit juice and change in BMI: A meta-analysis. Pediatrics, 139(4): e20162454.
https://doi.org/10.1542%2Fpeds.2016-2454

Aune, D., Giovannucci, E., Boffetta, P., Fadnes, L. T., Keum, N., Norat, T., Greenwood, D. C., Riboli, E., Vatten,
L. K., & Tonstad, S. (2017). Fruit and vegetable intake and the risk of cardiovascular disease, total
cancer and all-cause mortality – a systematic review and dose-response meta-analysis of prospective
studies. International Journal of Epidemiology, 46(3), 1029-1056. https://doi.org/10.1093/ije/dyw319
Aune, D. (2019). Plant foods, antioxidant biomarkers, and the risk of cardiovascular disease, cancer, and
mortality: A review of the evidence. Advances in Nutrition, 10(Suppl. 4), S404-S421.
https://doi.org/10.1093/advances/nmz042
Avery, J., & Hoffmann, P. (2018). Selenium, selenoproteins, and immunity. Nutrients, 10(9), 1203.
https://doi.org/10.3390/nu10091203
Azaïs-Braesco, V., Sluik, D., Maillot, M., Kok, F., & Moreno, L. A. (2017). A review of total & added sugar
intakes and dietary sources in Europe. Nutrition Journal, 16:6. https://doi.org/10.1186/s12937-016-
0225-2
Aziz, F. A. A., Ahmad, N. A., Razak, M. A. A., Omar, M., Kasim, N. M., Yusof, M., Sooryanarayana, R., Jamaludin
R., & Ying C. Y. (2018). Prevalence of and factors associated with diarrhoeal diseases among children
under five in Malaysia: a cross-sectional study. BMC Public Health, 18, 1363.
https://doi.org/10.1186/s12889-018-6266-z
Beal, T., Morris, S. S., & Tumilowics, A. (2019). Global patterns of adolescent fruit, vegetable, carbonated soft
drink, and fast-food consumption: a meta-analysis of global school-based student health surveys.
Food and Nutrition Bulletin, 40(4), 444-459. https://doi.org/10.1177/0379572119848287
Bennet, C., Copello, A., Jones C., Blissett, J. (2020). Children overcoming picky eating (COPE) – A cluster
randomised controlled trial. Appetite, 154: 104791. https://doi.org/10.1016/j.appet.2020.104791
Benton, D., & Young, H. A. (2019). Role of fruit juice in achieving the 5-a-day recommendation for fruit and
vegetable intake. Nutrition Reviews, 77(11):829-843. https://doi.org/10.1093/nutrit/nuz031
181
Berenson, G. S., Srinivasan, S. R., Bao, W., Newman, W. P. III, Tracy, R. E. , & Wattigney, W. A. (1998).
Association between multiple cardiovascular risk factors and atherosclerosis in children and young
adults. The Bogalusa heart study. New England Journal of Medicine, 338, 1650-1656.
https://doi.org/10.1056/NEJM199806043382302
Blumfield, M., Mayr, H., Vlieger, N. D., Abbott, K., Starck, C., Fayet-Moore, F., Marshall, S. (2022). Should we
‘Eat a Rainbow’? An umbrella review of the health effects of colorful bioactive pigments in fruits and
vegetables. Molecules, 27(13), 4061. https://doi.org/10.3390/molecules27134061
Caleyachetty, R., Echouffo-Tcheugui, J. B., Tait, C. A., Schilsky, S., Forrester, T., Kengne, A.P. (2015).
Prevalence of behavioural risk factors for cardiovascular disease in adolescents in low-income and
middle-income countries: an individual participant data meta-analysis. Lancet Diabetes &
Endocrinology, 3(7),-535–544. https://doi.org/10.1016/S2213-8587(15)00076-5
Carr, A., & Maggini, S. (2017). Vitamin C and immune function. Nutrients, 9(11), 1211.
https://doi.org/10.3390/nu9111211
Carter, P., Gray, L. J., Troughton, J., Khunti, K., Davies. M. J. (2010). Fruit and vegetable intake and incidence
of type 2 diabetes mellitus: systematic review and meta-analysis. BMJ, 341.
https://doi.org/10.1136/bmj.c4229
Chai, P. P K. (2016). Midin (Stenochlaena palustris)., the popular wild vegetable of Sarawak. UTAR Agriculture
KM6 Science Journal, 2(2): 18-20.
Chai, W., & Liebman, M. (2005). Oxalate content of legumes, nuts, and grain-based flours. Journal of Food
Composition and Analysis, 18(7):723-729. https://doi.org/10.1016/j.jfca.2004.07.001
Chen, G. G., Koh, W. P., Yuan, J. M., Qin, L. Q., & van Dam, R., M. (2018). Green leafy and cruciferous vegetable
consumption and risk of type 2 diabetes: results from the Singapore Chinese Health Study and meta-
analysis. British Journal of Nutrition, 119(9):1057-1067. https://doi.org/10.1017/S0007114518000119
Chew, S. C., Loh, S. P. & Khor, G. L. (2012). Determination of folate content in commonly consumed Malaysian
Foods. International Food Research Journal, 19(1), 189-197.
Chi, D. L., & Scott, J. M. (2019). Added sugar and dental caries in children: A scientific update and future
steps. Dental Clinics of North America, 63(1): 17-33. https://doi.org/10.1016%2Fj.cden.2018.08.003
Chilman, L., Kennedy-Behr, A., Frakking, T., Swanepoel, L., & Verdonck, M. (2021). Picky eating in children:
a scoping review to examine its intrinsic and extrinsic features and how they relate to identification.
International Journal of Environmental Research and Public Health, 18(17): 9067.
https://doi.org/10.3390%2Fijerph18179067
Chong, K. H., Lee, S. T., Ng, S. A., Khouw, I., & Poh, B. K. (2017). Fruit and vegetable intake patterns and their
associations with sociodemographic characteristics, anthropometric status and nutrient intake
profiles among Malaysian children aged 1–6 years. Nutrients, 9(8): 723.
https://doi.org/10.3390/nu9080723
Chung, L. M. Y., & Fong, S. S. M. (2018). Appearance alteration of fruits and vegetables to increase their
appeal to and consumption by school-age children: A pilot study. Health Psychology Open, 5(2): 1-
10. https://doi.org/10.1177/2055102918802679
Cole, N.C., Musaad, S.M., Lee, S. Y., Donovan, S. M., & The STRONG Kids Team. (2019). Home feeding
environment and picky eating behavior in preschool-aged children: A prospective analysis. Eating
Behaviors, 30: 76-82. https://doi.org/10.1016/j.eatbeh.2018.06.003
182
Cotton, M., Innes, S., Jaspan, H., Madide, A., & Rabie, H. (2008). Management of upper respiratory tract
infections in children. South African Family Practice, 50(2), 6-12.
https://doi.org/10.1080%2F20786204.2008.10873685
Dahlsgaard, K. K., & Bodie, J. (2019). The (extremely) picky eaters clinic: a pilot trial of a seven-session group
behavioral intervention for parents of children with avoidant / restrictive food intake disorder.
Cognitive and Behavioral Practice, 26(3):492-505. https://doi.org/10.1016/j.cbpra.2018.11.001
Darfour-Oduro, S. A., Buchner, D. M., Andrade, J. E., & Grigsby-Tousaint, D. S. (2018). A comparative study
of fruit and vegetable consumption and physical activity among adolescents in 49 Low-and-Middle-
Income Countries. Scientific Reports, 8, 1623 https://doi.org/10.1038/s41598-018-19956-0
de Wild, V. W. T., de Graaf, C., Boshuizen, H.C., Jager, G. (2015). Influence of choice on vegetable intake in
children: an in-home study. Appetite, 91:1–6. https://doi.org/10.1016/j.appet.2015.03.025
Department of Statistics Malaysia. (2020). Statistics on Causes of Death, Malaysia, 2020.

https://www.dosm.gov.my/v1/index.php?r=column/pdfPrev&id=QTU5T0dKQ1g4MHYxd3ZpMzhE
MzdRdz09 Accessed 6 January 2022.
Department of Statistics Malaysia. (2022). Key Findings of Population and Housing Census of Malaysia 2020:
Urban and Rural. Release date: 23 December 2022.
https://www.dosm.gov.my/v1/index.php?r=column/cthemeByCat&cat=509&bul_id=ZFRzTG9ubTkv
eFR4YUY2OXdNNk1GZz09&menu_id=L0pheU43NWJwRWVSZklWdzQ4TlhUUT09# Accessed 1 KM6
April 2023.

Dresler, E., Whitehead, D., & Mather, A. (2017). The experiences of New Zealand-based children in consuming
fruits and vegetables. Health Education, 117(3), 297309. https://doi.org/10.1108/HE-08-2016-0032
Direktorat Jenderal Bina Kesehatan Masyarakat DKR. (2003). Pedoman Umum Gizi Seimbang (PUGS):
Panduan Untuk Petugas [DKR Indonesia, editor]. Jakarta, Indonesia: Depkes RI.
Du, H., Li, L., Bennett, D., Guo, Y., Turnbull, I., Yang, L., Bragg, F., Bian, Z., Chen, Y., Chen, J., Milwood, I.Y.,
Sansome, S., Ma, L., Huang, Y., Zhang, N., Zheng, X., Sun, Q., Key, T. J., Collins, R., Peto, R., Chen, Z., &
China Kadoorie Biobank Study. (2017). Fresh fruit consumption in relation to incident diabetes and
diabetic vascular complications: A 7-y prospective study of 0.5 million Chinese adults. PLoS Medicine,
14(4): e1002279. https://doi.org/10.1371/journal.pmed.1002279
Duncanson, K., Shrewsbury, V., Burrows, T., Chai, L. K., Ashton, L., Taylor, R., Gow, M, Ho, M., Ells, L., Stewart,
L., Garnett, S., Jensen, M. E., Nowicka, P., Littlewood, R., Demaio, A., Coyle, D. H., Walker, J. L., &
Collins, E. C. (2021). Impact of weight management nutrition interventions on dietary outcomes in
children and adolescents with overweight or obesity: a systematic review with meta-analysis.
Journal of Human Nutrition and Dietetics, 34(1), 147-177. https://doi.org/10.1111/jhn.12831
Eat For Health. (2022). Recommended number of serves for children, adolescents and toddlers.
Eatforhealth.gov.au Australian Government National Health and Medical Research Council &
Australian Government Department of Health and Aged Care. https://www.eatforhealth.gov.au/food-
essentials/how-much-do-we-need-each-day/recommended-number-serves-children-adolescents-
and-toddlers
Edan, O. A. A., & Yahya, F. S. (2022). Socio-demographic characteristics and risk factors of functional
constipation in children: A case-control study. Sri Lanka Journal of Child Health, 51(2), 227-234.
http://dx.doi.org/10.4038/sljch.v51i2.10123
Farag, M. A., & Motaal, A. A. A. (2010). Sulforaphane composition, cytotoxic and antioxidant activity of
crucifer vegetables. Journal of Advanced Research, 1(1):65-70.
https://doi.org/10.1016/j.jare.2010.02.005
183
Fayet-Moore, F., McConnell, A., Cassettari, T., Tuck, K., Petocz, P., & Kim, K. (2019). Vegetable intake in
Australian children and adolescents: The importance of consumption frequency, eating occasion and
its association with dietary and sociodemographic factors. Public Health Nutrition, 23(3), 474-487.
https://doi.org/10.1017/S136898001900209X ?
Folkvord, F., Naderer, B., Coates, A., & Boyland, E. (2021). Promoting fruit and vegetable consumption for
childhood obesity prevention. Nutrients, 14(1), 157. https://doi.org/10.3390/nu/14010157
Greger, M. (2020). A whole food plant-based diet is effective for weight loss: The evidence. American Journal
of Lifestyle Medicine, 14(5), 500-510. https://doi.org/10.1177/1559827620912400
Groele, B., Glabska, D., Gutkowska, K., & Guzek, D. (2019). Mothers’ vegetable consumption behaviors and
preferences as factors limiting the possibility of increasing vegetable consumption in children in a
national sample of Polish and Romanian respondents. Nutrients, 11(5): 1078.
https://doi.org/10.3390/nu11051078
Grunwald, G. K., Seagle, H. M., Peters, J. C., & Hill, J. O. (2001). Quantifying and separating the effects of
macronutrient composition and non-macronutrients on energy density. British Journal of Nutrition,
86(2), 265-276. https://doi.org/10.1079/bjn2001404
Guillin, O. M., Vindry, C., Ohlmann, T., & Chavatte, L. (2019). Selenium, selenoproteins and viral infection.
Nutrients, 11(9), 2101. https://doi.org/10.3390/nu11092101
KM6
Hafner, E., Lavriša, Ž., Hribar, M., Krušicˇ, S., Kušar, A., Žmitek, K., Skrt, M., Poklar, Ulrih, N., & Pravst, I. (2022)
Verifying the use of food labelling data for compiling branded food databases: A case study of sugars
in beverages. Frontiers in Nutrition, 9, 794468. https://doi.org/10.3389/fnut.2022.794468
Halvorsen, R.E., Elvestad, M., Molin, M., & Aune, D. (2021). Fruit and vegetable consumption and the risk of
type 2 diabetes: a systematic review and dose-response meta-analysis of prospective studies. BMJ
Nutrition, Prevention & Health, 4:e000218. https://doi.org/10.1136/bmjnph-2020-000218
Hanssen, H. (2022). Vascular biomarkers in the prevention of childhood cardiovascular risk: From concept
to clinical implementation. Frontiers in Cardiovascular Medicine, 9, 935810.
https://doi.org/10.3389/fcvm.2022.935810
He, W. J., Lv, C. H., Chen, Z., Shi, M., Zeng, C. X., Hou, D. X., & Qin, S. (2023). The regulatory effect of
phytochemicals on chronic diseases by targeting Nrf2-ARE signalling pathway. Antioxidants,
12(2):236. https://doi.org/10.3390/antiox12020236
Hermina, & Prihatini, S. (2016). Fruits and vegetables consumption of Indonesian population in the context
of balanced nutrition: a further analysis of individual food consumption survey (SKMI) 2014. Buletin
Penelitian Kesihatan, 44, 205-218.
Hemilä, H., & Chalker, E. (2013). Vitamin C for preventing and treating the common cold. Cochrane Database
Systematic Review, 2013(1):CD000980. https://doi.org/10.1002/14651858.CD000980.pub4
Hemilä, H. (2017). Vitamin C and infections. Nutrients, 9(4):339. https://doi.org/10.3390/nu9040339
Heyman M. B., & Abrams S. A., (2017). Fruit juice in infants, children, and adolescents: Current
Recommendations. Pediatrics, 139(6), e20170967. https://doi.org/10.1542/peds.2017-0967
Huang, Z., Rose, A. H., & Hoffmann, P. R. (2012). The role of selenium in inflammation and immunity: from
molecular mechanisms to therapeutic opportunities. Antioxidant and Redox Signalling, 16(7), 705-
743. https://doi.org/10.1089/ars.2011.4145
Huang, Z., Liu, Y., Qi, G., Brand, D., & Zheng, S. G. (2018). Role of vitamin A in the immune system. Journal
of Clinical Medicine, 7(9): 258. https://doi.org/10.3390%2Fjcm7090258
184
Hume, C., Grieger, J. A., Kalamkarian, A., D’Onise, K., & Smithers, L. G. (2022). Community gardens and their
effects on diet, health, psychososial and community outcomes: a systematic review. BMC Public
Health, 22(1): 1247. https://doi.org/10.1186/s12889-022-13591-1
Hwang, E. S., & Kim, G. H. (2013). Effects of various heating methods on glucosinolate, carotenoid and
tocopherol concentrations in broccoli. Food Composition and Analysis, 64(1): 103-111.
https://doi.org/10.3109/09637486.2012.704904
Illić, A., Rumbak, I., Brečić, R., Barić, I. C., & Bituh, M. (2022). Increasing fruit and vegetable intake of primary
school children in a quasi-randomized trials: Evaluation of the three-year school-based
multicomponent intervention. Nutrients, 14(10): 4197. https://doi.org/10.3390%2Fnu14194197
Imamura, F., O’Connor, L., Ye, Z., Mursu, J., Hayashino, Y., Bhupathiraju, S. N., & Forouhi, N. G. (2015).
Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and
incidence of type 2 diabetes: systematic review, meta-nalaysia, and estimation of population
attributable fraction. BMJ, 351: h3576. https://doi.org/10.1136/bmj.h3576
IPH. (2017). National Health and Morbidity Survey (NHMS) 2017: Adolescent Nutrition Survey. Institute of
Public Health, National Institutes of Health, Ministry of Health Malaysia.
https://iku.gov.my/images/IKU/Document/REPORT/NHMS2017/NutritionSurveyNHMS2017.pdf
IPH. (2020). National Health and Morbidity Survey (NHMS) 2019: Vol. I: Non-communicable diseases: Risk
factors and other health problems. Institute of Public Health, National Institutes of Health, Ministry KM6
of Health Malaysia
https://iku.moh.gov.my/images/IKU/Document/REPORT/NHMS2019/Report_NHMS2019-

NCD_v2.pdf
Ismail, M. N., Norimah, A. K., Poh, B. K., Ruzita, A. T., Nik Mazlan, M., Nik Shanita, S., Roslee, R. & Nur Zakiah,
M.S. (2009). Nutritional status and dietary habits of primary school children in Peninsular Malaysia
(2001-2002). Universiti Kebangsaan Malaysia.
Jeffrey, E.H., & Araya, M. (2009). Physiological effects of broccoli consumption. Phytochemistry Reviews,
8(1):283-237. https://doi.org/10.1007/s11101-008-9106-4
Kähkönen, K., Sandell, M., Rönkä, A., Hujo, M., & Nuutinen, O. (2021). Children’s fruit and vegetable
preferences are associated with their mothers’ and fathers’ preferences. Foods, 10, 261.
https://doi.org/10.3390/foods10020261
Kibayashi, E. (2022). P078 Effects of Shokuiku and current eating and lifestyle behaviors on well-balanced
dietary habits in Japanese university students. Journal of Nutrition Education and Behavior, 54(7S):
S54. https://doi.org/10.1016/j.jneb.2022.04.118
Kolahdooz, F., Nader, F., Daemi, M., Jang, S.L., Johnston, N., & Sharma, S. (2019). Prevalence of known risk
factors for type 2 diabetes mellitus in multiethnic urban youth in Edmonton: Findings from the WHY
ACT NOW Project. Canadian Journal of Diabetes, 43: 207-214.
https://doi.org/10.1016/j.jcjd.2018.10.002
Koo, H. C., Poh, B. K., Lee, S. T., Chong, K. H., Bragt, M. C. E., Talib, R. A., & SEANUTS Malaysia Study Group.
(2016). Are Malaysian children achieving dietary guideline recommendations? Asia Pacific Journal
of Public Health, 28(5 Suppl), 8S-20S. https://doi.org/10.1177/1010539516641504
Koppen, I. J. N., Vriesman, M. H., Saps, M., Rajindrajith, S., Shi, X., van Etten-Jamaludin, F. S., Di Lorenzo, C.,
Benninga, M. A., & Tabbers, M. M. (2018). Prevalence of functional defecation disorders in children:
A systematic review and meta-analysis. Journal of Pediatrics, 198, 121-130.e6.
https://doi.org/10.1016/j.jpeds.2018.02.029
185
Kosti, R., I., Tsiampalis, T., Kouvari, M., Chrysohoou, C., Georgousopoulou, E., Pitsavos, C., & Panagiotakos,
D. B. (2022). The association of specific types of vegetables consumption with 10-year type II diabetes
risk: Findings from the ATTICA cohort study. Journal of Human Nutrition and Dietetics, 36(1)226-
240. https://doi.org/10.1111/jhn/13056
KPKT (2021). Dasar Kebun Komuniti Bandar. Kementerian Perumahan dan Kerajaan Tempatan.
https://www.kpkt.gov.my/kpkt/resources/user_1/MENGENAI%20KPKT/DASAR/DKKB.pdf Accessed
3 April 2023
Kunaratnam, K., Halaki, M., Wen, L. M., Baur, L. A., & Flood, V. M. (2020). Tracking preschoolers’ lifestyle
behaviors and testing maternal sociodemographics and BMI in predicting child obesity risk. Journal
of Nutrition, 150(12), 3068-2074. https://doi.org/10.1093/jn/nxaa292
Kurotani, K., Shinsugi, C., Miyoshi, M., & Takimoto H. (2020). Overviews of Shokuiku promotion. Japan
Journal of Nutrition and Dietetics, 78(Supplement): S50-S59.
https://doi.org/10.5264/eiyogakuzashi.78.S50
Lai, W.K., Sidik, S. M., Lekhraj, R., Gan, W. Y., & Ismail, S. I. F. (2022). Prevalence and predictors of overweight
and obesity among adolescents in Seremban, Negeri Sembilan, Malaysia. Cureus, 14(1), e21795.
https://doi.org/10.7759/cureus.21795
Landry, M. J., van den Berg, A. E., Hoelscher, D. M., Asigbee, F. M., Vandyousefi, S., Ghaddar, R., Jeans, M. R.
KM6 Waugh, L., Nikah, K., Sharma, S. V., & Davis, J. N. (2021). Impact of a school-based gardening, cooking,
nutrition intervention on diet intake and quality: The TX Sprouts randomized controlled trial.
Nutrients, 13(9): 3081. https://doi.org/10.3390%2Fnu13093081
Lauer, R. M., Connor, W. E., Leaverton, P. E., Reiter, M. A., & Clarke, W. R. (1975). Coronary heart disease risk
factors in school children: the Muscatine study. Journal of Pediatrics, 86, 697-706.
https://doi.org/10.1016/S0022-3476(75)80353-2
Lee, W. T. K., Ip, K. S., Chan, J. S. H., Lui, N. W. M., & Young, B. W. Y. (2008). Increased prevalence of
constipation in pre-school children is attributable to under-consumption of plant foods: A community-
based study. Journal of Paediatrics and Child Health, 44(4), 170-175. https://doi.org/10.1111/j.1440-
1754.2007.01212.x
Leiter, L. A., & Lewanczuk, R. Z. (2005). Of the renin-angiotensin system and reactive oxygen species: Type
2 diabetes and angiotensin II inhibition. American Journal of Hypertension, 18(1):121-128.
https://doi.org/10.1016/j.amjhyper.2004.07.001
Leon, B.M., & Maddox, T.M. (2015). Diabetes and cardiovascular disease: Epidemiology, biological
mechanisms, treatment recommendations and future research. World Journal of Diabetes, 6(13): 1246-
1258. https://doi.org/10.4239/wjd.v6.i13.1246
Li, N., Wu, X., Zhuang, W., Wu, C., Rao, Z., Du, L., & Zhou, Y. (2022). Cruciferous vegetable and isothiocyanate
intake and multiple health outcomes. Food Chemistry, 375:121816.
https://doi.org/10.1016/j.foodchem/2021.131816
Liliwirianis, N., Musa, N. L. W., Zain, W. Z. W. M., Kassim, J., & Karim, S. A. (2011). Preliminary studies on
phytochemical screening of ulam and fruit from Malaysia. E-Journal of Chemistry, 8(1): S285-S288.
Lim, S. L., Teoh, C., Zhao, X., Umareddy, I., Grillo, V., Singh, S. S., & Khouw, I. (2020). Attitudes & beliefs that
influence healthy eating behaviours among mothers of young children in Singapore: A cross-sectional
study. Appetite, 148, 104555. https://doi.org/10.1016/j.appet/2019.104555
Liska, D., Kelley, M., & Mah, E. (2019). 100% fruit juice and dental health: A systematic review of literature.
Frontiers of Public Health, 7:190. https://doi.org/10.3389/fpubh.2019.00190
186
Loo, M. (2009). Upper respiratory tract infection. Integrative Medicine for Children, 450-455.
https://doi.org/10.1016%2FB978-141602299-2.10060-X
Loso, J., Staub, D., Colby, S. E., Olfert, M. D., Kattelmann, K., Vilaro, M., Colee, J., Zhou, W., Franzen-Castle, L.,
& Mathews, A. E. (2018). Gardening experience is assocated with increased fruit and vegetable
intake among first-year college students: A cross-sectional examination. Journal of the Academy of
Nutrition and Dietetics, 118(2): 275-283. https://doi.org/10.1016/j.jand.2017.09.005
Luchini, V., Musaad, S., Lee, S. Y., & Donovan, S. M. (2017). Observed differences in child picky eating behavior
between home and childcare locations. Appetite, 116:123-131.
http://dx.doi.org/10.1016/j.appet.2017.04.021
Machida, D., & Yoshida, T. (2018). Vegetable intake frequency is higher among the rural than among the
urban or suburban residents, and is partially related to vegetable cultivation, receing, and purchasing
at farmers’ markets: A cross-sectional study in a city within Gunma, Japan. Journal of Rural Medicine,
13(2):116-123. http://dx.doi.org/10.2185/jrm.2960
Majdan, M., & Bobrowska-Korczak, B. (2022). Active compounds in fruits and inflammation in the body.
Nutrients, 16(12), 2496. https://doi.org/10.3390/nu14122496.
Maynard, M., Gunnell, D., Emmett, P., Frankel, S., & Smith, G. D. (2003). Fruit, vegetables, and antioxidants
in childhood and risk of adult cancer: the Boyd Orr cohort. Journal of Epidemiology & Community
Health, 57(3). http://dx.doi.org/10.1136/jech.57.3.218 KM6
McMahan, C. A., Gidding, S. S., Malcom, G. T., Tracy, R. E., Strong, J. P., McGill, H. C. Jr., Pathobiological

Determinants of Atherosclerosis in Youth Research Group. (2006). Pathobiological determinants of
atherosclerosis in youth risk scores are associated with early and advanced atherosclerosis.
Pediatrics, 118(4), 1447-1455. https://doi.org/10.1542/peds.2006-0970
MOH. (2022). Program Hidangan Berkhasiat di Sekolah (HiTS). Ministry of Health Malaysia.
https://nutrition.moh.gov.my/program-hidangan-berkhasiat-di-sekolah-hits/ Updated on 5 Feb 2022.
Accessed on 1 April 2023.
Mora-Urda, A. I., Martin-Almena, F. J., López, M. d. P. M. (2022). Relationship between the dietary
inflammatory index and cardiovascular health among children. International Journal of Environmental
Research and Public Health, 19, 15706. https://doi.org/10.3390/ijerph192315706
Mumena, W. A. (2021). Consumption of free sugars predicts nutrient intake of Saudi children. Frontiers in
Nutrition, 8:782853. https://doi.org/10.3389%2Ffnut.2021.782853
Myles, I. A. (2014). Fast food fever: reviewing the impacts of the Western diet on immunity. Nutrition Journal,
13, 61. https://doi.org/10.1186/1475-2891-13-61
NCCFN (2013). Malaysian Dietary Guidelines for Children and Adolescents 2013. National
Coordinating Committee on Food and Nutrition, Ministry of Health Malaysia, Putrajaya
NCCFN. (2021). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and
Nutrition, Ministry of Health Malaysia, Putrajaya.
Noradilah, M. J., & Zahara, A. M. (2012). Acceptance of a test vegetable after repeated exposures among
preschoolers. Malaysian Journal of Nutrition, 18(1), 67-75.
Norimah, A. K. & Lau, K.K. (2000). Nutritional status among Chinese preschoolers in Subang Jaya, Selangor.
Malaysian Journal of Nutrition, 6: 45-53.
Nutrition Australia (2021). Australian Dietary Guidelines: Standard Serves. https://nutritionaustralia.org/fact-

sheets/adgs-standard-serves/
187
Odegaard, A. O., Koh, W. P., Butler, L. M., Duval, S., Gross, M. D., Yu, M. C., Yuan, J. M., & Pereira, M. A. (2011).
Dietary patterns and incident type 2 diabetes in Chinese men and women: The Singapore Chinese
Health Study. Diabetes Care, 34(4):880-885. https://doi.org/10.2337/dc10-2350
Olmo, B. M. G., Butler, M. J., & Barrientos, R. M. (2021). Evolution of the human diet and its impact on gut
microbiota, immune responses, and brain health. Nutrients, 13(1), 196.
https://doi.org/10.3390/nu13010196
Paglia, L. (2019). The sweet danger of added sugars. European Journal of Paediatric Dentistry, 20(2): 89.
https://doi.org/10.23804/ejpd.2019.20.02.01
Petroski, W., & Minich, D. M. (2020). Is there such a thing as “Anti-Nutrients”? A narrative review of perceived
problematic plant compounds. Nutrients, 12(10): 2929. https://doi.org/10.3390/nu12102929
Poh, B.K., Tham, K. B. L., Wong, S. N., Chee, W. S. S., & Tee, E. S. (2012). Nutritional status, dietary intake
pattens and nutrition knowledge of children aged 5-6 years attending kindergartens in the Klang
Valley, Malaysia. Malaysian Journal of Nutrition, 18(2): 231-242.
Rachmi, C. N., Jusril, H., Ariawan, I., Beal, T., & Sutrisna, A. (2021). Eating behaviour of Indonesian
adolescents: A systematic review of the literature. Public Health Nutrition, 24(S2), S84–S97.
https://doi.org/10.1017/S1368980020002876
KM6 Raggio, L. & Gambaro, A. (2018). Study on the reasons for consumption of each type of vegetable within a
population of school-aged children. BMC Public Health, 18: 1163. https://doi.org/10.1186/s12889-018-
6067-4
Rai, A. K., Singh, N., Rani, R., Kanse, S., & Shingh, S. (2019). Selenium in food, its detection methods and
human health: A review. Trends in Biosciences, 12(12), 849-854.
Raverdeau, M, & Mills, K. H. (2014). Modulation of T cell and innate immune responses by retinoic acid.
Journal of Immunology (Baltimore, Md.: 1950), 192(7), 2953-2958.
https://doi.org/10.4049/jimmunol.1303245
Rock, C. K., Thomson, C., Gansler, T., Gapstur, S. M., McCullough, M. L., Patel, A. V., Andrews, K. S., Bandera,
E. V., Spees, C. K., Robien, K., Hartman, S., Sullivan, K., Grant, B. L., Hamilton, K. K., Kushi, L. H., Caan,
B. J., Kibbe, D., Black, J. D., Wiedt, T. L., McMahon, C., Sloan, K., & Doyle, C. (2020). American Cancer
Society guideline for diet and physical activity for cancer prevention. CA: A Cancer Journal for
Clinicians, 70(4), 245-271. https://doi.org/10.3322/caac.21591
Rodriguez-Moran, M., Mendia, L. E. S., Galvan, G. Z., Guerrero-Romero, F. (2011). The role of magnesium in
type 2 diabetes: a brief based-clinical review. Magnesium Research, 24(4)156-62.
https://doi.org/10.1684/mrh.2011.0299
Rogers, P. C., & Barr, R. D. (2020). The relevance of nutrition to pediatric oncology: A cancer control
perspective. Pediatric Blood & Cancer, 67(Suppl. 3), e28213. https://doi.org/10.1002/pbc.28213
Schwager, J., Bompard, A., Weber, P., & Raederstorff, D. (2015). Ascorbic acid modulates cell migration in
differentiated HL-60 cells and peripheral blood leukocytes. Molecular Nutrition and Food Research,
59(8), 1513-1523. https://doi.org/10.1002/mnfr.201400893
Serafini, M., & Peluso, I. (2016). Functional foods for health: The interrelated antioxidant and anti-
inflammatory role of fruits, vegetables, herbs, spices and cocoa in humans. Current Pharmaceutical
Design, 22(44), 6701-6715. https://doi.org/10.2174/1381612823666161123094235
Shefferly, A., Scharf, R.J., & DeBoer, M. D. (2016). Longitudinal evaluation of 100% fruit juice consumption
on BMI status in 2 – 5-year-old children. Pediatric Obesity, 11(3): 221-227.
https://doi.org/10.1111/ijpo.12048
188
Siwarom, S., Aekplakorn, W., Pirojsakul, K., Paksi, W., Kessomboon, P., Neelapaichit, N., Chariyalertsak, S.,
Assanangkornchai, S., & Taneepanichskul, S. (2021). Metabolic syndrome in Thai adolescents and
associated factors: the Thai National Health Examination Survey V (NHES V). BMC Public Health, 21,
678. https://doi.org/10.1186/s12889-021-10728-6
Song, L., & Thornalley, P. J. (2007). Effect of storage, processing and cooking on glucosinolate content of
Brassica vegetables. Food and Chemical Toxicology, 45(2): 216-224.
https://doi.org/10.1016/j.fct.2006.07.021
Soon. A. T. K., & Ding, P. (2021). A review of wild indigenous eggplant, terung asam Sarawak (Solanum
lasiocarpum Dunal.) Sains Malaysiana, 50(3): 595-603. https://doi.org/10.17576/jsm-2021-5003-03
Stan, S. D., Kar, S., Stoner, G. D., Singh, S. V. (2008). Bioactive food components and cancer risk reduction.
Journal of Cellular Biochemistry, 104(1), 339-356. https://doi.org/10.1002/jcb.21623
Strong, J.P., Zieske, A.W., & Malcom, G.T. (2001). Lipoproteins and atherosclerosis in children: an early
marriage? Nutrition, metabolism, and cardiovascular diseases: NMCD, 11(Suppl. 5):16-22.
Sudha, V. V., Reddy, R. V. S. K., & Swami, D. V. (2021). Moringa: A tree with benefits beyond vegetable.
International Journal of Innovative Horticulture, 10(1): 23-34. https://doi.org/10.5958/2582-
2527.2021.00002.6
Tappin, D., Grzeda, M., Joinson, C, & Heron, J. (2020). Challenging the view that lack of fibre causes KM6
childhood constipation. Archives of Disease in Childhood, 105, 864-868.
http://dx.doi.org/10.1136/archdischild-2019-318082

te Velde, S. J., Twisk, J. W. R., & Brug, J. (2007). Tracking of fruit and vegetable consumption from adolescence
into adulthood and its longitudinal association with overweight. British Journal of Nutrition, 98(2),
431-438. https://doi.org/10.1017/S0007114507721451
Tee, E. S., Ismail, M. N., Nasir, M. A., & Kahtijah, I. (1997). Nutrient Composition of Malaysian Foods, 4th
Edition, Malaysian Food Composition Database Programme, Institute for Medical Research, Kuala
Lumpur.
Tharmabalan, R. T. (2023). Nutritional profiles of four promising wild edible plants commonly consumed by
the Semai in Malaysia. Current Developments in Nutrition,
https://doi.org/10.1016/j.cdnut.2023.100054
Thornton, K. A., Mora-Plazas, M., Marin, C., & Villamor, E. (2014). Vitamin A deficiency is associated with
gastrointestinal and respiratory morbidity in school-age children. Journal of Nutrition, 144(4), 496-
503. https://doi.org/10.3945%2Fjn.113.185876
Trofholz, A. C., Schulte, A., & Berge, J. M. (2016). How parents describe picky eating and its impact on family
meals: a qualitative analysis. Appetite, 110: 36-43. https://doi.org/10.1016/j.appet.2016.11.027
UNICEF. (2021). Fed to fail: The crisis of children’s diets in early life. Child Nutrition Report. In Brief.
https://www.unicef.org/media/107226/file/Fed_to_Fail_-_BRIEF_-_ENGLISH_-_Final.pdf
USDA (2016). National Nutrient Database for Standard Reference, Release 28. US Department of Agriculture,
Agricultural Research Service, Nutrient Data Laboratory. http://www.ars.usda.gov/ba/bhnrc/ndl.
Ventura, A. K., & Worobey, J. (2013). Early influences on the development of food preferences. Current
Biology, 23(9), R401R408. https://doi.org/10.1016/j.cub.2013.02.037
Walker, R. W., Dumke, K. A., & Goran, M. I. (2014). Fructose content in popular beverages made with and
without high-fructose corn syrup. Nutrition, 30(7-8), 928-935.
https://doi.org/10.1016/j.nut.2014.04.003
189
Wang, P. Y., Fang, J. C., Gao, Z. H., Zhang, C., & Xie, S. Y. (2016). Higher intake of fruits, vegetables or their
fiber reduces the risk of type 2 diabetes: A meta-analysis. Journal of Diabetes Investigation, 7(1): 56-
69. https://doi.org/10.1111%2Fjdi.12376
Wallace, T. C., Bailey, R. L., Blumberg, J. B., Burton-Freeman, B., Chen, O. C. Y., Crowe-White, K. M.,
Drewnowski, A., Hooshmand, S., Johnson, E., Lewis, R., Murray, R., Shapses, S. A., & Wang, D. D. (2020).
Fruits, vegetables, and health: A comprehensive narrative, umbrella review of the science and
recommendations for enhanced public policy to improve intake. Critical Reviews in Food Science
and Nutrition, 60(13), 2174-2211. https://doi.org/10.1080/10408398.2019.1632258
Wanichsetakul, W., & Wongteerasut, A. (2021). Risk factors of functional constipation among Thai children.
Southeast Asian Journal of Tropical Medicine and Public Health, 52(2), 191-202.
WCRF. (2018). Continuous update project: Analysing research on cancer prevention and survival.
Recommendations and public health and policy implications. https://www.wcrf.org/wp-
content/uploads/2021/01/Recommendations.pdf Accessed on 5 January 2023.
Wells, N. M., Todd, L. E., Henderson, C. R. Jr., Myers, B. M. Barale, K., Gaolach, B., Ferenz, G., Aitken, M.,
Hendrix, L, Taylor, C., & Wilkins, J. L. (2022). The effects of school gardens on fruit and vegetable
consumption at school: A randomized controlled trial with low-income elementary schools in four
U.S. states. Preventive Medicine Reports, 31:102053. https://doi.org/10.1016/j.pmedr.2022.102053
KM6 WHO. (2017). Diarrhoeal disease.

https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
Williamson, G., Plumb, G. W., Uda, Y., Price, K. R., & Rhodes, M. J. C. (1996). Dietary quercetin glycosides:
antioxidant activity and induction of the anticarcinogenic phase II marker enzyme quinone reductase
in Hepalclc7 cells. Carcinogenesis, 17(11):2385-2387. https://doi.org/10.1093/carcin/17.11.2385
Wong, J. Y., Matanjun, P., Ooi, Y. B. H., & Chia, K. F. (2013). Characterization of phenolic compounds,
carotenoids, vitamins and antioxidant activities of selected Malaysian eld edible plants. International
Journal of Food Sciences and Nutrition, 64(5): 621-631. https://doi.org/10.3109/09637486.2013.763910
Wong, J. Y., Matanjun, P., Ooi, Y. B. H., & Chia, K. F. (2014). Evaluation of antioxidant activities in relation to
total phenolics and flavonoids content of selected Malaysian wild edible plants by multivariate
analysis. International Journal of Food Properties, 17(8):1763-1778.
https://doi.org/10.1080/10942912.2012.724756
Wongprawmas, R., Xhakollari, W., Spadoni, R., Renner, B., & Canavari, M. (2022). Effect of multimedia
interventions on children’s furit and vegetable consumption in a real-life setting. Young Consumers,
24(1):40-55. https://doi.org/10.1108/YC-05-2022-1519
Yamada, M., Sekine, M., & Tatsuse, T. (2019). Psychological stress, family environment, and constipation in
Japanese children: The Toyoma Birth Cohort Study. Journal of Epidemiology, 29(6), 220-226.
https://doi.org/10.2188/jea.JE20190016
Yamada, M., Sekine, M., Tatsuse, T., & Fujimura, Y. (2021). Lifestyle, psychological stress, and incidence of
adolescent constipation: results from the Toyoma birth cohort study. BMC Public Health, 21, 47.
https://doi.org/10.1186/s12889-020-10044-5
Yoshii, K., Hosomi, K., Sawane, K., & Kunisawa, J. (2019). Metabolism of dietary and microbial vitamin B
family in the regulation of host immunity. Frontiers in Nutrition, 6, 48.
https://doi.org/10.3389/fnut.2019.00048
Zalilah, M. S., Khor, G. L., Mirnalini, K., & Sarina, S. (2005). Food neophobia and nutritional outcomes in
primary school children. Journal of Community Nutrition, 7(3), 121-129.
190
Zalilah, M. S., Khor, G. L., Sarina, S., Huang, S. L., Chin, Y.S., Barakatun, N. M. Y., Chan, Y. M., & Maznorila, M.
(2015). The relationship between household income and dietary intakes of 1-10 year old urban
Malaysian. Nutrition Research and Practice, 9(3), 278-287. https://doi.org/10.4162/nrp.2015.9.3.278
Zeinstra, G. G., van der Haar, S., & Haveman-Nies, A. (2021). Strategies to increase primary school children’s
fruit and vegetable intake during 10AM snack time. Appetite, 163:105235.
https://doi.org/10.1016/j.appet.2021.105235
Zhu, F., Du, B., & Xu, B. (2018). Anti-inflammatory effects of phytochemicals from fruits, vegetables, and food
legumes: A review. Critical Reviews in Food Science and Technology, 58(8), 1260-1270.
https://doi.org/10.1080/10408398.2016.1251390
Zieske, A. W., Malcom, G. T., & Strong, J. P. (2002). Natural history and risk factors of atherosclerosis in
children and youth: the PDAY study. Pediatric Pathology & Molecular Medicine, 21(2), 213-237.
https://doi.org/10.1080/15227950252852104
Zoidis, E., Seremelis, I., Kontopoulos, N., & Danezis, G. P. (2018). Selenium-dependent antioxidant enzymes:
Actions and properties of selenoproteins. Antioxidants (Basel), 7(5), 66.
https://doi.org/10.3390/antiox7050066
Zuwariah, I., Syahida, M., Faridah, H., Rodhiah, R., & Fakhri, M. H. (2021). Screening of vitamin, mineral and
antioxidants in selected vegetables, fruit and grains for the elderly. Food Research, 5(Suppl. 1), 122-
131. https://doi.org/10.26656/fr.2017.5(S1).020 KM6
191
KM6
192
Key Message 7
Eat adequate amount of rice, other cereals, whole

grain cereal-based products and tubers
KM7
Eat adequate amount of rice, other cereals, whole grain cereal-based products and tubers.
Key Message 7
Eat adequate amount of rice, other cereals,

whole grain cereal-based products and tubers
Assoc. Prof. Dr. Nik Shanita Safii, Ms. Maizatul Azlina Chee Din, Dr. Nurfarhana Diana Mohd Nor,
Assoc. Prof. Dr. Wan Azdie Mohd Abu Bakar, Mr. Mohd Faez Bachok and Ms. Nuurdiana Mohd Rafien
7.1 Terminology
Breads
Breads are the product basically obtained by baking transglutaminase are permitted food conditioners to
a yeast-leavened dough prepared from flour or meal, be used in bread production. Common examples of
or a combination of these with water and yeast. breads allowed in Malaysian markets under the
According to Food Act 1983, Regulations 52 (2), Food Act 1983, are white bread, fruit bread, milk
propionic acid and its sodium, potassium or calcium bread, meal bread, rye bread, wheat-germ bread,
salts can be used as permitted preservatives in whole-meal bread and enriched breads MOH,
breads while ammonium chloride, calcium and (1985).
sodium salt of fatty acid lactylates, fumarates and
194
Breakfast cereal Cereal-based products

Breakfast cereal is processed cereal that is usually Cereal products mostly made from a variety of
taken as breakfast in the morning. Based on FLIP grains including rice, wheat, maize, oats, rye, barley,
study by Angelino et al. (2019), cereal breakfast can millet, quinoa, and sorghum derive either from the
be categorized into 5 main category: bars, muesli, processing of grain through one or more mechanical
flakes, bran cereals and puffed cereals. Bars made of or chemical operations, or from the processing of
cereal grains and shaped as a bar. Muesli contains flour, meal or starch (FAO, 1996).
rolled oats and sometimes added with other cereal
grains. Flakes are cereals that produce different Dietary fiber
rolled out and toasted cereals. While, bran cereals Dietary fiber is the edible parts of plants or
are the group of bran cereals from different cereals analogous carbohydrates that are resistant to
and can be formed into different shapes such as digestion and absorption in the human small
sticks. Puffed cereals are cereals formed from the intestine with complete or partial fermentation in
expansion process of cereal grains and mostly the large intestine. Dietary fiber includes
added with other ingredient such as cocoa. polysaccharides, oligosaccharides, lignin, and
(Angelino et al., 2019). Sugar, honey, malt, salt and associated plant substances. Dietary fibers promote
any other foods are allowed to be used in cereal beneficial physiological effects including laxation,
breakfast production in Malaysia MOH, (1985). and/ or blood cholesterol attenuation, and/ or blood
glucose attenuation (AACC, 2001).
Carbohydrate
Carbohydrate is a naturally occuring compound Glycaemic index (GI)
with general chemical formula Cx(H2O)y, and made A way to classify different types of carbohydrate-
up of molecules of carbon (C), hydrogen (H), and containing foods based on its ability to raise the KM7
oxygen (O) (Davidson, 2020). In a classic definition, blood glucose level. GI is defined as the incremental
carbohydrates are interpreted as polyhydroxy area under the blood glucose response curve elicited
aldehydes, ketones, alcohols, acids with their simple by a 50g available carbohydrate portion of a food
derivatives and their polymers having linkages of expressed as a percentage of the response to 50g
the acetal type (FAO/WHO, 1998). Acting as a anhydrous glucose taken by an individual (Wolever,
macronutrient as well as fat, protein and fats, 2013).
carbohydrate serve as important energy sources for
human (USDHHS & USDA, 2020) and becomes Glycaemic load (GL)
essential structural components in organism The GL refers to the cumulative exposure to
(Davidson, 2020). Carbohydrates are the least postprandial glycemia, as a measure of insulin
concentrated form of energy providing 4 kcal per demand, over a specified period of time (Salmeron
gram (NHMRC, 2013) and can be classified according et al., 1997). It does not take into account the pattern
to degree of polymerization: sugars, oligosaccharides of loading within the specified time e.g., few high –
and polysaccharide (FAO/WHO, 1998). glycaemic impact meals versus frequent meals of
low glycaemic impact. It is calculated indirectly as
Cereals the product of the average GI of carbohydrate foods
Cereals are the edible seeds known as kernel or consumed and the total carbohydrate intake over a
grains of the grass family, Gramineae or Poaceae specified time period (Jenkins et al., 1981).
(Frølich & Aman, 2010). True cereal grains include
wheat, oat, rice, corn, barley, rye, kamut, triticale, Noodles and pasta
sorghum, fonio, millet, teff, and canary seed (AACCI, Mee (noodles), bihun, laksa, macaroni and spaghetti
2006). All cereal grains have three anatomical can be classified under group of pasta. According to
components: the bran, endosperm, and germ. Each Food Act 1983, (MOH, 1985) pasta are food products
component contributes to a different nutritional that obtained by extruding or moulding units of
composition. Bran consists primarily of the main dough made of cereal flour and may contains
outer layers of the grain which is rich in dietary fiber, permitted colouring substance and
vitamins, minerals, and phytochemicals (Seal et al., transglutaminase, sulphur dioxide or sulphites as a
2016). The endosperm constitutes about 60-85% of permitted food conditioner. Carbohydrate foods, egg
the grain, comprised mainly of carbohydrates in the solids and salts are the main ingredients of pasta.
form of starches with some protein and B vitamins
(Frølich & Aman, 2010). The germ is the smallest
fraction (2.5-3%) of the grain, containing a high lipid
and protein content and some vitamins and
minerals (Mathews & Chu, 2020).
195
Rice Tuber and root

Grains of Oryza sativa from which the husk has been Tuber and root are plants grown throughout the
removed are known as rice (MOH, 1985). Among world in hot and humid regions which contain 70–
different varieties of rice found at retails outlets in 80% water, 16–24% starch and trace quantities
Malaysia include local and imported white rice, (<4%) of proteins and lipids (Hoover, 2001). They are
brown unpolished rice, wild rice, basmati, parboiled, planted to yield starchy roots, rhizomes, corns,
fragrant rice and glutinous rice. The main criteria in stems and tubers. These include potatoes, sweet
the classification of rice are length of grain, content potatoes, tapioca (cassava), yam, lotus root, ginger
of head rice, content of broken rice and milling root and sweet turnip (sengkuang) (MOH, 1985).
degree (BERNAS, 2021).
Ultra-Processed Food (UPF)
Refined grains Ultra-processed foods are characterized by NOVA
Refined grains are referred to the grains that have as industrial formulations generated through
passing through milled process, a process that compounds extracted, derived or synthesized from
removes the bran and germ to give grains a finer food or food substrates. Ultra-processed foods also
texture and improve their shelf life (NHMRC, 2013). commonly contain artificial substances such as
Since the milling process has removed dietary colours, sweeteners, flavours, preservatives,
FIBERs, iron and B vitamins, most refined grains are thickeners, emulsifiers and other additives used to
enriched back with most B vitamins (thiamin, promote aesthetics, enhance palatability and
riboflavin, niacin, folic acid) and iron (USDA, 2019). increase shelf life (Monteiro et al., 2019; Lane et al.,
2020). Starches and glucose-fructose/glucose syrup
Common examples of refined grains are white flour, are the most commonly used carbohydrate-based
KM7 degermed cornmeal, white bread, and white rice . ingredients in UPF compared to dextrose, maltose,
Foods popular on the market such as burgers, maltodextrin and inverted sugar (Fardet & Rock,
macaroni and cheese, crackers, cakes, cookies and 2020). Sweetened breakfast cereals, mass-produced
pancakes are common examples of foods that packaged breads and buns, biscuits (cookies), pizza
contain these refined grains (USDHHS & USDA, and pasta, instant noodles are common examples of
2020). UPF in the Malaysian market (Asma’ et al., 2019).
Whole grain
Snacks
A snack is composed of solid food with or without a Whole grains refer to cereal food consist of the
beverage that occurs between habitual meal intact, ground, cracked or flaked caryopsis, whose
occasions for the individual, is not a substitute for a principal anatomical components are the starchy
meal, and provides substantially fewer calories than endosperm, germ, and bran, which are present in
would be consumed in a typical meal (Johnson & the same relative proportions as they exist in the
Anderson, 2010). intact caryopsis (AACCI, 1999; Jones, 2010).
Starches Whole grain products

Many glucose units are linked together into long Whole grain products are food products made with
chains. Examples of foods containing starch include at least one whole grain ingredient (AACC, 2000). In
vegetables (e.g., carrots), starchy roots and tubers Malaysia, according to Food Amendment (No 4)
(e.g., potatoes), grains (e.g., brown rice, oats, wheat, 2020 Regulations 18, in order to declare a product as
barley, corn), and legumes (beans and peas; e.g., a whole grain product, the food must contain 100%
kidney beans, garbanzo beans, lentils, split peas) whole grain ingredients for wheat flour, rice flour,
(USDHHS & USDA, 2015). rice and grains; a minimum of 60% whole grain
ingredients for bread; and a minimum of 25% or 8 g
Sugars per serving whole grain ingredients for other
Composed of one unit (monosaccharide, such as products under Food Act, 1983 MOH, (1985).
glucose or fructose) or two joined units
(disaccharide, such as lactose or sucrose). Sugars
include those occurring naturally in foods and
beverages, those added to foods and beverages
during processing and preparation, and those
consumed separately (USDHHS & USDA, 2015).
Other terminologies for sugars which include total
sugars, free sugars, added sugars and hidden sugars
can be found in Key Message 12.
196
7.2 Introduction
Cereals and cereal products are the basis of diets in the refined form of cereals, choosing whole grain
many different cultures and cuisines in both cereals is a better option. Nevertheless, fortification
developed and developing countries, providing a of cereals and cereal-based products can be
major proportion of dietary energy and nutrients optimized to improve the key nutrient content
(Laskowski et al., 2019). The popularly consumed (Smith et al., 2020). This is important as ready-to-eat
cereals include wheat, corn, rice, barley, and foods such as breakfast cereals and various types of
sorghum. Cereals contribute to more than 50% of bread are among the popular diet in children and
the food energy supply, mainly from the 75% adolescents.
carbohydrates, and 6-15% protein content (WHO,
2003). Global cereal production annual forecast, Second to cereals are tubers and other starchy roots
pegged at 2788 million tonnes, indicates that the which are also an important source of energy
world food security depends on its production (FAO, worldwide. This includes potatoes, yams, sweet
2021). potatoes, taro and cassava. Nutritionally, tubers are
highly potential to provide economical sources of
In Malaysia, rice is the main cereal and staple energy, besides containing various micronutrients
consumed due to its cultural importance for all and other compounds beneficial to health
major ethnic groups, palatability, and ease of (Chandrasekara & Kumar, 2016). Hence, tubers and
preparation. Rice is easily available and accessible other starchy root plants are good options for
in the country as its production is subsidized and cereals. However, cautions need to be taken when
supply is assured by means of various policies, it involves ultra-processed food which include
including the National Agrofood Policy which sweet, fatty, or salty packaged snacks made from KM7
ensures enough production of rice as it is the staple cereals or tubers as excessive consumption of UPF
food for Malaysians. This is followed by wheat and products may cause adverse health effects (Marino
wheat-based products which include noodles, et al., 2021).
breads, and pastas (Sundaram & Tan, 2019).
It is evident that cereals, particularly whole grains
Cereals have become the main source of energy and are important for health beyond the simple provision
plant-based protein. On top of that, whole grain food of energy and other major nutrients. This includes
which contain both bran and germ were found to lowering the risk of cardiovascular diseases and
provide FIBER, minerals, trace elements, vitamins, type 2 diabetes as well as some types of cancer
carotenoids, polyphenols and numerous bioactive (McRae, 2017). Since children and adolescents are
compounds with antioxidant and anti-carcinogenic still growing and developing, it is utmost important
properties (Gani et al., 2012). As the bran and germ to inculcate the healthier way of eating cereals and
are removed during the milling process to produce cereal based products, ensuring their healthy future.
Childhood is a critical phase where growth and There are many other studies reported that
development occur. It has been well accepted that nutritional status during childhood is a determinant
the first 1000 days of a child’s life - that is the period of health status in later life. Children who have been
beginning after conception up until the child is 2 practicing unhealthy eating habits may develop
years old – is crucial to determine a lifelong health chronic diseases such as diabetes and
status. Early nutrient deficiency is associated with cardiovascular diseases when they become adults
impairment of brain function (Derbyshire & Obeid, (Weihrauch-Blüher et al., 2018). In addition, evidence
2020), health status and children’s growth and shows that dietary habits start during childhood and
development (Beluska-Turkan et al., 2019) in the persist through adulthood (Movassagh et al., 2017).
long term. In addition, this period is also crucial in Therefore, it is important for parents or caregivers to
preventing the development of obesity by adhering ensure children practise healthy eating habits from
to the healthy eating practice (Blake-Lamb et al., an early age. Focusing on increasing whole grains
2016; Woo Baidal et al., 2016) in a child’s daily diet, a growing body of literature
has suggested that whole grains offer various health
benefits. The discussion is as follow:
197
7.3.1 Gastrointestinal health prevent these diseases. This study is consistent with
a systematic review by Chanson-Rolle et al. (2015)
One of many key findings from previous literature where it is reported that intake of 45g/day of whole
shows that whole grain is associated with grain foods reduces the risk of type 2 diabetes by
gastrointestinal health. Cooper et al. (2017) reported 20% if compared to intake of 7.5g/day of whole grain
that in a 6-week intervention study, whole grain foods.
adult consumers had a significant increase in bowel
movement frequency after the intervention ended. Findings from 3 prospective cohort studies which
On the other hand, there was no increase in bowel involved 194,784 participants showed that higher
movement frequency among refined grain adult consumption of whole grains, which include whole
consumers. Furthermore, whole grain consumption grain breakfast cereal, oatmeal, dark bread, brown
is reported to have an inverse association with rice, added bran, and wheat germ has a significant
gastrointestinal cancers especially colorectal type association with a lower risk of type 2 diabetes (Hu
(Tullio et al., 2020) This is possibly explained by et al., 2020). Another large cohort study including
higher nutrient content and phytochemicals in 55,465 participants aged 50 to 65 years at baseline,
whole grains compared to refined grains. Consistent reported that 16g intake of whole grains per day was
with Xu et al. (2018), there was an association associated with 11% and 7% risk reduction of type
between whole grain consumption and decreased 2 diabetes in men and women, respectively (Kyrø et
risk of gastric cancer risk, however refined grain al., 2018). Furthermore, wheat, rye and oats were
consumption was associated with increased risk of significantly associated with reduced risk of type 2
gastric cancer. diabetes in men, while only wheat and oats were
associated with a lower risk of type of diabetes in
KM7 One of the factors relating to whole grains and women.
gastrointestinal benefits is that whole grains
promote gut microbiota. It has been established that In addition, a significant association was found
gut microbiota has an important role in health. In a between a high intake of whole grains with reduced
review by Tosh & Bordenave (2020), it has been risk of coronary heart disease, cardiovascular
reported that whole grains, particularly oats and disease, total cancer and all causes mortality, where
barley support beneficial gut microbiota. Similarly risk reductions were observed up to an intake of
reported by Kristek et al. (2018) where whole grains 210-225g/day of whole grains (7-7 ½ servings/day)
are potential to stimulate microbiota diversity and (Aune et al., 2016). There have been several
this is explained by phenolic acid content in whole mechanisms suggested to explain the health
grains. benefits of whole grain intake. As whole grains are
rich in fiber, they may help in lowering risk of
7.3.2 Chronic diseases (DM, HPT, cancer, hypertension, hypertriglyceridemia and lowering
heart disease) concentrations of total and low-density lipoprotein
cholesterol, which all are cardiovascular risk factors.
According to the National Health and Morbidity Other than that, whole grain intake has been
Surveys (NHMS) 2019, the prevalence of diabetes associated with a better glycaemic control by
mellitus has shown an increasing trend from 2011 reducing the postprandial glucose and insulin
to 2019 (National Institutes of Health, 2019). A study responses.
found that over a third of children and adolescents
with diabetes type 1 were overweight and obese, 7.3.3 Weight management
particularly girls (Marlow et al., 2019). Furthermore,
the study reported that this group has increased risk Previous studies also suggest that whole grains can
of cardiovascular disease. A review paper by help in managing body weight. In a randomized
Barazzoni et al. (2017) concluded that low glycemic cross-over trial, 50 adults underwent a whole grain
index and high fiber diets may have health benefits diet (179g/day of whole grain) and a refined grain
for people with diabetes, insulin resistance and diet (13g/day of whole grain). Results showed the
obesity. whole grain diet significantly reduced body weight,
fat-free mass and sagittal abdominal diameter
Whole grain which is high in fiber has been compared to the refined grain diet (Roager et al.,
suggested to have a potential in lowering the 2017). It has also been observed that during the
incidence of type 2 diabetes, cardiovascular whole grain diet, the energy intake is reduced which
diseases and certain cancers (Seal et al., 2021). explains body weight loss. The authors further
According to McRae (2017), 2 to 3 servings of whole explained that whole grains induce satiation which
grains which is approximately 45g daily may help to then led to lower energy intake. Another randomized
198
double-blind study reported that obese adults who Another review study which investigated the role of
consumed two loaves of whole grain wheat bread nutrition and executive functioning among children
per day to replace their staple foods for 12 weeks and adolescents, found that healthier foods which
showed decrease in visceral fat area compared to include whole grains, fish, fruits and vegetables has
obese adults who consumed refined wheat bread a positive association with executive functioning.
(Kikuchi et al., 2018). Executive functioning is an important component
to make goal-directed behaviours such as inhibitory
In line with the results, Koo et al. (2018) reported that control, working memory, attention and planning
a 12-weeks high whole grain diet intervention have (Cohen et al., 2016). As suggested by the authors, the
shown to have lower BMI-for-age z score, body fat possible mechanisms in this association is healthier
percentage and waist circumference in foods contain all the nutrients needed in developing
overweight/obese children aged 9 to 11 years. A brain function, such as vitamin B, vitamin C and
recent review also supports the associations of zinc.
whole grain consumption with better body weight
management (Kissock et al., 2020). 7.3.5 Limit intake of refined grain
carbohydrate
7.3.4 Cognitive function
A diet that is high in processed foods, added sugars,
Cognitive function has also been associated with and other refined carbohydrates is a principal factor
dietary habits. Kim & Yun (2018) found that an driving the growing epidemics of type 2 diabetes
adequate intake of whole grains (2-4 times/day), (T2D), hypertension (HTN), and cardiovascular (CV)
fruits (1-2 times/day), milk and dairy products (1-2 disease (CVD) (Bhardwaj et al., 2016). The study from
cups/day) have the potential to reduce risks of mild DiNicolantonio & O’Keefe (2017) showed increase in KM7
cognitive impairment in adults aged over 50 years. the intake of carbohydrates appears to have
Besides, a short-term intervention study reported contributed to dyslipidemia in the Alaskan Inuit.
that the protein brain-derived neurotrophic factor
(BDNF) increased after consumption of whole grain A systematic review by Rocha et al. (2017) showed
rye kernel-based bread by 27% compared to there was a positive association between
consumption of wheat flour-based bread in 19 ‘‘unhealthy’’ dietary patterns and cardiometabolic
healthy adults (Sandberg et al., 2018). BDNF is alterations in children and adolescents. The studies
particularly important in memory formation (Allen showed an association between dietary patterns
et al., 2011). and cardiometabolic alterations. The patterns were
characterized as unhealthy when associated with
Previous studies showed that there are 3 types of the consumption of ultra-processed products, poor
diet that involve in improving cognitive function and in fiber, and rich in sodium, fat and refined
brain ageing, namely Mediterranean diet (MeDi), carbohydrates.
Dietary Approaches to Stop Hypertension (DASH)
and Mediterranean-DASH Intervention for Besides, frequent refined carbohydrate-rich food
Neurodegenerative Delay (MIND) diets. From these consumption generates chronic hyperglycemia and
3 diets, DASH and MIND recommend to include thus chronic hyperinsulinemia, the latter interfering
whole grains in a daily diet. The DASH diet is with growth factors and sex hormones, which
basically high in fruits, vegetables, nuts, legumes, themselves modulate morphology and secondary
whole grains, low fat dairy products, and low intake sex characteristics (Cordain et al., 2003). For
of sodium, sweetened beverages, and red and example, Zuniga et al. (2017) showed that
processed meats. While for MIND diet, it includes carbohydrate intake, mainly food items rich in
green leafy vegetables, other vegetables, nuts, refined carbohydrates, reduces body odor
berries, beans, whole grains, fish, poultry, olive oil attractiveness. Also, refined carbohydrates are
and wine. The diet also recommends to limit the among the factors suspected to accelerate skin
intake of red meats, butter, stick margarine, pastries, aging and photo-aging (Cosgrove et al., 2007; Purba
sweets and fried or fast foods. A review study et al., 2001). Considering that facial masculinity/
reported that MIND diet has a higher effect in femininity influences attractiveness (Puts et al.,
slowing cognitive decline than MeDi or DASH diets 2012), it is possible that an increase in refined
(Gardener & Rainey-Smith, 2018). The authors carbohydrate consumption has affected facial
further discussed that dietary habit affects brain attractiveness.
function and structure which then influence
cognitive outcomes.
199
An epidemiological cross-sectional study was croquettes; mayonnaise; and alcoholic drinks

conducted between May 2017 and May 2018. The produced by fermentation followed by distillation
studies showed that there was a probability of such as whisky, gin, and rum
myopia in children with highly refined
carbohydrates consumption in France (Berticat at. Another study from large observational prospective
al., 2020). Overall, 86/264 (32.6%) children study (n=105159), was showed higher consumption
investigated showed myopia in at least one eye. of ultra-processed foods was associated with higher
Myopia is a multifactorial refractive disorder risks of cardiovascular, coronary heart, and
characterized by blurry distance vision with eyes cerebrovascular diseases. This study primarily
displaying steep corneal curvature and/or longer focused on the NOVA group of ultra-processed
axial length as compared with emmetropes. High foods. This group includes mass produced packaged
myopia is a risk factor for potentially blinding breads and buns, sweet or savoury packaged
complications such as retinal detachment, snacks, industrialised confectionery and desserts,
subretinal neovascularization, early cataract, and sodas and sweetened beverages, meatballs, poultry
glaucoma. Complications will have an enormous and fish nuggets, and other reconstituted meat
impact on children and adolescents in their lives. products transformed with the addition of
preservatives other than salt (eg., nitrites), instant
7.3.6 Ultra-Processed Food (UPF) noodles and soups, frozen or shelf stable ready
meals, and other food products made mostly or
Ultra-processed food (UPF) consumption has entirely from sugar, oils, and fats, and other
increased drastically worldwide and already substances not commonly used in culinary
represents 50%–60% of total daily energy intake in preparations, such as hydrogenated oils, modified
KM7 several high-income countries. In the meantime, the starches, and protein isolates. The associations were
prevalence of overweight and obesity has risen similar when used the amount of ultra-processed
continuously during the last century. Finding from food intake (g/day), rather than the proportion
large observational prospective study has showed (hazard ratio for a 100 g/day increase of ultra-
higher consumption of UPF was associated with processed food in the diet 1.04 (95% confidence
gain in BMI and higher risks of overweight and interval 1.02 to 1.07); P=0.001 for CVD risk).
obesity. However, ultra-processed food like
beverages, dairy products, fats and sauces, and 7.3.7 Glycaemic index and glycaemic load
meat, fish, and egg were each associated with
increased overweight and obesity risks, while ultra- A recent systematic review of prospective cohort
processed starchy foods and breakfast cereals were studies that examined the association of cereal fiber
associated with an increased risk of overweight but with type 2 diabetes risk concluded that consuming
not obesity (Beslay et al., 2020). foods rich in fiber is associated with modestly
reduced risk of type 2 diabetes (Cho et al., 2013).
Finding from Seguimiento Universidad de Navarra Findings from prospective cohort study by
(SUN) prospective cohort study by Rico-Campa and Bhupathiraju et al. (2014), showed consume a diet
colleagues, (2019) found a positive dose-response rich in whole grains and indicate that a diet low in
association between consumption of ultra- glycaemic index and rich in fiber and minimally
processed foods and all-cause mortality. processed whole grains may lower the risk of Type
Participants in the highest quarter of consumption 2 Diabetes.
(>4 servings/day) had a 62% higher all-cause
mortality rate than those in the lowest quarter (<2 Review paper by Vega-Lopez et al., (2018), finding
servings/ day). besides, the classification of foods in from a cross-sectional analysis with 3931 Japanese
the SUN food frequency questionnaire according to young women (18–20 years old) indicated positive
degree of processing (NOVA), UPF such as Petit associations of dietary glycaemic index with fasting
suisse; custard; flan; pudding; ice cream; ham; glucose and HbA1c and of glycaemic load with
processed meat (chorizo, salami, mortadella, fasting glucose. In studies that included individuals
sausage, hamburger, morcilla); pate; foie-gras; spicy with insulin resistance and diabetes, results were
sausage/meatballs; potato chips; breakfast cereals; inconsistent. Using baseline data from an
pizza, including pre-prepared pies; margarine; intervention among 238 obese low-income Latino
cookies; chocolate cookies; muffins; doughnuts; adults with type 2 diabetes, glyceamix index, but
croissant or other non-handmade pastries; cakes; not glyceamix load, was positively associated with
churros; chocolates and candies; nougat; marzipan; HbA1c. In an analysis of data from 640 adults with
carbonated drinks; artificially sugared beverages; type 2 diabetes, fasting glucose and HbA1c were
fruit drinks; milkshakes; instant soups and creams; positively associated with glyceamix load, but not
200
glyceamix index after adjusting for multiple diabetes risk appears to have a stronger association
potential dietary confounders. In summary, results with glyceamix load than with glyceamix index, but
from prospective studies continue to suggest an dietary fiber or its sources (e.g., whole grains and
equivocal association between type 2 diabetes risk fruits/vegetables), and total carbohydrate intake
and glyceamix index or glyceamix load. Type 2 could contribute to the array of results reported.
7.4 Current Status
Data on habitual food intake of adolescents in Since dietary fiber was not mandated as a
Malaysia displayed the daily intake of cereals, compulsory nutrient under the Food Act 1983 and
grains, cereal products, and tubers. Cereals and Malaysia Food Regulation 1985, thus, dietary fiber
grains were the most commonly ingested food labelling can only be found in certain food products
group per day out of all food categories (4.6 times). on the Nutrition Information Panel (NIP).
On the whole, 99.9% of Malaysian adolescents eat
white rice on a daily basis. Besides white bread Wheat, oats, maize, and rice are the most frequently
(88.7%) and fried rice (88.2%), the most popular eaten grains in Malaysia, with wheat accounting for
cereals and grains consumed in the country were 77.7% of total daily whole grain consumption
nasi lemak (80.8%), instant noodle (78.3%) and (Norimah et al., 2015). Consumption of whole grains
chicken rice (75.2%). While almost half of youngsters has been proven to lower the risk of numerous non-
(53.2%) reached the daily recommended intake of communicable illnesses, including cardiovascular
cereals and grains (4 to 8 servings), one-third (31.2%) disease, type 2 diabetes, and certain cancers (Aune
consumed fewer than 4 servings of cereals and et al., 2016; Chanson-Rolle et al., 2015). Nevertheless,
grains per day (NHMS, 2017). in virtually every country throughout the world, KM7
whole grain intake falls short of the guidelines. Data
On the other hand, adolescents' understanding of from nationally representative surveys indicated
the relevance of dietary FIBER in health was rarely that average intakes in children and adolescents
documented in Malaysia (Daud et al., 2018). In vary from around 2g/day in Malaysia and Italy to
addition, dietary consumption among Malaysian about 23g/day in Ireland and as high as 58g/day in
adolescents also was not reported in the national Denmark (Meynier et al., 2020). In the United States,
statistics. In Malaysia, research on adolescents' the quantitative guideline for whole grains is 48g per
dietary intake was insufficient, owing to the fact that day, yet just 3% of children and adolescents met this
the recruited adolescents were either from a single standard (Norimah et al., 2015). French children and
state or from small-scale sample size, making it adolescents have shown a consistent decline in
difficult to apply information throughout the nation whole grain intake (Bellisle et al., 2014). The data
(Majid et al., 2016). varies across the globe indicating that the value can
be either as far away from the recommendation or
Despite adequate carbohydrate intake, crude FIBER exceeded the guidelines. The same pattern was
consumption among teenagers was found to be observed among Malaysian adolescents. Only a
extremely low, and much lower than the Malaysian small percentage of Malaysian children and
RNI (2.5g/d versus 26-38g/d) (Majid et al., 2016). It adolescents eat whole grains, and even among
is clear that the FIBER consumption is ten times those who do, intakes were far below recommended
lower than recommended in the national guideline. levels (Norimah et al., 2015).
201
The similar study (Meynier et al., 2020) reported that At least half of the students studied bought food and
one of the most important elements affecting whole drinks one to four times weekly. It showed that they
grain intake is to enhance product labelling in order purchased food and drinks every day while at
to increase customers' ability to identify whole school. Fast food was consumed by 2.5% of
grains in the food products. On the other note, under Malaysian adolescents daily, while 84.4% consumed
the Food Act 1983 and Malaysia Food Regulations it one to six days per week. Even among young
1985, labeling of ‘whole grain’ was gazetted adolescents aged 12 to 15 years old in low- and
effectively starting 21 July 2021 allowed users to middle-income countries (LMICs), fast-food eating
read the ‘whole grain’ label on food products. A was prevalent (Li et al., 2020). Fast food munching
plethora of new products with different levels of and skipping meals were also similarly common
whole grain content are available on the market. among Korean and American adolescents (Hong et
al., 2014; Larson et al., 2016). Despite the scarcity of
A study of Malaysian school children's meal data, evidence from developing countries, including
patterns revealed that only 30.0% of them ate India, reports comparable results (Deka et al., 2015;
breakfast every day (seven days a week). Jain et al., 2016; Joseph et al., 2015). With these
Approximately 57.7% of the adolescents brought eating patterns and current evidence in mind,
their daily lunch (seven days a week) from home. No healthy eating habits should be instilled in school
desire to eat and lack of time were found to be the children as early as the age of school students.
two most common reasons for teens skipping
breakfast and lunch. More than half of Malaysian Flavoured beverages or carbonated drinks (23.6%),
adolescents (54.6%) had their dinner. A lack of potato fries/ nuggets/ sausages (15.9%), candy and
appetite and being on a diet or making an effort to chocolates (13.6%), and ice-cream (11.7%) were
KM7 lose weight are the two most common reasons cited discovered as the most popular foods and / or drinks
by Malaysian youngsters for missing dinner. purchased outside of the school area by school aged
Breakfast consumption was the lowest when children. This demonstrated that such meals were
compared to lunch and dinner meals, a trend that marketed outside of school and were among the
has persisted since the previous survey in 2012. favourites among students. Apart from that, social
Nevertheless, the current findings showed that the media (YouTube, Facebook, Instagram, and others)
prevalence of daily breakfast consumption has and television were identified as the primary media
increased. The most popular meal brought to school sources that influenced adolescents' eating
was nasi lemak or fried rice or mixed rice, followed patterns, accounting for 37.9% and 36.7%,
by bread or bun or sandwich (NHMS, 2017). respectively (NHMS, 2017).
During recess, more than two-third (71.3%) of the The power to buy food lies in the hands of school
adolescents bought food from the school cafeteria. students when they are at school. Adolescents
In comparison to two decades earlier, the current spend their pocket money more on food and
percentages were observed to be slightly lower. beverages (Institute for Public Health, 2017).
Over half of adolescents snacked between once and Adolescent spending habits enhance the likelihood
three times per week, with the most often eaten of purchasing unhealthy foods such as fast food,
snack items being bread or bun or sandwich (33.0%), flavoured or carbonated beverages.
biscuits (22.0%), fruits (19.8%), fish crackers (17.9%),
potato fries (15.0%), ice cream (14.3%), and nuts Non-essential food intake on a regular basis may
(2.7%). lead to a number of adverse health consequences,
such as obesity, insulin resistance, and heart disease
Some of the adolescents (11.6%) bought food and/or (Jaworowska et al., 2013). Adolescent eating habits
drinks outside of school five times or more per week that are unhealthy have long-term consequences for
with 58.6% bought one to four times per week. The one's health (Beal et al., 2019). Thus, establishing
findings, as mentioned earlier, also revealed that healthy eating habits during this particular age
elementary school children were twice as likely to group is critically crucial towards combating non-
purchase food and drink than high school students. communicable diseases in the future.
202
Key Recommendation (KR) 1: Eat an adequate amount of cereals, cereal-based products and
tubers daily according to age group.

Health Professional

Consume snack or light meal in Ensure the number of servings Educate parents/ caregivers
between breakfast, lunch or according to age group and teachers to limit intake of
dinner based on tuber, (Refer to Table 3.2 and 3.3 in ultra-processed foods (eg:
wholegrain cereals or products, KM3) cream/ flavoured buns and
fruit or milk if energy need is biscuits, pastries, cakes, and
more than 1500 kcal/day cake mixes, breakfast cereals,
(Refer to Table 3.2 and 3.3 in cereal and energy bars, fatty
KM3) or salty packaged snacks
such as potato chips, yam
chips, sweet potato chips).
KR1: HTA2: KR1: HTA2: - KM7

Ensure the number of servings Create awareness to include a
according to age group variety of cereals, cereal-based
(Refer to Table 3.2 and 3.3 in products and tubers in every
KM3) main meal.
KR1: HTA3: - -
Create awareness to include a
variety of cereals, cereal-based
products and tubers in every
main meal
Key Recommendation (KR) 2: Ensure at least half of the daily intake of cereals and cereal-based
products are from whole grains.

Health Professional
KR2: HTA1:
Choose at least 1 to 2 servings of the daily intake of cereals and cereal-based products from whole
grains.
KR2: HTA2:
Choose whole grain alternatives for noodles and pasta, bread, breakfast cereals, cakes, biscuits and
other cereal based products.
KR2: HTA3:
Choose whole-meal bread, whole-wheat capati, putu mayam ragi (string hoppers), whole grain
noodles, thosai or porridges over similar refined products.
KR2: HTA4:
Cook white rice mixed with whole grains sources such as brown rice, hulled barley, oats, corn and
parboiled rice (adolescent).
203
Key Recommendation (KR) 2: Ensure at least half of the daily intake of cereals and cereal-based
products are from whole grains. (cont.)

Health Professional
KR2: HTA5:
Add whole grains source such as corn, hulled barley and oats to soups (e.g., mushroom soup or beef
stew).
- KR2: HTA6:
Educate children and adolescents to read the ingredients list of
cereal-based product labels. Opt for products with higher
percentages of whole grains.
- KR2: HTA7:
Create awareness among children and adolescents to read the
ingredients list of cereal-based product labels. Opt for products
with higher percentages of whole grains.
KM7
Key Recommendation (KR) 3: Choose and prepare healthier meals using tuber and cereal-based
products.

Health Professional
KR3: HTA1:
Choose or prepare healthier food made from tubers and cereals such as boiled sweet potatoes,
tapioca, yams, steamed corn kernels, rice puddings and others.
KR3: HTA2:
Choose a variety of unprocessed/ minimally processed tubers over processed tubers such as fatty,
sweet, savoury and salty packaged snacks.
KR3: HTA3:
Choose low sugar/ no added sugar cereal-based products instead of high sugar or sugar coated
ready-to-eat breakfast cereals, cream biscuits, snacks (eg: cakes, wafer, waffle).
- KR3: HTA4:
Educate children and adolescents to choose low sugar/no added
sugar cereal-based products and avoid product with high sugar or
sugar coated ready-to-eat breakfast cereals, cream biscuits,
snacks (eg: cakes, wafer, waffle, doughnut, pastries).
204
Key Recommendation (KR) 4: Ensure the choice of cereal-based products are high in FIBER, low
in fat, sugar and salt.

Health Professional
KR4: HTA1:
Choose cereal based products labelled as high FIBER and low in fat, sugar and salt content. Add fresh
or dried fruits, seeds and nuts to enhance the taste.
- KR4: HTA2:
Educate the children and adolescents to read the nutrition
information panel and choose for high FIBER content on the
label.
- KR4: HTA3:
Guide the children and adolescents to recognize Healthier
Choice Logo and identify healthier products within the same
food category.
KM7
205
7.6 References
AACCI (1999). Whole grain definition. American Association of Cereal Chemists International. Cereal Foods
World 45:79 - 85.
AACC (2001). Report of the dietary fiber definition committee to the Board of Directors of the American
Association of Cereal Chemists. Cereal Foods World 46(3):112-126.
AACCI (2006). Cereals & Grains Association Submits Comments to FDA regarding Whole Grains Label
Statements [Letter]. (Accessed on 3 October 2020).
Allen, S.J., Watson, J.J., & Dawbarn, D. (2011). The neurotrophins and their role in Alzheimer’s disease. Curr.
Neuropharmacol,. 9, 559–573.
Angelino, D., Rosi, A., Dall'Asta, M., Pellegrini, N., Martini, D. (2019). Evaluation of the Nutritional Quality of
Breakfast Cereals Sold on the Italian Market: The Food Labelling of Italian Products (FLIP) Study.
Nutrients. 11(11):2827. https://doi:10.3390/nu11112827.
Anaïs, Rico-Campà., Miguel, A Martínez-González., Ismael Alvarez-Alvarez., Raquel, de Deus Mendonça.,

Carmen, de la Fuente-Arrillaga., Clara, Gómez-Donoso., & Maira, Bes-Rastrollo. (2019). Association
between consumption of ultra-processed foods and all cause mortality: SUN prospective cohort study.
British Medical Journal (Clinical research ed.) · May 2019 DOI: 10.1136/bmj.l1949
KM7
Asma, A., Lokman, N.A.H., Hayati, M.Y., & Zainuddin A.A. (2019). Ultra-Processed Food Classification, their
Contribution to Sodium and Added Sugar Availability, and its Relationship with Nutritional Status
among Adults in Terengganu, Malaysia. IIUM Medical Journal Malaysia, 18(3).

https://doi.org/10.31436/imjm.v18i3.193
Askari, M., Heshmati,J., Shahinfar, H., Tripathi, N., & Daneshzad, E. (2020). Ultra-processed food and the risk
of overweight and obesity: a systematic review and meta-analysis of observational studies. Int J Obes
(Lond).;44(10):2080-2091. doi:10.1038/ s41366-020-00650-z
Aune, D., Keum, N., Giovannucci, E., FadneVols, L. T., Boffetta, P., Greenwood, D. C., Tonstad, S., Vatten, L. J.,
Riboli, E., & Norat, T. (2016). Whole grain consumption and risk of cardiovascular disease, cancer, and
all cause and cause specific mortality: systematic review and dose-response meta-analysis of
prospective studies. BMJ, 353:i2716. doi: https://doi.org/10.1136/bmj.i2716
Barazzoni, R., Deutz, N.E.P., Biolo, G., Bischoff, S., Boirie, Y., Cederholm, T., Cuerda, C., Delzenne, N., Leon
Sanz, M., Ljungqvist, O., Muscaritoli, M., Pichard, C., Preiser, J. C., Sbraccia, P., Singer, P., Tappy, L.,
Thorens, B., Van Gossum, A., Vettor, R., & Calder, P. C. (2017). Carbohydrates and insulin resistance
in clinical nutrition: Recommendations from the ESPEN expert group. Clinical Nutrition, 36(2), 355–
363.
Beal, T., Morris, S.S., & Tumilowicz, A. (2019). Global Patterns of Adolescent Fruit, Vegetable, Carbonated
Soft Drink, and Fast-Food Consumption: A Meta-Analysis of Global School-Based Student Health
Surveys. Food and Nutrition Bulletin, 40(4), 444–459. https://doi.org/10.1177/0379572119848287.
Beluska-Turkan, K., Korczak, R., Hartell, B., Moskal, K., Maukonen, J., Alexander, D. E., Salem N., Harkness,
L., Ayad, W., Szaro, J., Zhang, K., & Siriwardhana, N. (2019). Nutritional Gaps and Supplementation in
the First 1000 Days. Nutrients, 11(12), 2891. doi: 10.3390/nu11122891
Bellisle, F., Hébel, P., Colin, J., Reyé, B., & Hopkins, S. (2014). Consumption of whole grains in French children,
adolescents and adults. British Journal of Nutrition, 112(10), 1674–1684.
https://doi.org/10.1017/S0007114514002670.
206
Bernard, Srour, Benjamin Allès., Mélanie, Deschasaux., & Carlos A. Monteiro. (2019). Ultra-processed Food
Consumption and Risk of Type 2 Diabetes Among Participants of the NutriNet-Santé Prospective
Cohort. JAMA Intern Med. 180(2):283-291. doi:10.1001/jamainternmed.2019.5942
Bernard, Srour., Léopold, K Fezeu., Emmanuelle Kesse-Guyot., Benjamin Allès, Caroline Méjean, Roland M
Andrianasolo, Eloi Chazelas, Mélanie Deschasaux, Serge Hercberg, Pilar Galan, Carlos A Monteiro,
Chantal Julia & Mathilde, Touvier. (2019). Ultra-processed food intake and risk of cardiovascular
disease: prospective cohort study (NutriNet-Santé). the bmj | BMJ;365:l1451 | doi: 10.1136/bmj.l1451
BERNAS (2021). Rice Type in Malaysia. PadiBeras Nasional Berhad.

https://www.bernas.com.my/bernas/index.php/ricepedia/rice-type-in-malaysia
Berticat, C., Mamouni, S., Ciais, A., Villain, M., Raymond, M., & Daien, V. (2020). Probability of myopia in
children with high refined carbohydrates consumption in France. BMC Ophthalmology, 20(1), 1–8.
https://doi.org/10.1186/s12886-020-
Beslay, M., Srour, B., Méjean, C., et al. (2020). Ultra-processed food intake in association with BMI change
and risk of overweight and obesity: a prospective analysis of the French NutriNet-Santé cohort. PLoS
Med. 17(8) :e1003256. doi:10.1371/journal.pmed.1003256
Bhaskar Bhardwaj, Evan L.O’Keefe & James H.O’Keefe. (2016) Death by Carbs: Added Sugars and Refined
Carbohydrates Cause Diabetes and Cardiovascular Disease in Asian Indians. PMC PubMed Central,
PMC6139832. KM7
Bhupathiraju, S.N., Tobias, D.K., Malik, V.S., Pan, A., Hruby, A., Manson, J.E., Willett, W.C., & Hu, F.B. (2014).
Glycemic index, glycemic load, and risk of type 2 diabetes: Results from 3 large US cohorts and an
updated meta-analysis. American Journal of Clinical Nutrition, 100(1), 218–232.
https://doi.org/10.3945/ajcn.113.079533
Blake-Lamb, T.L., Locks, L. M., Perkins, M. E., Woo Baidal, J. A., Cheng, E. R., & Taveras, E. M. (2016).
Interventions for Childhood Obesity in the First 1,000 Days A Systematic Review. /American Journal
of Preventive Medicine, 50(6), 780–789.
Chanson-Rolle, A., Meynier, A., Aubin, F., Lappi, J., Poutanen, K., Vinoy, S., et al. (2015). Systematic Review
and Meta-Analysis of Human Studies to Support a Quantitative Recommendation for Whole Grain
Intake in Relation to Type 2 Diabetes. PLoS ONE 10(6): e0131377.
Chandrasekara, A. & Josheph Kumar T. (2016). Roots and Tuber Crops as Functional Foods: A Review on
Phytochemical Constituents and Their Potential Health Benefits. Int J Food Sci. 3631647. doi:
10.1155/2016/3631647.
Cho, S.S., Qi, L., Fahey, G.C. Jr., & Klurfeld, D.M. (2013). Consumption of cereal fiber, mixtures of whole grains
and bran, and whole grains and risk reduction in type 2 diabetes, obesity, and cardiovascular disease.
Am J Clin Nutr 98:594–619.
Cohen, J.F.W., Gorski, M.T., Gruber, S.A., Kurdziel, L.B.F., & Rimm, E.B. (2016). The effect of healthy dietary
consumption on executive cognitive functioning in children and adolescents: a systematic review.
British Journal of Nutrition, 116(06), 989–1000.
Cooper, D.N., Kable, M.E., Marco, M.L., De Leon, A., Rust, B., Baker, J.E., Horn, W., Burnett, D., & Keim, N.L.
(2017). The Effects of Moderate Whole Grain Consumption on Fasting Glucose and Lipids,
Gastrointestinal Symptoms, and Microbiota. Nutrients, 9(2), 173.
Cordain, L., Eades, M.R. & Eades, M.D. (2003), Hyperinsulinemic disease of civilization: more than just
Syndrome X. Comp Biochem Physiol A Mol Integr Physiol. 136(1):95-112. doi: 10.1016/s1095-
6433(03)00011-4
207
Cosgrove, M.C., Franco, O.H., Granger, S.P., Murray, P.G. & Mayes, A.E. (2007), Dietary nutrient intakes and
skin-aging appearance among middle-aged American women. Am J Clin Nutr 2007:86:1225-31.
Daud, N.M., Fadzil, N.I., Yan, L.K., Makbul, I.A.A., Yahya, N.F.S., Teh, A.H., & Rahman, H.A. (2018). Knowledge,
attitude and practice regarding dietary FIBER intake among Malaysian rural and urban adolescents.
Malaysian Journal of Nutrition, 24(1), 77–88.
Davidson, E. A. (2020). Carbohydrate. Encyclopedia Britannica.

https://www.britannica.com/science/carbohydrate
Deka, M., Malhotra, A., Yadav, R., & Gupta, S. (2015). Dietary pattern and nutritional deficiencies among
urban adolescents. Journal of Family Medicine and Primary Care, 4(3), 364.
https://doi.org/10.4103/2249-4863.161319.
Derbyshire, E., & Obeid, R. (2020). Choline, Neurological Development and Brain Function: A Systematic
Review Focusing on the First 1000 Days. Nutrients, 12(6), 1731.
DiNicolantonio, & James O’Keele. (2017), markedly increased intake of refine carbohdrates and sugar is
associated with rise of coronary heart disease and diabetes among the Alaskan Inuit.
BMJ_doi:10.1136/openhrt-2017-000673.
FAO (1996). Draft Definition and Classification of Commodities, (Accessed on 22 November 2021).
KM7 https://www.fao.org/waicent/faoinfo/economic/faodef/fdef01e.htm
FAO/WHO (1998). Carbohydrate in Human Nutrition. Report of joint FAO/ WHO Expert Consultation paper
66. FAO Food and Nutrition, Rome.
https://books.google.com.my/books/about/Carbohydrates_in_Human_Nutrition.html?id=Mf3lxvWfA9oC&
printsec=frontcover&source=kp_read_button&hl=en&redir_esc=y#v=onepage&q&f=false
FAO (2019). Ultra-processed foods, diet quality, and health using the NOVA classification system. Monteiro
CA, Cannon G, Lawrence M, Costa Louzada ML & Pereira Machado P. Food and Agriculture
Organization of the United Nations. Rome.
http://www.fao.org/3/ca5644en/ca5644en.pdf.
FAO (2021). FAO Cereal Supply and Demand Brief. World Food Situation. Cereal production and inventories
to decline but overall supplies remain adequate. Food and Agriculture Organization of the United
Nations. Available online: http://www.fao.org/worldfoodsituation/csdb/en/ (Released date: 2
September 2021).
Fardet, A., & Rock, E. (2020). Ultra-Processed Foods and Food System Sustainability: What Are the Links?.
Sustainability. 12(15). 6280. https://doi.org/10.3390/su12156280
Frølich, W., & Aman, P. (2010).Whole Grain for Whom and Why? Food and Nutr Res 54:5056.
Gani, A., Wani, S.M., Masoodi, F.A. & Hameed, G. (2012). Whole-grain cereal bioactive compounds and their
health benefits: A review. J Food Process Technol. 3:1-10.
Gardener, S. L., & Rainey-Smith, S. R. (2018). The Role of Nutrition in Cognitive Function and Brain Ageing
in the Elderly. Current Nutrition Reports. 7(3): 139-149
Hoover, R. (2001). Composition, molecular structure, and physicochemical properties of tuber and root
starches: a review. Carbohydrate Polymers, 45(3): 253-267. https://doi.org/10.1016/S0144-
8617(00)00260-5.
208
Hong, S., Bae, H.C., Kim, H.S., & Park, E.C. (2014). Variation in meal-skipping rates of Korean adolescents
according to socio-economic status: Results of the Korea Youth Risk Behavior Web-based Survey.
Journal of Preventive Medicine and Public Health, 47(3), 158–168.
https://doi.org/10.3961/jpmph.2014.47.3.158.
Hu, Y., Ding, M., Sampson, L., Willet, W.C., Manson, J.E., Wang, M., Rosner, B., Hu, F.B., & Sun, Q. (2020). Intake
of whole grain foods and risk of type 2 diabetes: results from three prospective cohort studies. BMJ,
370:m2206.
IPH. (2017). The National Health and Morbidity Survey 2017: Adolescent Nutrition Survey 2017. In
Perpustakaan Negara Malaysia: Vol. I. Institute for Public Health, National Institutes of Health,
Ministry of Health Malaysia, Selangor.
https://www.cambridge.org/core/product/identifier/CBO9781107415324A009/type/book_part.
IPH (2020). National Health and Morbidity Survey (NHMS) 2019. Vol. 1: NCDs – Non-Communicable
Diseases: Risk Factors and other Health Problems. Institute of Public Health, National Institutes of
Health, Ministry of Health Malaysia, Selangor.
https://iptk.moh.gov.my/images/technical_report/2020/4_Infographic_Booklet_NHMS_2019_-
_English.pdf
Jain, A., Jain, A., Pankaj, J., Sharma, B., & Paliwal, A. (2016). The study of obesity among children aged 5-18
years in Jaipur, Rajasthan. Muller Journal of Medical Sciences and Research, 7(2), 125. KM7
https://doi.org/10.4103/0975-9727.185013.
Jaworowska, A., Blackham, T., Davies, I.G., & Stevenson, L. (2013). Nutritional challenges and health
implications of takeaway and fast food. Nutrition Reviews, 71(5), 310–
318.https://doi.org/10.1111/nure.12031.
Jenkins D.J., Wolever, T.M., Taylor, R.H., Barker H., Fielden, H., Baldwin., Bowling, A.C., Newman, H.C.,
Jenkins, A.L. & Goff, D.V. (1981). Glycaemic index of foods: A Physiological basis for carbohydrate
exchange. Am J Clin Nutr 34:362-366.
Johnson, G.H. & Anderson, G.H. (2010). Snacking definitions: Impact on interpretation of the literature and
dietary recommendations. Crit Rev Food Sci Nutr 50(9):848-871.
Jones, J.M. (2010). Regulatory aspects of whole grain and whole grain foods: Definitions and labeling. Cereal
Chem 87:150-154.
Joseph, N., Nelliyanil, M., Rai, S., Raghavendra Babu, Y.P., Kotian, S.M., Ghosh, T., & Singh, M. (2015). Fast
food consumption pattern and its association with overweight among high school boys in Mangalore
city of southern India. Journal of Clinical and Diagnostic Research, 9(5), LC13–LC17.
https://doi.org/10.7860/JCDR/2015/13103.5969.
Kikuchi, Y., Nozaki, S., Makita, M., Yokozuka, S., Fukudome, S., Yanagisawa, T., & Aoe, S. (2018). Effects of
Whole Grain Wheat Bread on Visceral Fat Obesity in Japanese Subjects: A Randomized Double-Blind
Study. Plant Foods for Human Nutrition, 73(3), 161–165.
Kim, K.Y., & Yun, J.M. (2018). Association between diets and mild cognitive impairment in adults aged 50
years or older. Nutrition Research and Practice, 12(5), 415-425
Kissock, K. R., Neale, E. P., & Beck, E. J. (2021). Whole Grain Food Definition Effects on Determining
Associations of Whole Grain Intake and Body Weight Changes : A Systematic Review. Advances in
Nutrition. 12, 693–707.
209
Koo, H., Poh, B., & Abd Talib, R. (2018). The GReat-Child™ Trial: A Quasi-Experimental Intervention on Whole
Grains with Healthy Balanced Diet to Manage Childhood Obesity in Kuala Lumpur, Malaysia.
Nutrients, 10(2), 156-xxx.
Kristek, A., Schär, M.Y., Soycan, G., Alsharif, S., Kuhnle, G.G.C., Walton, G., & Spencer, J.P.E. (2018). The gut
microbiota and cardiovascular health benefits: A focus on wholegrain oats. Nutrition Bulletin, 43(4),
358–373.
Kyrø, C., Tjønneland, A., Overvad, K., Olsen, A., & Landberg, R. (2018). Higher Whole-Grain Intake Is
Associated with Lower Risk of Type 2 Diabetes among Middle-Aged Men and Women: The Danish
Diet, Cancer, and Health Cohort. The Journal of Nutrition, 148 (9): 1434-1444.
Lane, M.M., Davis J.A., Beattie, S., Gómez-Donoso, C., Loughman, A., O'Neil, A., Jacka, F., Berk, M., Page, R.,
Marx, W., & Rocks, T. (2020). Ultra-Processed Food and Chronic Non-Communicable Diseases: A
Systematic Review and Meta-Analysis of 43 Observational Studies. Obesity Reviews. 22(3).
https://doi.org/10.1111/obr.13146.
Larson, N.I., Miller, J.M., Watts, A.W., Story, M.T., & Neumark-Sztainer, D.R. (2016). Adolescent snacking
behaviors are associated with dietary intake and weight status. In Journal of Nutrition (Vol. 146, Issue
7, pp. 1348–1355). https://doi.org/10.3945/jn.116.230334.
Laskowski, W., Górska-Warsewicz, H., Rejman, K., Czeczotko, M., & Zwolinska J. (2019). How important are
KM7 cereals and cereal products in the average Polish diet? Nutrients. 11(3):679-700.
Li, L., Sun, N., Zhang, L., Xu, G., Liu, J., Hu, J., Zhang, Z., Lou, J., Deng, H., Shen, Z., & Han, L. (2020). Fast food
consumption among young adolescents aged 12–15 years in 54 low- and middle-income countries.
Global Health Action, 13(1).pages? https://doi.org/10.1080/16549716.2020.1795438.
Majid, H.A., Ramli, L., Ying, S.P., Su, T.T., & Jalaludin, M.Y. (2016). Dietary intake among adolescents in a
middle-income country: An outcome from the Malaysian health and adolescents longitudinal research
team study (the myhearts study). PLoS ONE, 11(5), 1–14. https://doi.org/10.1371/journal.pone.0155447.
Marino M, Puppo F, Del Bo C, Vinelli V, Riso P, Porrini M & Martini D (2021). A Systematic Review of
Worldwide Consumption of Ultra-Processed Foods: Findings and Criticisms. Nutrients. 13(8): 2778.
https://doi.org/10.3390/nu13082778.
Marlow, A.L., Rowe, C.W., Anderson, D., Wynne, K., King, B.R., Howley, P., & Smart, C. (2019). Young children,
adolescent girls and women with type 1 diabetes are more overweight and obese than reference
populations, and this is associated with increased cardiovascular risk factors. Diabetic Medicine, 36
(11), 1487-1493.
Mathews, R & Chu, Y. (2020). Global review of whole grain definitions and health claims. Nutr Rev 78(1):98-
106.
McRae, M.P. (2017). Health benefits of dietary whole grains: An umbrella review of meta-analysis. J Chiropr
Med. 16(1): 10-18. doi: 10.1016/j.jcm.2016.08.008.
Meynier, A., Chanson-Rollé, A., & Riou, E. (2020). Main factors influencing whole grain consumption in
children and adults—a narrative review. Nutrients, 12(8), 1–22. https://doi.org/10.3390/nu12082217.
MOH (1985). FOOD ACT 1983. 281 Laws of Malaysia PART VIII (1983).
http://fsq.moh.gov.my/v6/xs/dl.php?filename=8d5c76ef4e25e89a74bfe93dda41c2a5.pdf
210
Monteiro, C. A., Cannon, G., Levy, R. B., Moubarac, J., C., Louzada, M., L., Rauber, F., Khandpur, N., Cediel,
G., Neri, D., Martinez-Steele, E., Baraldi, LG., Jaime, PC. (2019). Ultra-Processed Foods: What They Are
And How To Identify Them. Public Health Nutr. 22(5), 936-941.
https://doi.org/10.1017/S1368980018003762.
Movassagh, E. Z., Baxter-Jones, A. D. G., Kontulainen, S., Whiting, S. J., & Vatanparast, H. (2017). Tracking
Dietary Patterns over 20 Years from Childhood through Adolescence into Young Adulthood: The
Saskatchewan Pediatric Bone Mineral Accrual Study. Nutrients, 9 (9), 990.
NCCFN (2013). Malaysian Dietary Guidelines for Children and Adolescents. National Coordinating
Committee on Food and Nutrition. Putrajaya: Ministry of Health Malaysia.
NCCFN (2021). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and Nutrition.
Putrajaya: Ministry of Health.
NIH (2019). National Health and Morbidity Survey 2019. Non-communicable diseases, healthcare demand
and health literacy. National Institutes of Health, Ministry of Health, Malaysia.
http://iku.gov.my/nhms-2019
NHMS (2017). National Health Morbidity Survey 2017. Adolescent Health Survey. Kuala Lumpur: Institute
for Public Health, Ministry of Health, Malaysia.
https://iku.moh.gov.my/images/IKU/Document/REPORT/NHMS2017/AHSReportNHMS2017.pdf
KM7
NHMRC (2013). Australian dietary guidelines. National Health and Medical Research Council, Canberra.
Norimah, A. K., Koo, H. C., Hamid Jan, J. M., Mohd Nasir, M. T., Tan, S. Y., Appukutty, M., Nurliyana, A. R.,
Thielecke, F., Hopkins, S., Ong, M. K., Ning, C., & Tee, E. S. (2015). Whole grain intakes in the diets of
Malaysian children and adolescents-findings from the MyBreakfast study. PLoS ONE, 10(10), 1–15.
https://doi.org/10.1371/journal.pone.0138247
Purba, M., Kouris-Blazos, A., Wattanapenpaiboon, N., Widjaja Lukito, Elizabet M Rothenberg, Bertil C. Steen,
& Mark L. Wahlqvist. (2001) Skin Wrinkling: Can Food Make a Difference? Journal of the American
College of Nutrition, Vol. 20, No. 1, 71–80
Puts, D. A., Jones, B. C., & Debruine, L. M. (2012). Sexual selection on human faces and voices. Journal of
Sex Research, 49(2–3), 227–243. https://doi.org/10.1080/00224499.2012.
Rico-Campà, A., Martínez-González, M.A., Alvarez-Alvarez, I., et al. (2019). Association between
consumption of ultra-processed foods and all causes of mortality: SUN prospective cohort study.
BMJ;365:l1949. doi:10.1136/bmj.l1949
Roager, H. M., Vogt, J. K., Kristensen, M., Hansen, L. B. S., Ibrügger, S., Mærkedahl, R. B., Bahl, M. L., Lind, M.
V., Nielsen, R. K., Frøkiær, H., Gøbel, R. J., Landberg, R., Ross, A. B., Brix, S., Holck, J., Meyer, A. S.,
Sparholt, M. H., Christensen, A. F., Carvalho, V., Hartmann, B., Holst, J. J., Rumessen, J. J., Linneberg,
A., Sicheritz-Pontén, T., Dalgaard, M. D., Blennow , A., Frandsen, H. L., Villas-Bôas, S., Kristiansen, K.,
Vestergaard, H., Hansen, T., Ekstrøm, C. T., Ritz, C., Nielsen, H. N., Pedersen, O. B., Gupta, R., Lauritzen,
L., & Licht, T. R. (2017). Whole grain-rich diet reduces body weight and systemic low-grade
inflammation without inducing major changes of the gut microbiome: a randomised cross-over trial.
Gut Microbiota, 68(1):83-93.
Rocha, N.P., Milagres, L.C., Longo, G.Z., Riberio, A.Q., & Novaes, J.F. (2017), Association between dietary
pattern and cardiometabolic risk in children and adolescents: a systematic review. J Pediatr (Rio
J):93:214-22.
Salmeron, J., Manson, J., E., Stampfer, M., J., Colditz, G.A.,Wing A.,L., & Willett, W., C. (1997). Dietary fiber,
glycaemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA. 277:472-477.
211
Sandberg, J., Björck, I., & Nilsson, A. (2018). Increased Plasma Brain-Derived Neurotrophic Factor 10.5 h
after Intake of Whole Grain Rye-Based Products in Healthy Subjects. Nutrients, 10(8), 1097-xxxx.
Seal, C.J.,Nugent,A.P., Tee E. S., & Thielecke, F., (2016). Whole-grain Dietary Recommendations: The Need
or a Unified Global Approach. Br J Nutr 115:2031-2038.
Seal, C. J., Courtin, C. M., Venema, K., & Vries, J. (2021). Health benefits of whole grain: effects on dietary
carbohydrate quality, the gut microbiome, and consequences of processing. Comprehensive Reviews
in Food Science and Food Safety. 20:2742–2768.
Shilpa N Bhupathiraju, Deirdre K Tobias, Vasanti S Malik, An Pan, Adela Hruby, JoAnn E Manson, Walter C
Willett, and Frank B Hu. (2014). Glycemic index, glycemic load, and risk of type 2 diabetes: results
from 3 large US cohorts and an updated meta-analysis. Am J Clin Nutr doi: 10.3945/ajcn.113.079533.
Smith, J.D., Jain, N., & Bailey, R.L. (2020). Ready-to-eat fortification: a modelling study on the impact of
changing ready-to-eat cereal fortification levels on population intake of nutrients. Public Health
Nutrition. 23(12): 2165-2178.
Sonia Vega-López, Bernard J. Venn. & Joanne L. Slavin. (2018). Relevance of the Glycemic Index and
Glycemic Load for Body Weight, Diabetes, and Cardiovascular Diseases. Nutrients 2018, 10, 1361;
doi:10.3390/nu10101361
KM7 Sundaram, J.K., & Tan, Z.G. (2019). Achieving Food Security for all Malaysians. Khazanah Research Institute,
Kuala Lumpur.
Tosh, S. M., & Bordenave, N. (2020). Emerging science on benefits of whole grain oat and barley and their
soluble dietary fibers for heart health, glycaemic response, and gut microbiota. Nutrition Reviews,
78(S1), 13–20.
Tullio, V., Gasperi, V., Catani, M. V., & Savini, I. (2020). The Impact of Whole Grain Intake on Gastrointestinal
Tumors: A Focus on Colorectal, Gastric, and Esophageal Cancers. Nutrients, 13(1), 81.
US Department of Agriculture (2019). What are refined grains. https://ask.usda.gov/s/article/What-are-

refined-grains
US Department of Health and Human Services and US Department of Agriculture (2015). 2015–2020 Dietary
Guidelines for Americans. 8th ed. (Accessed on 10 July 2020).
US Department of Health and Human Services and US Department of Agriculture (2020). 2020–2025 Dietary
Guidelines for Americans. (Accessed on 22 November 2021.
https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-
2020-2025.pdf
Vega-López, S., Venn, B. J., & Slavin, J. L. (2018). Relevance of the glycemic index and glycemic load for
body weight, diabetes, and cardiovascular disease. Nutrients, 10(10), 1–27.
https://doi.org/10.3390/nu10101361
Weihrauch-Blüher, S., Schwarz, P., & Klusmann, J.-H. (2018). Childhood obesity: increased risk for
cardiometabolic disease and cancer in adulthood. Metabolism, 97, 147-152.
WHO (World Health Organization) (2003). Diet, Nutrition and the Prevention of Chronic Diseases. WHO,
Geneva, Switzerland.
Woo Baidal, J.A., Locks, L.M., Cheng, E.R., Blake-Lamb, T.L., Perkins, M.E., & Taveras, E.M. (2016). Risk
Factors for Childhood Obesity in the First 1,000 Days. American Journal of Preventive Medicine, 50(6),
761–779.
212
Wolever T.M.S. (2013). Is glycaemic index (GI) a valid measure of carbohydrate quality? Eur J Clin Nutr
67(5):522-531.
Xu, Y., Yang, J., Du, L., Li, K., & Zhou, Y. (2018). Association of whole grain, refined grain, and cereal
consumption with gastric cancer risk: A meta-analysis of observational studies. Food Science &
Nutrition, 7(1), 256–265.
Zuniga A., Stevenson R.J., Mahmut M.K. & Stephen I.D. (2017). Diet quality and the attractiveness of male
body odor. Evolution and Human Behavior, 38, 136–143.
https://doi.org/10.1016/j.evolhumbehav.2016.08.002
KM7
213
KM7
214
Key Message 8
Consume recommended amount of protein rich foods

such as fish, eggs, lean meat and poultry, nuts and
legumes
KM8
Consume recommended amount of protein rich foods

such as fish, eggs, lean meat and poultry, nuts and
legumes
Assoc. Prof. Dr. Satvinder Kaur, Assoc. Prof. Dr. Foo Leng Huat, Assoc. Prof. Dr. Wee Bee Suan,
Ms. Suriati Zakaria and Ms. Norfaiezah Ahmad
8.1 Terminology
Beans Legumes
Beans, also known scientifically as Phaseolus Legumes grow in a pod such as the whole range of
vulgaris L, is the most common food legume that beans, peas and lentils, including baked beans,
can be consumed raw or cooked. It has high kidney beans, soya beans, red, green, yellow and
variability in terms of its shape, size, and colour. brown lentils, black-eyed peas or garden peas.
Egg Meat
Egg usually refers to chicken eggs but can also Meat includes all or part of the muscle component
include eggs from poultry and birds, for instance of any cattle, sheep, goat, buffalo, deer, pig or rabbit
duck and quail. carcass. It excludes offals such as liver, kidney, brain
and heart.
Fish
Fish includes all fresh or processed marine and Nuts
freshwater fish. It does not include shellfish and fish Nut is a general term for the large, dry, oily seeds or
eggs. fruit of some plants. Examples of nuts are almonds,
cashews, coconuts, peanuts, pistachios and
walnuts. There are also edible tree nuts including
216
pecan, brazilian nuts, hazelnuts, and macadamia. crustaceans (such as shrimp, prawn, lobster, and
Peanuts are under the legume’s groups, however, as crab). It can be obtained either from marine or
per consumer definition, it falls under the nuts freshwater.
category and has a similar nutrient profile to tree
nuts. Processed meat/ fish/ seafood
Processed meat refers to meat/fish/ seafood that has
Poultry been altered through salting, curing, fermentation,
Poultry refers to chicken, duck, goose, turkey, smoking, or other processes to enhance flavor or
ostrich, quail and other ‘bird like’ foods (flesh and improve preservation.
offals) except its eggs.
Seeds
Shellfish Seeds are obtained from fruit or flower and normally
Shellfish are exoskeleton-bearing aquatic removed before the main parts of the fruit or flower
invertebrates and species commonly used as food. are consumed. Seeds include sunflower seeds,
These include mollusks (such as cockles, clams, pumpkin seeds, and chia seeds.
mussels, oysters, squids and scallops) and
8.2 Introduction
8.2.1 Protein needs for growth PUFA for brain development, especially in their early
years of life. Some examples of Malaysian fishes that
Protein is essential for most cell functions as it is a are high in omega 3 fatty acids are anchovies, KM8
core element in human cell function. Especially in sardines, freshwater catfish (patin), mackerel
children and adolescents, protein is an important (tenggiri), Indian mackerel (kembung), seabass

nutrient as it is abundantly required for the growth, (siakap) and torpedo-scad (cencaru).
maintenance, and repair of body tissues. In addition,
protein is required for hormone and enzyme Another widely available protein source- option is
synthesis including antibodies. During the growth eggs. It contains complete protein and is easily
phase, often observed among children and accessible to all populations. Incorporating eggs
adolescents, protein synthesis is more than protein daily in children’s and adolescents’ diets would help
degradation thus, it becomes a key nutrient to achieve sufficient protein intake daily. This would
ensure adequate growth in childhood and help in optimum growth, especially for height
adolescence. This chapter on protein intake is an among growing children. Egg, especially the white
update to the Malaysian Dietary Guidelines for portion, is rich in protein and essential amino acids
Children and Adolescents 2013 (NCCFN, 2013). while the egg yolk contains cholesterol. Despite that,
it is now being termed as a complete protein and
8.2.2 Sources of protein able to fulfill daily protein requirements, especially
for children and adolescents. In addition to that,
Protein consists of 20 amino acids but not all can be eggs are ranked as the most cost-effective food for
synthesized by the body and thus, it must be children as they can supply protein, choline, and
obtained from dietary intake. These are known as vitamins A, E and D (Papanikolaou & Fulgoni, 2020).
essential amino acids (could name a few EAA) and Eggs can ensure sufficient daily choline amounts for
examples of foods that contain essential amino children and adolescents as previous studies found
acids are eggs, cheese, mushrooms, fish, peas, many children lack choline in their dietary intake
chickpeas, lentils, soybeans, and peanuts. Plant (Weideman et al., 2018).
protein and animal protein are both sources of
protein in the diet. High-quality protein is obtained Plant-based diet comprises largely of plant-based
from animal-based foods attributed to its ability to foods and a reduction of about 50% of animal-based
supply all amino acids in comparison to plant-based protein is gaining more attention. This approach is
foods. Proteins from fish-based are superior as termed sustainable eating and one that helps reduce
compared to meat and poultry. This is mainly metabolic complications (Lonnie & Johnstone,
because of vitamin B12, iodine, and polyunsaturated 2020). In addition, it helps reduce carbon footprints,
fatty acids (PUFA) content. Higher consumption of promoting a healthier planet (WHO, 2021a; The EAT-
Malaysian freshwater fish could supply sufficient Lancet Commission, 2019). Incorporating beans,
omega-3 fatty acids and it is more affordable than lentils and seeds are seen as a good alternative to
deep marine sources. Fish is an ideal source of achieving daily protein requirements for healthy
protein for growing children who requires higher infants. At the same time, it is a good source of
217
antioxidants and phytochemicals. Encouraging a protein offers great health benefits that require more
shift in children’s and adolescent diets by including attention towards its implementation.
more plant-based protein and reducing animal
8.3.1 Protein role in growth and puberty overweight or obese. Malnutrition includes
undernutrition (wasting, stunting, underweight),
Protein is an essential nutrient to support children's inadequate vitamins or minerals, overweight and
growth right from infancy. Being provided with obesity. Malnutrition is a serious health condition
sufficient protein intake consisting of all amino acids that usually results with diet related non-
allows proper growth during the first 2 years of life. communicable diseases.
Growth, neuro-development and long-term positive
health outcome are linked to protein quality and 8.3.3 Low-protein intake in diets
quantity during this period (Michaelsen & Greer,
2014). There are twenty different amino acids a) Protein deficiency
needed by the body, whereby nine are essential
amino acids that must be obtained from the diet. Protein Energy Malnutrition (PEM) is defined as a
The remaining eleven amino acids are nutritionally lack of supply of sufficient energy or protein to meet
non-essential because the body can make them the body’s metabolic demands. Children with PEM
from other compounds. While protein is essential for have poor growth with wasting (low weight-for-
growth, balanced intake from early life is important height) and stunting (low height-for-age). Its most
KM8
as over consumption has been associated with severe clinical forms are marasmus and
obesity in later life especially among children kwashiorkor. Children with moderate to severe
experiencing catch up growth (Lind et al., 2017). acute malnutrition have 3 to 9 times higher mortality
than well-nourished children (Ghosh-Jerath et al.,

Protein appears to be important for bone growth as 2017). The NHMS report that was published in 2019
well, especially among pre-pubertal children. In revealed Malaysia has a total of 21.8% of children
situations where protein intake is low, the who were stunted while 9.7% were wasted.
production of IGF-I (insulin-like growth factor-I) is Children with PEM exhibited impaired immune
affected therefore, impairs bone longitudinal growth function and likely contributed to chronic
and its formation (Bonjour, 2011). Studies that were respiratory infections, diarrhea, suboptimal
done among healthy children and adolescents cognitive, neurological and mental health problems
showed that skeleton growth is most responsive to as well as motor development over the lifespan.
protein intake during this period. Recent systematic review and meta-analysis of 5
prospective cohort studies have shown that a unit
During adolescence, puberty takes place. Changes increase in HAZ for children ≤ 2 years was
in physical and psychosocial events happen during associated with a 0.22-SD improvement in cognitive
the transition from a child to adolescence. Types of function later in childhood at 5 to 11 years (Vaivada
protein (animal vs. plant) could play a role in puberty et al., 2020) Besides, early childhood malnutrition
onset, especially among males (Alimujiang et al., (PEM) during 1st year of life is also found to be
2018). The introduction of different protein types in associated with conduct problems and aggressive
the diet during mid childhood has the potential to behavior. A longitudinal study reported conduct
influence the onset of menarche, although more problems are elevated in children and adolescents
research is required to distinguish the difference with a history of early childhood malnutrition (Galler
between boys and girls (Gunther et al., 2010). Protein et al., 2012).
originating from animal sources was linked to earlier
puberty onset meanwhile, protein from vegetable b) Anemia
sources showed delayed onset (Villamor & Jansen,
2016). Iron is a nutrient found in many proteins in the body.
As such, it is important to consume enough iron in
8.3.2 Health implications the diet. Foods such as red meat, egg and cockles
are good sources of iron, besides being rich in
According to WHO (2021a), globally there were a protein. A child can develop iron deficiency anemia
total of 149 million of children under 5 years of age (IDA) if he/she does not get enough iron over a
were estimated to be stunted, 45 million were prolonged period. IDA is characterized by a
estimated to be wasted while 38.9 million were decrease in the number of erythrocytes or
218
hemoglobin concentration in the blood. Lack of iron 8.3.4 High-protein intake in diets
in the body interferes with the development and
structure of hemoglobin in the blood cell. This is a There are risks with protein intakes exceeding the
condition that limits the ability of the blood to carry safe level (greater than 30% of total calories). Diet
oxygen throughout the body and remove carbon which is high in animal protein generates a large
dioxide efficiently. Iron deficiency anemia can amount of acid in body fluids. The kidney responds
interfere with brain development, affecting a child’s to this dietary acid challenge with net acid excretion
motor skills, attention and ability to learn (Hamid while the skeleton supplies a buffer by active
Jan et al., 2010). IDA is recognized to have long resorption of the bone that increases calcium loss in
lasting effects on neurodevelopment, since iron is the urine and depletes bone minerals if not
required for many central nervous systems compensated with optimum calcium intakes. High
processes. A longitudinal study conducted among protein intake, especially animal protein during early
IDA children at 6 months of age (IDA 6) and at 12 childhood (≤ 18 months old) showed a probable
months of age (IDA 12) and follow-up when the association with higher body weight in later
children were at 10 years old, reported IDA 6 and childhood in several cohort studies (Arnesen et al.,
IDA 12 children demonstrated altered cortisol 2022). In addition, the British Birth Cohort Study
response patterns; both showed a more immediate among 21 months young children reported protein
decline and IDA 12 children showed a blunted intake during the first 2 years of life of more than
curvature compared to iron sufficient children. This 15% of energy are a risk factors for subsequently
indicated that IDA during infancy is associated with increased in weight gain (Pimpin et al., 2016).
long term neuroendocrine effects on stress Similarly with adolescents, high dietary protein
responsive cortisol patterns (Felt et al., 2012). In intake, particularly animal protein was shown to
addition to that, IDA during infancy is also reported contribute to central and general body adiposity KM8
to be associated with slower reaction times and (Segovia-Siapco et al., 2019).
poorer inhibitory control even after 8 to 9 years of

iron therapy (Algarin et al., 2013). Deficiency of iron High intake of animal sources also leads to large
in early life may also increase the risk of psychiatric amounts of saturated fat being consumed.
disorders, including mood disorders, autism Clinicians are also raising concerns about the effects
spectrum disorder, attention deficit hyperactivity of excessive protein intake on kidney function.
disorder, and developmental disorder (Chen et al., Compared with protein from plant sources, animal
2013). Latest studies had also confirmed that anemia protein has been associated with increased risk of
causes tissue hypoxia in kidneys earlier and at a end stage kidney disease (ESKD) in several
higher hemoglobin concentration than in other observational studies across different life stages.
organs, of which urinary kidney injury molecule Potential mediators of kidney damage from animal
levels found in IDA patients suggested a possible protein include dietary acid load, phosphate content,
subclinical renal injury in pediatric patients gut microbiome dysbiosis, and resultant
although renal functions and serum electrolytes inflammation (Ko et al., 2020).
were still normal (Gunes et al., 2015). There was also
a study reported the on relationship between IDA
and sensorineural hearing loss in pediatric and
adolescent populations (Schieffer et al., 2017)
219
8.4 Current Status
Adequate intake of protein has been recognized as the mean serving size of meat and poultry, fish and
a crucial dietary factor for physical growth and legume groups among children when it was
development as well as optimal health in childhood compared between urban and rural areas, and
and adulthood. Based on the recent review of food income status (Koo et al., 2016; Mohd Shariff et al.,
and nutrition in Malaysian children using two 2015). In a study of 749 children consisted of
nationwide nutrition surveys of the Southeast Asian toddlers (1-3 years), preschoolers (4-6 years) and
Nutrition Survey (SEANUTS Malaysia) and schoolchildren (7-10 years), there was no significant
MyBreakfast study conducted in 2013 and 2015, differences between the daily serving size of meat
respectively, reported that almost all children and and poultry, fish and legumes found among these
adolescents in both studies had achieved the children, when it was compared by three different
Malaysian Recommended Nutrient Intake (RNI) for income status, except for meat and poultry group in
protein (Table 8.1, in Appendices), regardless of preschoolers (Mohd Shariff et al., 2015). Moreover,
children living in either urban or rural areas the majority of these children were unable to
(Norimah & Nurliyana, 2019). These findings were achieve the recommended servings for legumes
further supported by several other school-based (89.7 to 100%) and fish (54.7 to 90.6%) compared to
studies of children conducted on different age the meat and poultry group (12.8 to 60.7%),
groups in several areas in Kuala Lumpur, Selangor regardless of age group and income status (Mohd
and Perak (Abdul Majid et al., 2016; Mohd Shariff et Shariff et al., 2015). Based on these studies carried
al., 2015; Yang et al., 2017). When type and quality of out in children and adolescents in Malaysia, it is
protein was further classified according to food clearly shown that most children do not meet the
KM8 groups, numerous studies showed that most recommended serving size of plant-based protein
children and adolescents had an adequate daily foods, as compared to animal-based protein sources
intake of animal-based proteins such as meat and such as meat, poultry and/ or fish. Hence, an
poultry and/or fish (Mohd Shariff et al., 2015; Koo et adequate, and balanced diet with protein-rich
al., 2016; Yang et al., 2017). On the contrary, plant- animal and plant-based foods should be regarded as
based protein sources such as legumes seem to be an important aspect in the public health strategy to
lower than that of animal-based protein foods in promote healthy eating such as the consumption of
their daily food consumption. Indian children tended a variety of protein sources from a combination of
to consume higher intakes of legumes, but animal and plant foods, as a most effective approach
significantly lower intakes of meat and poultry than for sustainable diets among populations across the
other ethnic groups in Malaysia (Koo et al., 2016). lifespans, including in children and adolescents.
Interestingly, there were few differences between
220
Key Recommendation (KR) 1: Consume protein from marine and freshwater sources based on
recommended intake per day.
General Health Professional Parents/ Caregiver


Consume fresh and Recommend fresh and Provide fresh and unprocessed
unprocessed fish from marine unprocessed fish from marine or fish from marine or freshwater
or freshwater in one main meal freshwater in one main meal in one main meal daily based
daily based on recommended daily based on recommended on recommended intake per
intake per day* intake per day* day*

Consume a variety of protein Recommend intake variety of Provide a variety of protein from
from marine or freshwater protein from marine or marine or freshwater shellfishes
shellfishes such as prawn, freshwater shellfishes such as such as prawn, squids, crab,
squids, crab, clam and cockles prawn, squids, crab, cockles and cockles and clam based on
based on recommended intake*. clam based on recommended recommended intake*. Replace KM8
Replace with other protein intake*. Replace with other with other protein sources as
sources as per health protein sources as per health per health requirement (e.g.

requirement (e.g. allergy)** requirement (e.g. allergy)**. allergy)**
*Refer to Table 8.1 and 8.2 *Refer to Table 8.1 and 8.2 *Refer to Table 8.1 and 8.2
in Appendices for portion size in Appendices for portion size in Appendices for portion size
** Refer Health Professionals ** Refer Health Professionals ** Refer Health Professionals.
Key Recommendation (KR) 2: Consume lean meat and poultry* based on recommended intake
per day. *Refer 8.1 Terminology


Consume lean meat or poultry Recommend lean meat or Provide lean meat or poultry
based on recommended intake poultry based on recommended based on recommended intake
per day. intake per day. per day.

Choose fresh or frozen poultry/ Recommend fresh or frozen Provide fresh or frozen
meat over highly processed poultry/ meat over highly poultry/ meat over highly
meat products such as processed meat products such processed meat products such
sausage and nuggets. as sausage and nuggets. as sausage and nuggets.

Limit organ meat including Suggest to limit organ meat Limit purchase of organ meat
kidney, spleen, and liver and including kidney, spleen and including kidney, spleen and
processed meat intake e.g., liver and processed meat intake liver and processed meat intake
sausages, patties and nuggets. e.g. sausages, patties and e.g. sausages, patties and
nuggets. nuggets.
221
Key Recommendation (KR) 3: Consume egg daily based on recommended intake per day*.
*Refer Table 8.1 and 8.2 in Appendices


Consume egg in one of the Recommend egg in one of the Include egg in one of child’s
daily meals (e.g. breakfast, daily meals (e.g. breakfast, daily meals (e.g. breakfast,
lunch, dinner) or snacks. lunch, dinner) or snacks. lunch, dinner) or snacks.

Choose fresh eggs instead of Emphasize consumption of Purchase fresh eggs instead of
salted/ preserved egg products. fresh eggs instead of salted/ salted/ preserved egg products.
preserved egg products.
Key Recommendation (KR) 4: Practice healthier cooking methods for fish, eggs, meat and
poultry dishes at home.
KM8


Choose healthier cooking Recommend healthier cooking Use healthier cooking methods
methods such as poaching, methods such as poaching, such as poaching, steaming,
steaming, boiling, braising, steaming, boiling, braising, boiling, braising, grilling,
grilling, roasting or air frying. grilling, roasting or air frying. roasting or air frying.

Choose lean cuts meat and Recommend lean cuts meat Purchase/ prepare lean cuts meat
skinless poultry for cooking. and skinless poultry for cooking. and skinless poultry for cooking.

Limit deep frying cooking Recommend to limit deep frying Practice to limit deep frying
methods. cooking methods. cooking methods.
- KR4: HTA4: KR4: HTA4:

Recommend shredded/ Prepare shredded/ chopped/
chopped/ minced meat and minced meat and poultry for
poultry for young children young children especially below
especially below 2 years old. 2 years old. Meat/ poultry
Meat/ poultry texture can be texture can be soften using
soften using stewing and/ or stewing and/or braising
braising methods. method.
- KR4: HTA 5: KR4: HTA 5:

Recommend to remove fish Remove fish bones when
bones especially for children preparing food especially for
below 2 years old. Fresh fish children below 2 years old.
fillets or cutlets are suitable as Fresh fish fillets or cutlets are
the bones have been removed. suitable as the bones have
been removed.
222
Key Recommendation (KR) 5: Consume legumes/ beans daily.


Consume legumes/ beans daily Recommend consumption of Provide legumes/ beans daily
based on recommended intake legumes/ beans daily based on based on recommended intake
per day. recommended intake per day. per day.

Consume a variety of different Recommend a variety of Provide a variety of different
types of legumes (lentils, different types of legumes types of legumes (lentils,
tempeh and tauhu). (lentils, tempeh and tauhu). tempeh and tauhu).

Recommend the use of beans/ Use beans/ legumes in dishes
legumes in dishes and/ or and/ or dessert preparation.
dessert preparation.
KM8
Recommend the use of legumes Use legumes (lentils, tempeh
(lentils, tempeh and tauhu) to and tauhu) to replace meat or

replace meat or poultry, poultry, as required*.
as required*.
*Refer to health professionals/ *Refer to health professionals/
Malaysian Dietary Guidelines 2020/ Malaysian Dietary Guidelines 2020/
Malaysian Dietary Guidelines for Malaysian Dietary Guidelines for
Vegetarians Vegetarians
Key Recommendation (KR) 6: Consume nuts and seeds in main meals/ snacks at least twice a
week.


Choose raw and roasted nuts/ Recommend adding nuts and Add nuts and seeds as
seeds without additional fats, seeds as ingredients in meal ingredients in meal
salt and sugar. preparations (spreads, dishes, preparations (spreads, dishes,
snacks). snacks).

Consume nuts/ seeds in main Recommend raw and roasted Prepare/ purchase raw and
meals and/ or snacks consumption nuts/ seeds without additional roasted nuts/ seeds without
at least twice a week. fats, salt and sugar. additional fats, salt and sugar.

Recommend to include nuts/ Include/ prepare nuts/ seeds in
seeds in main meals and/ or main meals and/or snacks
snacks consumption at least consumption at least twice a
twice a week. week.
223
8.5.1 Additional Information
Protein allergy
A food allergy is defined as an adverse health effect exposure to food allergens in the maternal and
arising from a specific immune response that occurs, infant diet is usually assessed by identifying the age
reproducibly, on exposure to a given food. It is also at which the first solid food is introduced, the
called food-hypersensitivity reaction, usually in feeding pattern, and breastfeeding. A case control
response to large molecules of food protein. The study conducted among 0 to 13 years old children
immune response to food may be immunoglobulin with food allergies in Kuwait reported cow’s milk
E (IgE)-mediated (immediate reactions), non-IgE allergies was the most common type of food
mediated (delayed reactions) or mixed (Licari et al. allergies among aged 0 to 2 years while tree nuts
2019). IgE-mediated food allergies are the most was common among 2 to 5 years (Alkazemi et al.,
common and occur most frequently in the first years 2018). Special attention should be given when
of life. Urticaria/angioedema, oral allergic syndrome, feeding children who are prone to food allergies. A
rhinitis, or acute asthma and anaphylaxis are the study conducted in Singapore reported children
common seen. Non-IgE food allergies are with mixed type food allergies were significantly
characterized by cutaneous reactions (such as shorter (z-score -1 lower). Children also exhibited
atopic dermatitis, contact dermatitis and lower weight for age z-score if they had skin
herpetiform dermatitis), respiratory reactions (such involvement as part of their symptom presentation
as Heiner’s syndrome) or gastrointestinal reactions. (Chong et al., 2018). Legumes and beans can be
Non-IgE and mixed FA are less understood, despite introduced once complementary feeding starts,
KM8 their frequency (Calvani et al., 2021). The food however, if any allergy concerns arise, infants should
allergies most common among young children are be referred to a healthcare professional for further
allergies to cow’s milk, soya, nuts, egg white, wheat assessment and recommendations.
and citrus (Whitney & Rofles, 2011). The timing of
Guides For Parents and Caregivers (ASCIA Guidelines Infant Feeding and Allergy Prevention,
2020)
a. When your infant is ready, introduce foods e. If possible, continue to breastfeed whilst you
according to what the family usually eats, introduce foods to your infant. There is some
regardless of whether the food is considered to limited evidence that this may reduce the risk
be a common food allergen. There is some of allergies developing, and there are many
evidence that the introduction of common other health benefits of continued breast
allergenic foods (including cooked eggs as raw feeding.
egg is not recommended, peanuts, nuts, fish)
should not be delayed. However further f. There is good evidence that for infants with
evidence is required to clarify optimal timing for severe eczema and/or egg allergy, that regular
each food. peanut intake before 12 months of age can
reduce the risk of developing peanut allergy. If
b. Only introduce one new common food allergen your child already has an egg allergy or other
at each meal, so that the problem food can be food allergies or severe eczema, you should
identified if there is an allergic reaction. discuss how to do this with your doctor.
c. If your infant has an allergic reaction, stop g. There is moderate evidence that introducing
giving that food and seek medical advice. cooked egg (raw egg is not recommended) into
an infant’s diet before 8 months of age, where
d. Unless there is an allergic reaction to the food, there is a family history of allergy, can reduce
continue to give the food to your baby regularly the risk of developing egg allergy.
(twice weekly or as recommended), as part of a
varied diet. Trying a food and then not giving it h. When introducing foods that other family
regularly may result in a food allergy members are allergic to, it is important to follow
developing. risk minimization strategies to prevent cross
contamination of allergens, for those who are
allergic to the foods.
224
8.6 References
Abdul Majid H, Ramli L., Ying, S.P., Su T.T., Jalaludin, M.Y., & Abdul Mohsein, N.A.S. (2016). Dietary Intake
among Adolescents in a Middle-Income Country: An Outcome from the Malaysian Health and
Adolescents Longitudinal Research Team Study (the MyHeARTs Study). PLoS ONE 11: e0155447.
Algarin, C., Nelson, C.A., Peirano, P., Westerlund, A., Reyes, S. & Lozoff, B. (2013). Iron deficiency anemia in
infancy and poorer cognitive inhibitory control at age 10 years. Developmental Medicine and Child
Neurology. 55(5): 453-458.
Alimujiang, A., Colditz, G.A., Gardner, J.D. et al. (2018). Childhood diet and growth in boys in relation to
timing of puberty and adult height: the Longitudinal Studies of Child Health and Development. Cancer
Causes Control 29, 915–926. https://doi.org/10.1007/s10552-018-1068-2.
Alkazemi, D., Albeajan, M., & Kubow, S. (2018). Early infant feeding practices as possible risk factors for
immunoglobulin E-mediated food allergies in Kuwait. International Journal of Pediatrics.
https://doi.org/10.1155/2018/1701903.
Arnesen, E.K., Thorisdottir, B., Lamberg-Allardt, C., Bärebring, L., Nwaru, B., Dierkes, J., Ramel, A., & Åkesson,
A. (2022). Protein intake in children and growth and risk of overweight or obesity: A systematic review
and meta-analysis. Food Nutr Res. 21;66. doi: 10.29219/fnr.v66.8242. PMID: 35261578; PMCID:
PMC8861858.
KM8
ASCIA (2020). Guidelines Infant Feeding and Allergy Prevention.

Bonjour, J.P. (2011). Protein intake and bone health. Int J Vit Nutr Res. 81(2-3):134-42. doi: 10.1024/0300-
9831/a000063. PMID: 22139564.
Calvani, M., Anania, C., Cuomo, B., D’Auria, E., Decimo, F., Indirli, G.C., Marseglia, G., Mastrorilli, V., Sartorio,
M.U.A., Santoro, A. & Veronelli, E. (2021). Non IgE or mixed IgE/Non IgE mediated gastrointestinal
food allergies in the first years of life: old and new tools for diagnosis. Nutrients. 13: 226.
Chen, M., Su, T., Chen, Y., Hsu, J., Huang, K., Chang, W., Chen, T. & Bai, Y. (2013). Association between
psychiatric disorders and iron deficiency anemia among children and adolescents: a nationwide
population-based study. BMC Psychiatric. 13: 161.
Chong K.W., Wright, K., Goh, A., Meyer, R. & Rao, R. (2018). Growth of children with food allergies in
Singapore. Asia Pacific Allergy. 8(4): e34.
Delimaris, I. (2013). Adverse effects associated with protein intake above the recommended dietary
allowance for adults. ISRN Nutrition. 126929.
EAT-Lancet Commission, (2019). Summary Report Healthy Diets from Sustainable Food Systems.
Felt, B.T., Peirano, P., Algarin, C., Chamorro, R., Sir, T., Kaciroti, N. & Lozoff, B. (2012). Long term
neuroendocrine effects of iron deficiency anemia in infancy. Pediatric Research 71(6): 707-712.
Galler, J.R., Bryce, C.P., Waber, D.P., Hock, R.S., Harrison, R., David Eaglesfield, G. & Fitzmaurice, G. (2012).
Infant malnutrition predicts conduct problems in adolescents. Nutritional Neuroscience Journal.
15(4): 186-192.
Ghosh-Jerath, S., Singh, A., Jerath, N., Gupta, S., Racine, E.F. (2017). Undernutrition and severe acute
malnutrition in children. BMJ. 359: Suppl 1.
Gunes, A., Ece, A., Aktar, F., Tan, I., Soker, M., Karabel, D., Balik, H., Uluca, U., Sen, V., Yolbas, I. (2015). Urinary
kidney injury molecules in children with iron deficiency anemia. Medical Science Monitor. 21: 4023-
4029.
225
Günther, A.L., Karaolis-Danckert, N., Kroke, A., Remer, T., & Buyken, A.E. (2010). Dietary protein intake
throughout childhood is associated with the timing of puberty. J Nutr. 140(3):565-71. doi:
10.3945/jn.109.114934. Epub 2009 Dec 30. PMID: 20042466.
Hamid Jan, J.M., Amal, K.M., Rohani, A. & Norimah, A.K. (2010). Association of iron deficiency with or without
anemia and cognitive function among primary school children in Malaysia. Malaysian Journal of
Nutrition 16(2): 261-270.
Ko, G., Rhee, C.M., Kalantar-Zadeh, K. & Joshi, S. (2020). The effects of high protein diets on kidney health
and longevity. Journal of the American Society of Nephrology. 31: 1667-1679.
Koo, H.C., Poh, B.K., Lee, S.T., Chong, K.H., Bragt, M.C., & Abd Talib, R. (2016). SEANUTS Malaysia Study
Group. Are Malaysian Children Achieving Dietary Guideline Recommendations? Asia Pac J Public
Health 28(5 Suppl):8S-20S.
Licari, A., Manti, S., Marseglia, A., Brambilla, I., Votto, M., Castagnoli, R., Leonardi, S. & Marseglia, G.L. (2019).
Food allergies: current and future treatments. Medicina 55:120.
Lind Mads, V., Larnkjær, Anni Mølgaard., Christian, Michaelsen., & Kim, F. (2017). Dietary protein intake and
quality in early life. Current Opinion in Clinical Nutrition and Metabolic Care, Volume 20 - Issue 1 - p
71-76 doi: 10.1097/MCO.0000000000000338.
KM8 Lonnie, M., & Johnstone, A.M. (2020). The public health rationale for promoting plant protein as an important
part of a sustainable and healthy diet. Nutrition Bulletin, 45(3), 281-293.
Michaelsen, K.F., & Greer, F.R. (2014). Protein needs early in life and long-term health. Am J Clin Nutr.
99(3):718S-22S. doi: 10.3945/ajcn.113.072603. Epub 2014 Jan 22. PMID: 24452233.
Mohd Shariff Z, Lin, K.G., Sariman, S., Lee, H.S., Siew, C.Y., Mohd Yusof, B.N., Mun, C.Y., & Mohamad, M.
(2015). The relationship between household income and dietary intakes of 1–10-year-old urban
Malaysian. Nutr Res Pract 9:278-287.
NCCFN (2013). Malaysian Dietary Guidelines for Children and Adolescent. National Coordinating
Committee on Food and Nutrition (NCCFN), Ministry of Health Malaysia, Putrajaya.
NCCFN (2020). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and Nutrition
(NCCFN), Ministry of Health Malaysia, Putrajaya.
Norimah, A.K, & Nurliyana, A.R. (2019). Food and Nutrition in Malaysian Children. Nestle Nutr Inst Workshop
Ser 91:123-130.
Papanikolaou, Y., & Fulgoni, V. L. (2020). Eggs are cost-efficient in delivering several shortfall nutrients in
the American diet: A cost-analysis in children and adults. Nutrients, 12(8), 2406.
Pimpin, L., Jebb, S., Johnson, L., Wardle, J., Ambrosini, G.L. (2016). Dietary protein intake is associated with
body mass index and weight up to 5 y of age in a prospective cohort of twins. Am J Clin Nutr 103:389–
97.
Schieffer K.M., Connor, J.R., Pawelczyk, J.A. & Sekhar, D.L. (2017). The relationship between iron deficiency
anemia and sensorineural hearing loss in the pediatric and adolescent population. American Journal
of Audiology 26: 155-162.
Segovia-Siapco, G., Khayef. G., Pribis, P., Oda, K., Haddad, E., & Sabaté, J. (2019). Animal Protein Intake Is
Associated with General Adiposity in Adolescents: The Teen Food and Development Study. Nutrients.
31;12(1):110. doi: 10.3390/nu12010110. PMID: 31906138; PMCID: PMC7019331.
226
UNICEF/WHO/World Bank (2021). Group Joint Child Malnutrition Estimates. Levels and trends in childhood
malnutrition. Key findings of the 2021 edition.
Vaivada, T., Akseer, N., Akseer, S., Somaskandan, A., Stefopulos, M. & Bhutta, Z.A. (2020). Stunting in
childhood: an overview of global burden, trends, determinants, and drivers of decline. Am J Clin Nutr.
112(Suppl): 777S-791S.
Villamor, E., & Jansen, E. C. (2016). Nutritional determinants of the timing of puberty. Annual review of
Public Health, 37, 33-46.
Weideman, A.M.; Barr, S.I.; Green, T.J.; Xu, Z.; Innis, S.M.; Kitts, D.D. (2018). Dietary choline intake: Current
state of knowledge across the life cycle. Nutrients, 10, 1513.
Whitney, E., & Rofles, S.R. (2011). Understanding Nutrition (12th ed). Wadsworth Cengage Learning.
WHO (2021a). Plant-based diets and their impact on health, sustainability and the environment A review
of the evidence: WHO European Office for the Prevention and Control of Noncommunicable Diseases.
Copenhagen: WHO Regional Office for Europe; 2021. Licence: CC BY-NC-SA 3.0 IGO.
WHO (2021b). Malnutrition. World Health Organization, Geneva. https://www.who.int/news-room/fact-

sheets/detail/malnutrition. Accessed: 6 October 2021
Yang, W.Y., Burrows, T., MacDonald-Wicks, L., Williams, L.T., Collins, C.E., Chee, W.S., & Colyvas, K. (2017). KM8
Body Weight Status and Dietary Intakes of Urban Malay Primary School Children: Evidence from the
Family Diet Study. Children 4:5.

227
Appendices
Table 8.1: Recommended protein intake for children and adolescents
Age group RNI (g/ day)
Infant 0-5 months 8
6-11 months 10
Children 1-3 years 12
4-6 years 16
7-9 years 23
Boys 10-12 years 30
13-15 years 45
KM8
16-19 years 51
Girls 10-12 years 31
13-15 years 42
16-19 years 42
Source : Recommended Nutrient Intakes (RNI), 2017
228
Appendices
Table 8.2: Example of common foods (per serving) in household measurement for intake of protein per day
Age Poultry/ Meat/ Egg Fish Legumes
6 to 8 month ½ tablespoon boneless chicken/ beef, lean (8 g) 1 tablespoon fish (4 g) -
9 to 11 month ½ tablespoon boneless chicken/ beef, lean (8 g) 2 tablespoon fish (8 g) -
1 to 2 years ½ tablespoon boneless chicken/ beef, lean (8 g) 2 tablespoon fish (8 g) ½ tablespoon tauhu (2 g)
3 years Male 2 tablespoon boneless chicken/ beef, lean (32 g) Ikan kembung ½ medium (60 g) 1 tablespoon tauhu (4 g)
Ikan selar ½ medium (70 g)
Ikan tenggiri (14 cm x 8 cm x 1 cm)
½ piece (40 g)
Female 1 tablespoon boneless chicken/ beef, lean (16 g)
4 to 6 years Male 2 tablespoon boneless chicken/ beef, lean (32 g) Tauhu ½ piece (50g)
229
Female 2 tablespoon boneless chicken/ beef, lean (32 g) Tauhu ¼ piece (25g)
7 to 9 years Male Chicken, drumstick 1 piece (100 g) or Ikan kembung 1 medium (120 g) Tauhu/ taukua (hard/ traditional/ fried),
Chicken, breast, without skin, medium size, Ikan selar 1 medium (135 g) 1 piece (100 g)
cooked 1/2 piece (60 g) or Ikan tenggiri (14 cm x 8 cm x 1 cm) Kidney beans/ red beans/ mung beans,
Female Beef, lean (1 palm size), cooked 1 piece (60 g) or 1 piece (85 g) cooked 1/2 cup (80 g)
Egg, hen 2 whole (130 g) Squid 2 small (60 g) Nuts, peanuts/ almonds/ cashew nuts/
Anchovies (head removed) 2/3 cup pistachio 8 pcs/ 1 dessert spoon (10 g)
10 to 12 years Male Chicken, drumstick 2 piece (200 g) or (25 g) Walnut 4 pcs/ 1 dessert spoon (10 g)
Chicken, breast, without skin, medium size, cooked Seed, chia seed/ flax seed/ pumpkin
1 piece (120 g) or seed/ 1 dessert spoon (10 g)
Beef, lean (1 palm size), cooked 2 piece (240 g) or Sesame seed Seed, kuaci/ watermelon
Egg, hen 4 whole (260 g) seed/ sunflower seed 3 dessert
spoons (30 g)
Female Chicken, drumstick 1 piece (100 g) or
Chicken, breast, without skin, medium size,
cooked 1/2 piece (60 g) or
Beef, lean (1 palm size), cooked 1 piece (60 g) or
Egg, hen 2 whole (130 g)

KM8
KM8
Age Poultry/ Meat/ Egg Fish Legumes
13 to 15 years Male Chicken, drumstick 2 piece (200 g) or

cooked 1 piece (120 g) or

16 to <18 years Male Chicken, drumstick 2 piece (200 g) or

cooked 1 piece (120 g) or
230
● 1/8 serving of fish=1 tsp fish (4 gram)

● 1/8 serving of poultry/ meat/ egg = 1 tablespoon boneless chicken (8 gram)
● 1/16 serving of legume = ½ tsp tauhu (2 gram)
Appendices
Table 8.3: Examples of fish and seafood equivalent to one serving
Food example Size serving
Anchovies (head removed) 2/3 cup (25g)
Ikan kembung 1 medium (66g)
Ikan selar 1 medium (70g)
Ikan tenggiri 14 cm x 8 cm x 1 cm
Squid 1 piece (85g) or 2 small (60g)
Table 8.4: Examples of poultry, meat and egg equivalent to one serving
Chicken, drumstick 1 piece (100g)
Chicken, breast, without skin, medium size, cooked 1/2 piece (60g)
Beef, lean (1 palm size), cooked 1 piece (60g) KM8
Egg, century/ duck 2 whole (150g)

Egg, hen (gred b) 2 whole (130g)
Egg, quail 10 whole (120g)
Table 8.5: Examples of legumes equivalent to one serving
Beans, yellow/ black soya bean, cooked 1/2 cup (90g)
Soya product, soya bean curd/ fucok sheet 20 x 7 cm / 2 pieces (30g)
Soya bean cake, fermented (tempeh) 2 pieces (90g)
Tauhu/ taukua (hard/ traditional/ fried) 1 piece (100g)
Compressed tauhu (dou fu gan) 6 x 6 cm
Tauhu, tau-hoo-pok 2 x 2 x 2cm / 4 round pieces (40g)
Soybean milk, fresh, unsweetened 2 glasses/ 1 bottle (500ml)
Soybean dessert, tau-hoo-fah, unsweetened 2 containers (700g)
Baked bean/ green peas, canned 1 cup / 1 small canned (200g)
Chickpea/ black-eyed pea, cooked 1/2 cup (80g)
Kidney beans/ red beans/ mung beans, cooked 1/2 cup (80g)
Various split pea/ lentils/ dhal/ chickpea dhal 1/2 cup (80g)
Kadalei, red lentils/ masoor, green lentils, urad 1/2 cup/ 50 pieces (65g)
231
Table 8.6: Examples of nuts and seeds equivalent to one serving
Nuts, peanuts/ almonds/ cashew nuts/ pistachio 8 pcs/ 1 dessert spoon (10g)
Peanut in shell, roasted 20 small pieces (15g)
Walnut 4 pcs/ 1 dessert spoon (10g)
Seed, chia seed/ flax seed/ pumpkin seed 1 dessert spoon (10g)
Sesame seed seed, kuaci/ watermelon seed/ sunflower seed 3 dessert spoons (30g)
KM8
232
Key Message 9
Consume milk and milk products daily

KM9
Key Message 9
Assoc. Prof. Dr. Chin Yit Siew, Prof. Dr. Barakatun Nisak Mohd Yusof, Asst. Prof. Dr. Serene Tung En Hui, Dr. Law Leh Shii,
Ms. Gui Shirley, and Ms. Siti Nur Hidayah Adznam
9.1 Terminology
Condensed milk or sweetened condensed Dairy products

milk Similar meaning with milk products, which include
Condensed milk or sweetened condensed milk is milk or a food that is derived from milk, alone or
the product obtained by evaporating from milk, a combined with another food, and that contains no
portion of its water or by recombining milk oil and no fat other than that of milk.
constituents and adding sugar to the remainder. It
shall contain not less than 8% of milk fat and 28% of Evaporated milk or unsweetened condensed
total milk solids. milk
Evaporated milk, or unsweetened condensed milk
Cow's milk protein allergy is the product obtained by evaporating from milk, a
Cow's milk protein allergy is defined as a portion of its water or by recombining milk
hypersensitive allergic reaction triggered by the constituents and part evaporation. It shall contain
child's immune system due to a reaction to cow's not less than 8% of milk fat and 28% of total milk
milk protein. solids.
234
Fermented milk or cultured milk Lactose intolerance

The product is prepared by culturing pasteurized Lactose intolerance is a common gastrointestinal
milk, sterilised milk, recombined milk, pasteurised condition caused by the inability to digest and
cream or reduced cream with suitable lactic acid absorb dietary lactose.
bacteria and includes yoghurt, cultured cream and
lassi. Milk
Milk refers to cow, buffalo, goat and sheep milk
Flavoured milk [fresh, pasteurised, sterilised and ultra-high
Flavoured milk is milk or recombined milk to which temperature (UHT milk) and milk powder (full
a permitted flavouring substance has been added cream, skimmed, malted and filled milk powder].
and may contain sugar or salt or both. It shall have
been heat-treated such as pasteurisation or UHT. It Milk products
shall contain not less than 2% of milk fat and 8% of Milk products include any product prepared from
non-fat milk solids. milk as the main ingredient and includes the food or
which a standard is prescribed in regulations, such
Filled milk as yoghurt, cultured or fermented milk and cheese.
Filled milk shall be a product which in general
composition, appearance, characteristic and Milk intolerance and allergy
intended use is similar to milk but the milk fat has Some children are sensitive to milk components at
been replaced wholly or partly by an equivalent any age from birth, which may adversely affect
amount of edible vegetable oil or edible vegetable cow's milk or formula made from cow's milk. The
fat. It shall contain not less than 3.25% of fat and 9% reaction could be lactose intolerance or milk allergy,
of non-fat milk solids. also known as Cow's Milk Protein Allergy (CMPA). KM9
Full cream milk powder or dried full cream Pasteurised milk

milk Fresh milk that has been efficiently heat-treated by
Full cream milk powder or dried full cream milk is the holding method or by the high temperature
milk or recombined milk from which the water has short time (HTST) method.
been removed. Full cream milk powder contains
more than 26% of milk fat. Plant-based milk alternatives
Water-soluble plant extracts, such as legumes (e.g.,
Fresh milk soybean and chickpea), nuts (e.g., almond, cashew
Fresh milk is directly sourced from cow, buffalo, goat nut, and hazelnut), seeds (e.g., sunflower and
and sheep. Fresh milk generally contains about 3% sesame), cereals (e.g., rice and oat) or pseudo-cereals
of milk fat. Fresh milk is usually heat treated before (e.g., quinoa), which imitates cow’s milk in
consumption. In the farm, it is usually boiled. At the appearance and consistency but different in
commercial scale, fresh milk is pasteurised. Unless nutrients content based on each product.
it is pasteurised, it is best to boil fresh milk before
consumption. Recombined milk
The product is prepared from the constituents of
Homemade milk products milk combined with water or milk or both and has
Milk products such as ice-cream, yoghurt, curd been subjected to pasteurisation, sterilisation or
(dadih, tairu) that can be prepared easily at home UHT.
following their own recipes.
Reconstituted milk
Low fat milk The liquid product is prepared by adding the water
Low fat milk is milk which contains not more than to full cream milk powder and shall be subjected to
1.5g of fat per 100ml of milk. pasteurisation, sterilisation or UHT.
Lactose-free milk and milk products Sterilized milk

Milk or milk products are added with the food Milk which has been filtered, homogenized and
enzyme lactase to eliminate the presence of lactose, thereafter heated to and maintained at a
which no longer fulfils the standard criteria of milk temperature of not less than 100°C for a length of a
and milk products. time sufficient.
235
Skimmed/ non-fat milk Whole milk

Skimmed/ non-fat milk is milk from which milk fat Whole milk is often referred to as fresh milk in the
has been removed. It shall not contain more than consumer retail market, and no constituent (such as
0.5% of milk fat and not less than 8.5% of non-fat fat) has been removed. The milk retains its fat (about
milk solids. 3.5 percent) and is slightly thick.
Ultra-high temperature (UHT) milk

Ultra-high temperature (UHT) milk is milk which has
been subjected to heat treatment by being retained
at a temperature of not less than 135ºC for at least
two seconds to render it commercially sterile and
immediately packed in sterile containers.
9.2 Introduction
Milk and milk products are one of the most 2021). Branched chain fatty acids are essential
nutritious foods that help in sustaining healthy bioactive components that play a significant role in
growth and development processes throughout gut colonisation (Ran-Ressler et al., 2014). However,
their lifetime among millions of populations, human data from clinical trials comparing cow’s
especially children (Muehlhoff et al., 2013). Milk and milk and goat’s milk is not available.
milk products are important sources of dietary
KM9 energy, carbohydrate, proteins and fats. The main The plant-based milk alternatives, such as soya milk,
component of milk is water. Carbohydrates exist in almond milk and oat milk, have increased demand
the form of lactose. Minerals and vitamins in milk being the substitutes for cow’s milk due to its no
and milk products, which include calcium, lactose content, particularly lactose intolerant or
magnesium, selenium, iodine, iron, riboflavin, α- allergic to milk proteins. The nutritional content of
tocopherol, vitamin B12, and pantothenic acid, are plant-based milk alternatives varies and depends on
important to fulfil dietary needs (FAO, 2022a). Milk different types of raw material used to produce it,
and milk products can be meaningful alternatives the process, and the added ingredients (Sethi et al.,
for children with limited access to fat sources and 2016). However, the plant-based milk alternatives
animal-based foods because milk is rich in saturated cannot completely fulfil the replacement of cow’s
fatty acids, monounsaturated fatty acids and milk regarding nutritional quality in terms of protein
polyunsaturated fatty acids such as α-linolenic acid content and quality, as well as vitamins and
(ALA), very long-chain n-3 fatty acids minerals. Therefore, plant-based milk alternatives
(EPA+DPA+DHA), conjugated linoleic acid, n-6 are not recommended to replace animal-based milk
PUFA and linoleic acid (LA) (Muehlhoff et al., 2013; among healthy children and adolescents.
Średnicka-Tober et al., 2016).
There are various types of milk and milk products in
Cow’s milk is more readily available on the market the market. The nutrient composition of milk and
than goat's milk. However, interest in goat’s milk is milk products is affected by various factors
growing as more people become aware of the including the stage of lactation, breed differences,
benefits of goat’s milk. In general, the nutritional the number of calving (parity), seasonal variations,
composition between cow and goat milk is age and health of the animal, feed and management
comparable (Appendix 1). The differences are only effects, which makes it difficult to compare
to the fat content and branched chain fatty acids. compositional data (in absolute terms) between
The fat content in goat’s milk has higher studies (Muehlhoff et al., 2013). Therefore, reading
digestibility, which is attributable to the smaller fat the label of the product packages is important to
globule size than cow’s milk (Boukria et al., 2020). identify the necessary nutrients of the milk and milk
Goat’s milk appears to be higher in branched chain products.
fatty acids compared to cow’s milk (Watkins et al.,
236
Milk and milk products have become choices cultured milk contain probiotics that may determine
among 6 billion people globally (FAO, 2022b). In the gut microbiota composition and metabolic
literature, due to their abundant nutrients, the activities. The interaction between probiotics and
benefits of milk and milk products mainly revolve gut microbiota is believed to influence the metabolic
around growth and bone strength improvement, pathways of lipid metabolism that might exert an
reduced risk of overweight and obesity, sleep quality effect on the nutritional status of the children
improvement, dental health and diet quality (Dougkas et al., 2019; Kouvelioti et al., 2017; Sanchez
improvement among children and adolescents. et al., 2014).
9.3.1 Health benefits of milk and milk Milk and milk products have the potential to
products improve sleep quality and diet quality. Improvement
in sleep quality is hypothesised related to certain
Consumption of milk and milk products promote compounds in milk, specifically tryptophan and
growth and enhance the strength of bones among melatonin. A systematic review of 14 articles that
children and adolescents due to its bone-beneficial target the older adults, toddlers, specific children,
nutrients, such as calcium, magnesium, potassium, and adults showed that a balanced diet including
zinc, phosphorus, and protein when compared to milk and milk products helped to improve overall
other food groups (de Lamas et al., 2019; Kouvelioti sleep quality (Komada et al., 2020), but the evidence
et al., 2017; Wallace et al., 2020). For example, is inconclusive. In addition, the consumption of milk
calcium and protein play a crucial role in bone and milk products are expected to improve diet
mineralization and collagen formation (Kouvelioti et quality among the children and adolescents as it is KM9
al., 2017). A single serving of milk and milk products rich in nutrients including vitamins and minerals.
such as cheese and yoghurt provide high calcium However, this evidence is limited to individual

bioavailability (FAO, 2022a). Vitamin D in fortified studies, which warrants future investigation (Bao
milk, eggs, meat, mushrooms, and oily fish help in Khanh et al., 2016; Dougkas et al., 2019).
the absorption of calcium (FAO, 2022a; Moreno et al.,
2012). However, the association of milk and milk Another potential benefit of consumption of milk
product consumption with linear growth, body and milk products is the reduced risk of developing
composition and body size were inconclusive (de dental problems, which include dental caries,
Lamas et al., 2019; Kouvelioti et al., 2017). In addition, decayed teeth, missing teeth, and filled tooth scores
in a systematic review of 17 longitudinal and for both primary and permanent teeth in children
interventional studies, positive associations of milk due to abundant amounts of calcium, phosphate,
and milk products with height and linear growth in casein, and lipids in milk and milk products (Dror &
children and adolescents were reported. The Allen, 2014). Casein phosphopeptides stop enamel
authors hypothesised that the positive influence demineralization and help remineralization, while
was due to insulin-like growth factor 1 (IGF-1), not casein in the salivary pellicle blocks the adherence
the dietary protein in milk and milk products. A of bacteria to the surface of teeth (Dror & Allen,
positive association between milk intake and IGF-1 2014). The findings were also supported by a recent
was reported (Dror & Allen, 2014). systematic review following a longitudinal study
(Mahboobi et al., 2021).
There are concerns that milk and milk products
contain high fats, which can negatively affect health Fortification is “the practice of deliberately
status. Although high in fats, the overall evidence increasing the content of one or more
from systematic review and meta-analysis indicated micronutrients (i.e., vitamins and minerals) in a food
that consumption of milk and milk products have an or condiment to improve the nutritional quality of
inverse association with childhood overweight or the food supply (WHO, 2022)”. The purpose of
obesity (Dougkas et al. 2019; Vanderhout et al. 2020). fortification is to enhance the nutritional quality of
This anti-obesity inversed association can be food or to compensate for nutrient loss during food
attributed to the roles of calcium in milk and milk processing, which helps to minimise health risk
products. According to a mechanistic study, (WHO, 2022). This is most relevant for Malaysians as
calcium elicits its anti-obesity roles in cells, animals, micronutrient deficiencies or also known as “hidden
and humans by regulating adipocyte metabolism, hunger”, is prevalent in Malaysia, especially
increasing faecal excretion, and controlling appetite calcium, iron, thiamine, riboflavin, niacin, vitamin C
(Zhang et al., 2019). In addition, fermented milk and vitamin A (Wan Manan et al., 2019). Milk and
products such as yoghurt, yoghurt drinks and milk products in the market are commonly fortified
237
with minerals (iron, zinc, calcium, and iodine), yoghurt, milk- and yoghurt- beverages were
vitamins (vitamin B, C, D, and folic acid), essential associated with better health indicators, namely
fatty acids, and pre-and/or probiotics (Eichler et al., lower body fat, reduced risk of cardiovascular
2019; Matsuyama et al., 2017). Among young diseases, and better cardiorespiratory fitness
children aged 6 to 47 months, consumption of milk (Santaliestra-Pasías et al., 2016). Therefore, children
that is fortified with iron is associated with a lower should consume adequate amount of milk and milk
risk of anaemia (low quality evidence). However, the products daily.
effects of fortified milk on height gain, changes in
body composition or haemoglobin concentration According to the Malaysian Food Pyramid, one
were marginal (low quality evidence) (Matsuyama serving of milk is equivalent to 1 glass of milk
et al., 2017). In addition, a randomised, single- (250mL), 1 slice of cheese, 1 cup of Greek style
masked, controlled trials revealed daily consumption yoghurt, or 4 dessert spoons of milk powder, heaped
of two servings of fortified milk intake among (NCCFN, 2020). The rationale for the
children was associated with higher anthropometric recommendations is to guide children and
measurements of 1.40cm in height, 1.35kg in adolescents in meeting their nutritional needs. Milk
weight, 0.96kg/m2, 0.66cm in mid-upper arm and milk products are good sources of multiple
circumference when compared to their counterparts micronutrients, including minerals and vitamins
who did not consume fortified milk (Cervo, 2017). (Dror & Allen, 2014) and their high-quality milk
proteins, namely the casein proteins (alpha-S1- and
9.3.2 Dietary reference intake of milk and alpha-S2-caseins, beta-casein, and kappa-casein)
milk products for children and and the whey proteins (alpha-lactalbumin,
adolescents lactoferrin, beta-lactoglobulin, and
KM9 glycomacropeptide) (Auestad, & Layman, 2021). The
In most countries, there are separate milk proteins are recognised to have unique
recommendations for milk and milk intake for bioactivities that contribute to satiety, antimicrobial,
children and adolescents. National mineral-binding, and anti-lipidemic properties

recommendations for milk and milk products are at (Auestad & Layman, 2021). According to FAO
around two to three servings or equivalent to 500mL (2022a), a glass of milk per day helps to achieve
for children less than nine years old, while three to recommended daily intake of essential
five servings or equivalent to 600mL for adolescents micronutrients of young children (1 to 5 years old)
(Dror & Allen, 2014). Consistent recommendation and school-aged children and adolescents (6-18
was reported in the food-based dietary guidelines of years old) (Table 9.1).
the eight selected countries, namely Kenya, Ireland,
Spain, India, New Zealand, Canada, Bolivia, and Over 70% of the food-based dietary guidelines
Chile, in which 500-750 ml/day for young children 2 provide messages regarding the consumption of
to 4 years old, pre-schoolers and toddlers (except milk and milk products. Among these guidelines,
Bolivia), 500-750 ml/day for school-aged children, cow’s milk appears to be the most common type of
and 500-800 ml/day for adolescents, respectively milk, some other easily accessible milk (e.g. goat’s
(UNICEF, 2021). Findings from the HELENA study milk) and milk products (e.g. cheese and yoghourt)
among adolescents across eight European countries are also recommended as an alternative to cow’s
concluded that higher consumptions of milk, milk as an effort to diversify the sources of milk
Table 9.1: Milk supplies essential micronutrients and contributes to healthy diets
Achievement of Recommended Intake (%)

Micronutrient
Young children School-aged children and
(1 to 5 years old) adolescents (6-18 years old)
Calcium 41-57 22-41
Magnesium 28-46 13-28
Vitamin A 22-25 18-22
Vitamin B12 69-139 52-69
Source: FAO (2022a)
238
group and considering cultural aspects of the compared to the consumption of low-fat milk (0.1-
regions. Goat’s milk is recommended in Africa and 2.0% fat) (OR = 0.61, 95% CI: 0.52, 0.72; p < 0.0001)
Latin America, and Caribbean regions, while cheese (Vanderhout et al., 2020). The evidence concludes
and yoghourt are popular in all the regions, namely that children and adolescents are recommended to
Africa, Asia and the Pacific, Europe, Latin America consume whole milk instead of low-fat milk.
and the Caribbean, near East, and North America
regions (Comerford et al., 2021). Consumptions of Despite the facts, the national dietary guidelines of
milk and milk products that include cheese and several countries such as Canada and New Zealand
yoghourt are part of the healthy dietary pattern for recommend low-fat milk and milk and milk products
achieving recommended nutrient intake; thus, with lower fat content for children and adolescents,
reducing disease burdens during adulthood specifically among children and adolescents with
(Comerford et al., 2021; National Health and Medical overweight and obesity (Alberta Health Services,
Research Council & Department of Health and Aged 2016; Dror & Allen, 2014; Manatū Hauora, Ministry
Care, 2022; NHS, 2021). Moreover, the quality of the of Health, 2012). In the United States, children with
milk and milk products are of great concern upon a higher risk of having obesity, elevated
recommendation. Similar recommendations are triglycerides, or cardiovascular diseases should seek
found in all the food-based dietary guidelines in consultation from doctors and nurses before
which milk and milk products with low fat, low deciding on suitable types of milk to be given (CDC,
sugar and low sodium are viewed as healthier 2021). Meanwhile, in the United Kingdom, semi-
choices for adults (Comerford et al., 2021; National skimmed milk is recommended for children
Health and Medical Research Council & between two and five years old, while skimmed milk
Department of Health and Aged Care, 2022). is not recommended for children under five but can
Choosing healthier milk and milk products with be used for cooking (NHS, 2019). In this case, the KM9
low/lower sugar and/or salt content is important as recommendation needs to be individualised for
children are expected to carry their milk children with overweight and obesity (Riley et al.,

consumption habits into their adulthood. The habits 2018). Such recommendations may be due to the
could exert lifelong positive effects on their overall high prevalence of childhood obesity in these
health status (Sipple et al., 2020) and prevention of countries, children and adolescents with overweight
diet-related health issues, including obesity, and obesity shall seek nutritional management from
osteoporosis, metabolic syndrome, hypertension, relevant healthcare professionals such as
cardiovascular diseases, stroke, hypertension, and nutritionists and dietitians.
colorectal cancer (Comerford et al., 2021; National
Milk Producers Federation, 2022; Zhang et al., 2021). The literature suggests that flavoured milk increases
milk consumption among children, and it
Whole cow’s milk should only be provided to contributes to the attainment of several essential
children above 12 months. Whole cow’s milk is nutrients, such as protein, calcium, and magnesium
distinguishable from low-fat milk due to the higher (Fayet-Moore, 2016; Patel et al., 2018). Despite
fat content. Introducing cow’s milk too early (< 1 limited evidence on the effects of flavoured milk
year old) might lead to intestinal bleeding and an consumption on overweight and obesity (Dougkas
increased burden on the kidneys to handle an et al., 2019; Patel et al., 2018), flavoured milk
abundant amount of protein and minerals (CDC, consumption should be limited due to its higher
2021). A systematic review reported that intake of content of sugar (Patel et al, 2018). This is aligned
whole cow’s milk was not associated significantly with recommendations of low-sugar flavoured milk
with increased cardio-metabolic risk, while limited by national dietary guidelines of the United States
evidence showed that exchange from whole milk to and Australia, the British Dietetic Association,
low-fat milk products helped to reduce health risk Dietitians Association of Australia, and the New
(Nicholl et al., 2021; O'Sullivan et al., 2020). Zealand Ministry of Health. Meanwhile, WHO and
Additional evidence was provided by another National Health Service suggest limiting flavoured
systematic review of cumulative evidence from 18 milk intake (Patel et al, 2018). While 1 packet of
studies concluded that higher consumption of flavoured milk consists of 7g of added sugar, the
whole cow’s milk was associated with a lower risk move of secondary schools in the United States to
of developing child adiposity; while another 10 remove chocolate milk significantly decreased the
studies showed no association. The meta-analysis consumption of added sugars (Thompson et al.,
revealed consumption of whole milk (3.25% fat) 2020). Hence, plain milk remains the best choice for
reduced the risk of overweight and obesity when the consumption of children and adolescents.
239
9.3.3 Milk intolerance and allergy milk products should not be eliminated because
they provide vital nutrients such as calcium,
Some children are sensitive to milk components at vitamins A and D, riboflavin, and phosphorus.
any age from birth, which may have an adverse Available data suggest that adolescents and adults
reaction to cow's milk or products made from cow's usually consume up to 12g lactose in a single dose
milk. The reaction could be lactose intolerance or (about 1 cup or 240 ml milk) with no or minimal
milk allergy, also known as Cow's Milk Protein symptoms (Usai-Satta et al., 2012). Hence, the
Allergy (CMPA). These conditions are two different dietary management for these patients shall consist
terms but are often used interchangeably. Table 9.1 of a diet low in lactose. In principle, the source of
shows the key differences between these two lactose includes all milk (whole, low-fat, non-fat,
conditions. cream, powdered, condensed, evaporated, goat,
acidophilus, and flavoured [chocolate, strawberry]).
9.3.3.1 Lactose intolerance
9.3.3.2 Cow's milk protein allergy
Lactose intolerance is rare in children younger than
5 but is mostly seen in adolescents and young adults Cow's milk protein allergy (CMPA) is the most
and is also commonly observed among Asians common food allergy among children globally,
(Mahesh et al., 2021). Lactose intolerance occurs due including in Malaysia. The exact local incidence rate
to reducing lactase activity in the brush border of is scarce, but worldwide data shows a confirmed
the intestine (Di Costanzo et al., 2021). The CMPA diagnosis ranges from 5-8% (Flom & Sicherer,
fermentation of undigested lactose would cause 2019). Meanwhile, about 5-15% of infants present
abdominal pain, bloating, flatulence, and diarrhoea, with symptoms associated with CMPA (Mahesh et
KM9 and disease severity varies among individuals. al., 2021). CMPA can develop since neonate, peak at
Although these gastrointestinal symptoms are one year and persist into adolescence. It is also
similar to CMPA, lactose intolerance does not observed that CMPA usually resolves at 3-4 years of
involve the immune response. The signs and age. The signs and symptoms of CMPA include
symptoms of lactose intolerance may appear within gastrointestinal symptoms such as diarrhoea,
one to two hours after the meal. As lactose is present bloating and vomiting and other allergic reactions,
in dairy, milk products, and mammalian milk, an including atopic eczema, allergic rhinitis or asthma
appropriate medical diagnosis is required to avoid (Di Costanzo et al., 2021).
unnecessary restrictions. Attention to the condition
is required as unattended lactose intolerance might The main goal of nutrition therapy is to eliminate
lead to dehydration, malnutrition, and poor weight milk protein which is part of milk and milk products.
gain or failure to thrive among babies (Lim & Lim, Hence, the appropriate medical diagnosis of CMPA
2008). is critical. Nonetheless, about 1-18% of children are
observed to self-report their CMPA status. The
For children with a confirmed lactose intolerant inappropriate diagnosis will lead to the unnecessary
diagnosis, reduction of lactose intake rather than elimination of milk and milk products, which may
complete elimination is recommended. Milk and cause suboptimal growth and nutritional status.
Table 9.2: Differences between lactose intolerance and cow's milk protein allergy
Component Lactose Intolerance Cow’s Milk Protein Allergy
Definition A sensitivity that occurs in the An allergy triggered by the immune

gastrointestinal system due to milk system due to a reaction to milk
carbohydrate (lactose). protein.
Mechanism Enzyme deficiency Immune-mediated reaction
Onset 5-6 years old and continues to The peak during the first year of life, a
adolescents and adulthood. trend to resolve in childhood.
Nutrition Reduce the amount of lactose-based diet Eliminate milk and milk products
Management
Source: Malaysian Society of Allergy and Immunology & Malaysian Paediatric Association (2012).
240
Children with CMPA appeared to be at increased viewed as expensive for those lower socio-
risk of lower body weight and height than other economic status families. As price and health were
types of food allergy. Furthermore, prolonged CMPA some of the factors related to the purchase of milk,
was likely to significantly decline weight and BMI specifically milk powder among Malaysian
z-scores between 2 and 4 years (Robbins et al., consumers; this may be the reason for the higher
2014). intake of milk or milk products among children from
families with higher income and educational levels
Exclusive breastfeeding for at least 4 months is (Prescott et al., 2002).
associated with a lower incidence of CMPA until 18
months. Furthermore, breastfeeding for 6 months Milk and milk products can be served at any meal
without any solid food or formula-fed cow's milk has and/ or between meals (NDC, 2011). The
been shown to prevent CMPA among young “Identification and Prevention of Dietary- and
children. Hence, the practice of exclusive lifestyle-induced health effects In Children and
breastfeeding and the introduction of infants” (IDEFICS) study across eight European
complementary feeding at 6 months should be countries revealed that consumption of milk
actively advocated to minimize the risk of CMPA, products such as yoghurt and cheese during snack
especially among children with a strong family time has a significant and positive relationship with
history of food allergy and allergic-related diseases better overall diet quality (Iglesia et al., 2020). An
(EFSA, 2019). experimentally designed study presented that the
provision of larger portions of milk was associated
9.3.4 Roles of parents, caregivers and with greater milk consumption among 3- to 6-year-
teachers old children in the United States (Kling et al., 2016).
However, parents should avoid adding extra sugar KM9
Milk consumption is part of the healthy dietary to food, including milk as the behaviour was
practice. Several factors are identified to determine associated with lower adherence to healthy dietary

the preference of children towards milk guidelines and increased risk of adiposity in children
consumption. The factors are divided into three (Dello Russo et al., 2018).
categories, namely intrinsic factors (milk content,
flavoured milk, sweeteners, heat treatment, and For children who do not like to drink milk or drink
membrane filtration), extrinsic factors (social less milk, it is important for parents, caregivers and
influence and perceived health beliefs), and teachers to increase their willingness to taste and
packaging factors (graphic and visual design factors, build an affinity for drinking milk every day by using
labelling factors, and packaging materials) (Sipple et creative and attractive ways to prepare and
al., 2020). In particular, one of the factors that is incorporate milk and milk products in their daily
worth discussing is that milk and milk product dietary practices. For example, milk can be served
consumption by children is greatly determined by in attractive forms such as home-made milk
social influences, especially from parents, caregivers, products such as ice-cream, dadih, yoghurt and
teachers, staff, and peers. Among them, the milkshakes, or it can be added in various recipes
influence of parents and caregivers is the greatest. such as in cookies, pudding, and custard. Children
Parents are responsible for providing guidance to prefer flavoured milk over plain milk; therefore,
their children and shaping the dietary habits of their promoting milk with flavours may help to attract
children through several approaches, such as children to consume more milk (Nicklas et al., 2017).
modelling dietary behaviours and feeding practices Although flavoured milk may increase milk intake,
(Srbely et al., 2019; Sipple et al., 2020). Furthermore, added sugars may promote increased energy intake
parents are also responsible for the availability and (Patel et al., 2018). In view of the sugar concerns in
accessibility of milk and milk products at home some of the milk and milk products, dairy industry
(Brett et al., 2016; Srbely et al., 2019; Sipple et al., and researchers can be the strategic partners in
2020). reducing the sugar content in milk products such as
flavoured milk, yoghurt, cultured milk and ice cream.
The availability and accessibility of milk and milk
products are also often related to the educational Children and their parents are urged to read
level and income status of the family. Children and nutrition labels to choose appropriate milk and milk
adolescents from lower income status and the products, preferably with low/lower sugar and/or
educational levels of families were reported to have salt and/or fat content (CDC, 2021; FDA, 2022). In a
lower intakes of milk and milk products (Koo et al., nutrition labelling interventional trial, a significant
2016; IPH, 2017). One of the reasons could be due to influence of nutrition label use with making
the affordability of milk and milk products which are healthier food purchases was reported (Ni Mhurchu
241
et al., 2018). In Malaysia, the practice of reading 2020). Continuous education and training to
nutrition labels among adolescents was reported to teachers, school canteen operators and school
be low, with 53.6% not using nutrition labels (IPH, administrators are important in creating and
2017). Several barriers, namely lack of interest, supporting the healthy school food environment and
reliance on past experience, hunger and craving, providing balanced and nutritious food for the
time restrictions, and taste of the food, were students (Azizan et al., 2021).
identified for the low use of nutrition labels among
Malaysian adolescents (Norsakira et al., 2019). 9.3.4.1 School milk programme
Besides, reading nutrition labels helps parents to
identify fortified milk as mandatory nutritional The School Milk Programme (SMP) has been
labelling is required for foods that are fortified, implemented in many countries. The
enriched, vitaminised, supplemented, and implementation of the programme varies among
strengthened with vitamins or minerals (MOH, different countries and there are usually three
2010). Therefore, nutrition education on milk and categories of milk distribution – free, subsidised and
milk products intakes are important for children and full-cost. In Malaysia, the SMP was launched in 1985
adolescents. Existing nutrition education strategies through the Ministry of Education as a welfare
include education and training through technology program for school children from hard core poor and
tools, peer education in schools, pamphlets, and poor families. The goal of the SMP was to improve
training with snacks (Nikniaz et al., 2020). At the the health and nutritional status of the school
same time, it is important to acknowledge that children for optimal physical growth while
nutritional interventions among pre-schoolers need encouraging milk consumption from young. Since
to be planned cautiously by taking into 2020, the SMP was implemented through the supply
KM9 consideration the factors such as implementation at of milk to school children enrolled in the
one setting (school facility), application of specific Supplementary Feeding Programme (RMT). School
behavioural change techniques, and involvement of children enrolling in the RMT are provided with
both parent and child to increase their effectiveness 200ml of unflavoured UHT full cream milk on a daily
(Srbely et al., 2019). basis. Plain milk is used in the RMT as most of the
flavoured milks contain high amounts of both total
Milk and milk products should be made available and free sugar, which contribute to a high daily
and accessible to children at home and school. sugar intake (Coyle et al., 2019). Apart from the
However, Nik Rosmawati et al., (2017) reported that school milk programme, the Ministry of Health
there was limited availability of milk and milk Malaysia, also has the Programme for the
products served in primary school canteens. Schools Rehabilitation of Malnourished children (PPKZM)
are urged to provide milk and milk product options food basket programme for children aged 6 months
for students. Parents and caregivers also may pack to below under 6 years of age. Although the initial
milk and milk products such as UHT milk, yoghurt, aim of this programme is for the prevention of
for their children to consume at school. It is critical malnutrition of the hard-core poor families, those
to educate parents, caregivers, and teachers about who were eligible for this programme will be
the benefits of milk and milk products and urge supplemented with 2kg of milk powder every month
them to ensure milk and milk products as a viable aside from other essential foods (MOH, 2015)
option for children at home and school. Parents and
caregivers should model healthy eating habits, and In the US, schools participating in the National
drink milk or consume milk products together with School Lunch Programme and the School Breakfast
their children (Scaglioni et al., 2018). In school and Programme are required to provide 1 cup of milk
childcare settings, peer modelling can also greatly everyday to students as part of their lunch and
affect child food and beverage choices (Burgess- breakfast in order to maintain and grow the milk
Champoux et al., 2016; Sipple et al., 2020). Besides, consumption of school children (Sipple et al., 2020).
multiple intervention strategies inducing public Milk provided to the students are required to be
advertisement and healthier products in schools or pasteurized and fortified with vitamins A and D, and
supermarkets with lowered prices were effective in at least two options of milk (one must be
increasing the intake of milk and milk products unflavoured), which can be fat-free or low-fat
(Nikniaz et al., 2020). varieties of flavoured or unflavoured milk are given
to the students. For students with special medical
Schools play an important role in promoting milk or dietary needs, non-dairy milk options are offered,
drinking habits among students. Making milk and and the alternative must provide a nutritional profile
milk product options available for students provides comparable to that of dairy milk as defined in the
a healthy school food environment (Nikniaz et al., meal requirement for lunches.
242
9.4 Current Status
The Adolescent Nutrition Survey (ANS) 2017 which 10g condensed milk or ice cream, or 5g of cheese on
was part of the National Health and Morbidity a daily basis. In addition, if the sum of all milk and
Survey (NHMS) 2017 reported the habitual food milk products exceeds 100g, the child was also
intake of 2096 adolescents aged 10 and 17 years classified as a “dairy user”. These findings were
through a 136-food item Food Frequency different from ANS 2017, which reported, half of
Questionnaire (FFQ). The study reported that a Malaysian adolescents consumed cultured drinks
majority of Malaysian adolescents (73.1%) did not (65.9%) and UHT milk (57.5%) with the median
consume milk and milk products as per intake of 0.1 times and 0.1 serving per day.
recommended (2-3 servings of milk or milk products Nevertheless, both studies concluded that intake of
a day), with more adolescents in urban areas milk and milk products among adolescents were not
reported to have higher intake of milk and milk achieved as per recommended.
products (26.3%) compared to those in the rural
areas (19.2%) (IPH, 2017). Other than the nationwide studies mentioned above,
several small-scale local studies were conducted
The SEANUTS was another nationwide study among children and adolescents, where most of
conducted among 1773 children aged 7 to 12 years these studies were conducted in the Klang Valley. A
(Koo et al., 2016). In this study, among children aged cross-sectional study conducted among 749
7-9 years of age, it was reported that those from the children aged 1-10 years examined the milk drinking
urban areas (0.62 servings/d), families with higher patterns of urban children of different household
income (0.89 servings/d) and education levels (0.77 income status in Kuala Lumpur, Malaysia (Khor et
servings/d for fathers; 0.83 servings/day for mothers) al., 2015). Out of the total sample of children, 82.0% KM9
consumed significantly higher quantities of milk and reported consuming milk at the time of the study
milk products compared to rural areas (0.48 with the highest among children aged 1-3 years

servings/d), lower income (0.43 servings/d) and (90.6%), followed by those aged 4-6 years (86.1%)
education levels (0.22 servings/d), respectively and 7-10 years (73.7%). The mean intake of milk
(p<0.05). As for children aged 10 to 12 years, children consumed by children aged 1-3 years was 692.8ml
from households with medium (0.62 servings/d) and which was equivalent to 3.5 cups per day, much
high income (0.74 servings/d) had significantly higher than the recommended. Children aged 4-6
higher intakes of milk and milk products compared years consumed 429.6ml which was 2.2 cups daily
to the low-income households (0.39 servings/d) and within the recommendation while the oldest
(p<0.05). When comparing the consumption of milk group consumed 214.8ml or 2 cups per day, much
and milk products with the Malaysian Dietary lower than recommended. When further examined
Guidelines (MDG) for Children and Adolescents the types of preferred milk consumed, growing-up
2013, less than 10% of these children achieved the milk was the most preferred milk type among
recommendation of 2 to 3 servings of milk and milk children aged 1 to 6 years, followed by full-cream
products. Further analysis shows that a significantly milk and plain milk. No significant difference was
higher proportion of children from families with reported in the mean amounts of milk consumed
higher income (12.8%) and maternal education level among ages 1-3 years from low to high income
(9.7%) (p<0.05) met the MDG recommendation for categories. Although growing-up milk was the
milk and milk products. highest consumed milk product in the study, it
should be interpreted with caution as growing-up
When looking into the consumption of different milk milk or follow-up formula should not be
and milk products, the SEANUTS study reported inappropriately promoted as they fall under the
that 69% of Malaysian children consumed milk and International Code definition of “breast-milk
milk products, which is higher than Indonesia (52%) substitute” (WHO, 2017). Another study among 207
and Vietnam (47%) but much lower than Thailand children aged 7- 13 years aimed to examine fluid
(98%). When comparing the different milk products consumption reported that the intakes of whole-
consumed, the main source of milk and milk milk (168.84 ± 169.25ml) and low-fat milk (14.20 ±
products for Malaysian children is from milk powder 60.60ml) were far lower than the recommended
(41%), while condensed milk (27%) by the (Kaur et al., 2017).
Indonesian children and UHT/flavoured milk by the
Thai (84%) and Vietnamese (34%) children (Le As for adolescents, a study conducted among 230
Nguyen et al., 2013). Dairy users are defined as either adolescents aged 10-14 years in Selangor aimed to
with a minimum average consumption of either 15g examine fluid intake reported a mean intake of
milk powder, 100g UHT/flavoured milk, 50g yoghurt, whole milk (108.59 ± 170.84ml) and low-fat milk
243
(65.39 ± 141.62ml), which only met 0.43 servings of children reported that 20.8% were allergic to
the recommendation of at least 2 servings of milk seafood, 12.0% were allergic to nuts, 0.8% were
per day (Tung et al., 2020). Another study among 439 allergic to seafood and milk, and 1.2% were allergic
adolescents aged 13 to 17 years reported that the to nuts and milk (Din et al., 2019).
frequency of consuming full-cream milk, low-fat
milk (2%) and skimmed milk daily were 73%, 55% In conclusion, regardless of nationwide or small-
and 38%, respectively (Teng et al., 2020). The My scale studies, the findings consistently reported that
Body is Fit and Fabolous at School (MyBFF@school) children and adolescents in Malaysia did not meet
study conducted among children with overweight the recommendation for the intake of milk and milk
and obesity aged 9 to 11 years and adolescents aged products. In particular, this is more likely to be noted
13 to 16 years in the Central region reported that a among older children, in rural areas and among
higher percentage of children (67.4%) met the children with lower socio-economic status. As milk
recommendation compared to adolescents (58.4%) and milk product consumption is essential for the
(Selamat et al., 2020) (p <0.001). optimal growth of children and adolescents; hence,
there is a need to ensure adequate consumption of
To date, no prevalence data on cow’s milk allergy milk and milk products among these age groups
alone have been reported in local studies. However, through various intervention strategies by multi-
a small-scale local study on food allergens among agencies and stakeholders in the country.
KM9
Key Recommendation (KR) 1: Consume adequate amount of milk and milk products daily
General Parents/ Caregiver Teacher Health Professional


Consume milk and milk Incorporate milk Advocate and promote Attend technical
products daily according products (such as the importance of training on strategies to
to the recommended cheese and yoghurt) as consuming milk and ensure adequate
number of servings snacks and part of the milk products daily to consumption of milk
(Refer to Tables 3.2 and meals. children and and milk products.
3.3 in Key Message 3). adolescents.

Drink milk during Pack milk and milk Advocate, promote and
breakfast, snack time products for school- implement strategies to
and/or before bedtime. going children to ensure adequate
consume at school and consumption of milk
considering proper food products.
handling.

Start drinking milk Ensure milk and milk Educate parents/
gradually for those who products are accessible caregivers/ teachers on
are not regular milk by children at home. proper ways to pack
drinkers until the servings the milk and milk
needed are reached. products to schools.

Continue to drink milk as Monitor and ensure
part of a daily healthy diet, children consume an
even after starting family adequate amount of
food, and breast milk and milk and milk products.
bottle-feeding weaning.
244
Key Recommendation (KR) 2: Choose a variety of milk and milk products.


Drink milk such as fresh Choose a variety of milk Recommend milk and Educate parents/
milk, sterilised milk, products such as milk products with low/ caregivers/ teachers/
ultra-high temperature yoghurt, yoghurt drinks lower sugar and/or children and
(UHT) milk, pasteurised and cultured milk with salt content. adolescents to read
milk or milk prepared from lower sugar content. nutrition label to
milk powder daily. choose appropriate
Sweetened condensed milk and milk products,
milk, sweetened preferably with
condensed filled milk and low/ lower sugar and/
creamer are not or salt content.
considered as milk and
should be discouraged.

Choose a variety of milk Choose plain milk KM9
products such as instead of sweetened
yoghurt, yoghurt drinks condensed milk.

and cultured milk with
lower sugar content.

Choose plain milk instead Read nutrition labels to
of sweetened condensed choose appropriate milk
milk. and milk products,
preferably with low/
lower sugar and /or salt
content or Healthy
Choice Logo (HCL).
KR2: HTA4: - - -
Read nutrition labels to
choose appropriate milk
and milk products,
preferably with low/ lower
sugar and/ or salt content
or Healthy Choice Logo
(HCL).
245
Key Recommendation (KR) 3: Enjoy milk and milk products daily.

KR3: HTA1: KR3: HTA1: KR3: HTA1: KR3: HTA1: Educate

Enjoy milk and milk Enjoy milk and milk Recommend milk and parents/ caregivers/
products with family products with family milk products with low/ teachers/ children and
members and friends. members and friends. lower sugar and/ or salt adolescents to read
content. nutrition label to
choose appropriate
milk and milk products,
preferably with low/
lower sugar and/ or
salt content.
- KR3: HTA2: KR3: HTA2: -

Use milk in various Encourage schools to
recipes or dishes. Avoid promote milk drinking
adding sugar to the habits among students.
KM9 recipes or dishes.
- KR3: HTA3: - -
Replace sweetened
condensed milk,
sweetened condensed
filled milk and creamer
with milk (ready to drink
or powdered milk) in
preparing drinks/
desserts.
- KR3: HTA4: - -
Substitute coconut milk
with milk in preparing
dishes.
- KR3: HTA5: - -
Serve milk in attractive
form such as cereals,
pudding, in homemade
ice-cream, dadih,
yoghurt and milk shake
with fresh/ dried fruits.
- KR3: HTA6: - -
Add milk or milk
products to meals i.e.
cereals, pudding.
- KR3: HTA7: - -
Boil fresh milk from the
farm before drinking.
Avoid adding sugar to
the milk.
246
Additional Recommendation (AR) for children and adolescents with lactose intolerance

Health Professional
AR 1: AR 1: AR1:
Inform parents/ caregiver/ Seek for medical advice to Educate parents/ caregivers/
teachers if experiencing lactose confirm a diagnosis of lactose teachers and children and
intolerance symptoms. intolerance or Cow’s Milk adolescents to identify lactose
Protein Allergy (CMPA). intolerance symptoms.
- AR 2: AR 2:
For children with concern for For children or adolescents with
lactose intolerance: concern for lactose
Recommend them to consume intolerance:
milk and milk products in a. Recommend them to
smaller amounts as tolerable, choose cheese and yoghurt
together with a food to aid in (they are lower in lactose
digestion. As tolerated, and the active cultures in
gradually progress to the full yoghurts can help with
recommendations. digestion). KM9
b. Consume plant-based milk
such as soy, almond, rice,

and oat milk with low/lower
sugar content as an
alternative choice. Plant-
based milk has lower protein
and calcium bioavailability
than milk.
c. Educate parents/ caregivers
about the nutritional
contents before deciding to
choose any of these milk
alternatives.
- AR 3: -
Inform parents if they observe
children or adolescents
experiencing lactose intolerance
symptoms.
247
9.6 References
Alberta Health Services. (2016). Nutrition guideline: Healthy Infants and Young Children. Milk.
https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-ng-healthy-infants-other-milks-
fluids-milk.pdf.
Auestad, N., & Layman, D. K. (2021). Dairy bioactive proteins and peptides: a narrative review. Nutrition
reviews, 79(Suppl 2), 36–47. https://doi.org/10.1093/nutrit/nuab097
Azizan, N. A., Papadaki, A., Su, T. T., Jalaludin, M. Y., Mohammadi, S., Dahlui, M., Nahar Azmi Mohamed, M.,
et al. (2021). Facilitators and Barriers to Implementing Healthy School Canteen Intervention among
Malaysian Adolescents: A Qualitative Study. Nutrients, 13(9), 3078. MDPI AG. Retrieved from
http://dx.doi.org/10.3390/nu13093078
Bao Khanh l., Burgers M.R., Huu Chinh N., Tuoc B.V., Dinh Dung N., Deurenberg P., Schaafsma A. & SEANUTS
Study Group. (2016). Nutrient intake in Vietnamese preschool and school-aged children is not
adequate: The role of dairy. Food and Nutrition Bulletin 37(1): 100–111.
https://doi.org/10.1177/0379572116631642
Boukria O., El Hadrami E.M., Boudalia S., Safarov J., Leriche F., Aït-Kaddour A. (2020) The effect of mixing
milk of different species on chemical, physicochemical, and sensory features of cheeses. A Review.
Foods 9(9): 1309-xxxx. doi: 10.3390/foods9091309.
KM9
Brett, N. R., Vanstone, C. A., Maguire, J. L., Rauch, F., & Weiler, H. A. (2016). Parental knowledge, perceptions
and consumption of milk and alternatives relates to intakes of young children 2–8 y of age. The FASEB
Journal, 30(S1), 295.3. https://doi.org/10.1096/fasebj.30.1_supplement.295.3
Burgess-Champoux, T. L., R. Rosen, W. Linsenmeyer, H. Faivre, C.Longley, S. English, B. W. Rice, E. L. Shanley,

R. Cosby, C. Strohbehn, and S. Arendt. 2016. Got milk! Exploring how student perceptions and
behaviors impact their milk selection in schools. Institute of Child Nutrition, Applied Research
Division, Hattiesburg, MS. Accessed Jan. 1, 2020. https://theicn.org/resources/347/technical-
reports/106623/Got-Milk-Exploring-How-Student-Perceptions-Impact-Their-Milk-Selection-in-
Schools.pdf
CDC (2021). Cow’s milk and milk alternatives.

https://www.cdc.gov/nutrition/infantandtoddlernutrition/foods-and-drinks/cows-milk-and-milk-
alternatives.html
Cervo, M. M. C. (2017). Effects of nutrient-fortified milk-based formula on nutritional status and psychomotor
skills of preschool children. Journal of Nutrition and Metabolism, 2017, 6456738.
https://doi.org/10.1155/2017/6456738
Comerford, K. B., Miller, G. D., Boileau, A. C., Masiello Schuette, S. N., Giddens, J. C., & Brown, K. A. (2021).
Global review of dairy recommendations in food-based dietary guidelines. Frontiers in Nutrition, 8,
671999. https://doi.org/10.3389/fnut.2021.671999
Coyle, D. H., Ndanuko, R., Singh, S., Huang, P., & Wu, J. H. (2019). Variations in Sugar Content of Flavored
Milks and Yogurts: a Cross-Sectional Study Across Three Countries. Current Developments In
Nutrition. 10.1093/cdn/nzz060.
de Lamas C., de Castro M.J., Gil-Campos M., Gil Á., Couce M.L. & Leis R. (2019). Effects of dairy product
consumption on height and bone mineral content in children: A systematic review of controlled trials.
Advances in Nutrition 10(suppl_2): S88-S96. doi: 10.1093/advances/nmy096.
248
Dello Russo, M., Ahrens, W., De Henauw, S., Eiben, G., Hebestreit, A., Kourides, Y., Lissner, L., Molnar, D.,
Moreno, L. A., Pala, V., Veidebaum, T., Siani, A., Russo, P., & IDEFICS Consortium (2018). The Impact
of Adding Sugars to Milk and Fruit on Adiposity and Diet Quality in Children: A Cross-Sectional and
Longitudinal Analysis of the Identification and Prevention of Dietary- and Lifestyle-Induced Health
Effects in Children and Infants (IDEFICS) Study. Nutrients, 10(10), 1350.
https://doi.org/10.3390/nu10101350
Di Costanzo M., Biasucci G., Maddalena Y., Di Scala C., De Caro C., Calignano A. & Canani R.B. (2021).
Lactose intolerance in pediatric patients and common misunderstandings about cow's milk allergy.
Pediatric Annals 50(4): e178-e185.
Din, A., Rashid, B., Ramli, K.I., Mansor, N.A., Abdullah, D. (2019). “Revelation of Children and Adult’s Food
Allergen in Malaysia.” Preprints, no. July: 1–7. https://doi.org/10.20944/preprints201907.0122.v1.
Dougkas, A., Barr, S., Reddy, S. & Summerbell, C. (2019). A critical review of the role of milk and other dairy
products in the development of obesity in children and adolescents. Nutrition Research Review 32(1):
106-127. Doi:10.1017/S0954422418000227.
Dror D.K. & Allen L.H. (2014). Dairy product intake in children and adolescents in developed countries:
trends, nutritional contribution, and a review of association with health outcomes. Nutrition Reviews
72(2): 68–81. https://doi.org/10.1111/nure.12078
EFSA (2019). Panel on Nutrition, Novel Foods and Food Allergens (NDA), Castenmiller J., de Henauw S., KM9
Hirsch Ernst K.I., Kearney J., Knutsen H.K., ... & Turck D. Appropriate age range for introduction of
complementary feeding into an infant's diet. EFSA Journal 17(9): e05780.

Eichler, K., Hess, S., Twerenbold, C., Sabatier, M., Meier, F., & Wieser, S. (2019). Health effects of micronutrient
fortified dairy products and cereal food for children and adolescents: A systematic review. PloS one,
14(1), e0210899. https://doi.org/10.1371/journal.pone.0210899
Expert Committee on Nutrition, Health Claims and Advertisement. (2010). Guide to nutrition labelling and
claims as at December 2010.
https://extranet.who.int/nutrition/gina/sites/default/filesstore/MYS%202010%20Guide%20to%20Nutr
ition%20Labelling%20and%20Claims.pdf (October 28, 2022).
FAO (2022a). Gateways to dairy production and products. Milk composition. http://www.fao.org/dairy-
production-products/products/milk-composition/en/
FAO (2022b). Gateways to dairy production and products. Milk and milk products. http://www.fao.org/dairy-
production-products/products/en/
Fayet-Moore, F. (2016). Effect of flavoured milk vs plain milk on total milk intake and nutrient provision in
children. Nutrition Reviews 74(1): 1-17.
FDA (2022). How to understand and use the nutrition facts label. https://www.fda.gov/food/new-nutrition-
facts-label/how-understand-and-use-nutrition-facts-label (Accessed October 25, 2022)
Flom J.D. & Sicherer S.H. (2019). Epidemiology of cow’s milk allergy. Nutrients 11(5): 1051.
Iglesia, I., Intemann, T., De Miguel-Etayo, P., Pala, V., Hebestreit, A., Wolters, M., Russo, P., Veidebaum, T.,
Papoutsou, S., Nagy, P., Eiben, G., Rise, P., De Henauw, S., & Moreno, L. A. (2020). Dairy Consumption
at Snack Meal Occasions and the Overall Quality of Diet during Childhood. Prospective and Cross-
Sectional Analyses from the IDEFICS/I.Family Cohort. Nutrients, 12(3), 642.
https://doi.org/10.3390/nu12030642
IPH (2017). National Health and Morbidity Survey (NHMS) 2017: Adolescent Nutrition Survey 2017. Institute
for Public Health, Ministry of Health Malaysia, Kuala Lumpur.
249
Kaur, A., Scarborough, P., & Rayner, M. (2017). A systematic review, and meta-analysis, of the impact of
health-related claims on dietary choices. International Journal of Behavioral Nutrition and Physical
Activity, 14, 93. https://doi.org/10.1186/s12966-017-0548-1Kavezade S., Mozaffari-Khosravi H.,
Aflatoonian M., Asemi M., Mehrabani S. & Salehi-Abargouei. (2018). The effects of whole milk
compared to skim milk and apple juice consumption in breakfast on appetite and energy intake in
obese children: a three-way randomized crossover clinical trial. BMC Nutrition 4: 44.
https://doi.org/10.1186/s40795-018-0253-8
Khor, G., Zalilah, M., Sariman, S., Huang, S., Mohamad, M., Chan, Y., Chin, Y., & Yusof, B. (2015). Milk Drinking
Patterns among Malaysian Urban Children of Different Household Income Status. Journal of Nutrition
and Health Sciences, 1(4), 1–7. https://doi.org/10.15744/2393-9060.1.401
Kling, S. M., Roe, L. S., Sanchez, C. E., & Rolls, B. J. (2016). Does milk matter: Is children's intake affected by
the type or amount of milk served at a meal?. Appetite, 105, 509–518.
https://doi.org/10.1016/j.appet.2016.06.022
Komada Y., Okajima I. & Kuwata T. (2020). The effects of milk and dairy products on sleep: A systematic
review. International journal of environmental research and public health 17(24): 9440.
https://doi.org/10.3390/ijerph17249440
Koo, H. C., Poh, B. K., Lee, S. T., Chong, K. H., Bragdt, M. C. E., & Abd Talib, R. (2016). Are Malaysian children
achieving dietary guideline recommendations? Asia Pacific Journal of Public Health, June, 1–13.
KM9 https://doi.org/10.1177/1010539516641504
Kouvelioti R., Josse A.R. & Klentrou P. (2017). Effects of dairy consumption on body composition and bone
properties in youth: A systematic review. Current developments in nutrition 1(8): e001214.

https://doi.org/10.3945/cdn.117.001214
Le Nguyen, B. K., Le Thi, H., Nguyen Do, V. A., Tran Thuy, N., Nguyen Huu, C., Thanh Do, T., Deurenberg, P.,
& Khouw, I. (2013). Double burden of undernutrition and overnutrition in Vietnam in 2011: results of
the SEANUTS study in 0·5-11-year-old children. The British Journal of Nutrition, 110 Suppl(2013),
S45-56. https://doi.org/10.1017/S0007114513002080
Lim S.C. & Lim N.L. (2008). Lactose intolerance. http://www.myhealth.gov.my/en/lactose-intolerance/
Mahboobi, Z., Pakdaman, A., Yazdani, R., Azadbakht, L., & Montazeri, A. (2021). Dietary free sugar and dental
caries in children: A systematic review on longitudinal studies. Health Promotion Perspectives, 11(3),
271-280. doi: 10.34172/hpp.2021.35.
Mahesh, P.A., Van Bever, H. & Vedanthan, P.K. (2021). Food Allergy: Introduction, Epidemiology Pathogenesis
and Clinical Presentation. In Textbook of Allergy for the Clinician (pp. 321-331). CRC Press.
Malaysian Society of Allergy and Immunology & Malaysian Paediatric Association. (2012). Guidelines for
the management of cow’s milk protein allergy in children 2012 (CMPA in children).
https://www.allergymsai.org/pdf/guideline-cows-milk.pdf
Matsuyama, M., Harb, T., David, M., Davies, P. S., & Hill, R. J. (2017). Effect of fortified milk on growth and
nutritional status in young children: a systematic review and meta-analysis. Public Health Nutrition,
20(7), 1214–1225. https://doi.org/10.1017/S1368980016003189
MOH (1985). Food Regulations 1985. Ministry of Health Malaysia.
MOH (2010). Guide to Nutrition Labelling and Claims. Expert Committee on Nutrition, Health Claims and
Advertisement, FSQ Division, Ministry of Health Malaysia.
MOH (2015). Garis Panduan Program Pemulihan Kanak-Kanak Kekurangan Zat Makanan (PPKZM). Ministry
of Health Malaysia.
250
Moreno, M. A., Furtner, F., & Rivara, F. P. (2012). Vitamin D and bone health. Archives of Pediatrics &
Adolescent Medicine, 166(7), 684. https://doi.org/10.1001/archpediatrics.2012.1066 Muehlhoff E.,
Bennett A. & McMohan D. (2013). Introduction. In E., Muehlhoff A., Bennett & D McMohan (Eds).
Milk and dairy products in human nutrition. FAO: Rome.
National Health and Medical Research Council & Department of Health and Aged Care. (2022). Milk,
yoghurt, cheese and/or their alternatives (mostly reduced fat). https://www.eatforhealth.gov.au/food-
essentials/five-food-groups/milk-yoghurt-cheese-andor-their-alternatives-mostly-reduced-fat
National Milk Producers Federation. (2022). Nutrition. https://www.nmpf.org/issues/nutrition-food-

safety/nutrition/ (accessed October 16, 2022)
NCCFN. (2020). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and
Nutrition, Ministry of Health Malaysia.
NHS. (2019). What to feed young children. https://www.nhs.uk/conditions/baby/weaning-and-

feeding/what-to-feed-young-children/ (accessed on October 24, 2022).
NHS. (2021). Dairy and alternatives your diet. https://www.nhs.uk/live-well/eat-well/food-types/milk

and-dairy-
nutrition/#:~:text=Milk%20and%20dairy%20products%2C%20such,part%20of%20this%20food%20
group.
KM9
Ni Mhurchu C, Eyles H, Jiang Y, Blakely T.(2018). Do nutrition labels influence healthier food choices?
Analysis of label viewing behaviour and subsequent food purchases in a labelling intervention trial.

Appetite. 2018 Feb 1;121:360-365. doi: 10.1016/j.appet.2017.11.105. Epub 2017 Nov 27. PMID:
29191745.
Nicholl A., Deering K.E., Evelegh K., Lyons-Wall P., Lawrence D., Mori T.A., Kratz M., & O'Sullivan TA. (2021).
Whole-fat dairy products do not adversely affect adiposity or cardiometabolic risk factors in children
in the Milky Way Study: a double-blind randomized controlled pilot study. The American journal of
clinical nutrition, 114(6), 2025–2042. Advance online publication. https://doi.org/10.1093/ajcn/nqab288
Nicklas, T. A., C. O’Neil, and V. Fulgoni III.. (2017). Flavored milk consumers drank more milk and had a
higher prevalence of meeting calcium recommendation than nonconsumers. J. Sch. Health 87:650–
657. https://doi.org/10.1111/josh.12537.
Nikniaz, Z., Tabrizi, J.S., Ghojazadeh, M. et al. (2020). Community-based interventions to increase dairy
intake in healthy populations: a systematic review. Public Health Rev 41, 18 - xx
https://doi.org/10.1186/s40985-020-00135-4
Nik Rosmawati NH; Manan, W.; Muda, W.; Izani, N.; Jamil, N. (2017). How Healthy Is Competitive Food
Served at Primary School Canteen in Malaysia? Int. Med. J, 24, 44–47
Norsakira, J., Norazmir, M. N., & Ruzita, A. T. (2019). Nutrition labelling: an exploratory study on personal
factors that influence the practice of reading nutrition labels among adolescents. Malaysian Journal
of Nutrition, 25(1), 143-153.
O'Sullivan T.A., Schmidt K.A. & Kratz M. (2020). Whole-fat or reduced-fat dairy product intake, adiposity,
and cardiometabolic health in children: A systematic review. Advances in Nutrition 11(4): 928–950.
https://doi.org/10.1093/advances/nmaa011
Patel A.I., Moghadam S.D., Freedman M., Hazari A., Fang M.L., & Allen I.E. (2018). The association of flavored
milk consumption with milk and energy intake, and obesity: A systematic review. Preventive medicine
111: 151–162. https://doi.org/10.1016/j.ypmed.2018.02.031
251
Prescott, J., Young, O., O’Neil, L., Yau, N.J.N &Stevens, R. (2002). Motives for food choice: a comparison of
consumers from Japan, Taiwan, Malaysia and New Zealand. Food Qual Preference. 13:489-495.
Ran-Ressler R.R., Bae S., Lawrence P., Wang D.H. & Brenna J.T. (2014). Branched-chain fatty acid content
of foods and estimated intake in the USA. British Journal of Nutrition 112(4): 565-72. doi:
10.1017/S0007114514001081.
Riley, L. K., Rupert, J., & Boucher, O. (2018). Nutrition in toddlers. American Family Physician 98(4):227-233.
Robbins K.A., Wood R.A. & Keet C.A. (2014). Milk allergy is associated with decreased growth in US children.
Journal of Allergy and Clinical Immunology 134(6): 1466-1468.
Sanchez, M., Panahi, S., & Trembley, A. (2014). Childhood obesity: A role for gut microbiota? International
Journal of Environmental Research and Public Health, 12(1), 162-175.
https://doi.org/10.3390/ijerph120100162Santaliestra-Pasías, A. M., Bel-Serrat, S., & Moreno y Gloria
Bueno, L. A. (2016). Consumption of dairy products in youth, does it protect from cardio-metabolic
risk? Nutrición Hospitalaria, 33(Supl. 4):32-36. http://dx.dpi.org/10.20960/nh.342.
Scaglioni, S., Cosmi, V. De, Ciappolino, V., Brambilla, P., & Agostoni, C. (2018). Factors Influencing Children’
s Eating Behaviours. 1–17. https://doi.org/10.3390/nu10060706
Selamat, R., Raib, J., Abdul Aziz, N. A., Zulkafly, N., Ismail, A. N., W Mohamad, W. N. A., Nasruddin, N. I. N.,
KM9 Jalaludin, M. Y., Md Zain, F., Ishak, Z., Yahya, A., & Mokhtar, A. H. (2020). Dietary Practices and Meal
Patterns among Overweight and Obese School Children in Malaysia: Baseline Data from a School-
Based Intervention Study. Ecology of Food and Nutrition, 59(3), 263–278.
https://doi.org/10.1080/03670244.2019.1694922
Sethi, S., Tyagi, S. K., & Anurag, R. K. (2016). Plant-based milk alternatives an emerging segment of functional
beverages: a review. Journal of food science and technology, 53(9), 3408–3423.
https://doi.org/10.1007/s13197-016-2328-3
Sipple, L. R., Barbano, D. M., & Drake, M. (2020). Invited review: Maintaining and growing fluid milk
consumption by children in school lunch programs in the United States. Journal of Dairy Science,
103(9), 7639–7654. doi:10.3168/jds.2020-18216
Srbely, V., Janjua, I., Buchholz, A. C., & Newton, G. (2019). Interventions aimed at increasing dairy and/or
calcium consumption of preschool-aged children: A systematic literature review. Nutrients, 11(4),
714. https://doi.org/10.3390/nu11040714
Średnicka-Tober D., Barański M., Seal C.J., Sanderson R., Benbrook C., Steinshamn, H., Gromadzka-
Ostrowska J., Rembiałkowska E., Skwarło-Sońta K., Eyre M., Cozzi G., Larsen M.K., Jordon T., Niggli
U., Sakowski T., Calder P.C., Burdge G.C., Sotiraki S., Stefanakis A., Stergiadis S., … Leifert C. (2016).
Higher PUFA and n-3 PUFA, conjugated linoleic acid, -tocopherol and iron, but lower iodine and
selenium concentrations in organic milk: a systematic literature review and meta- and redundancy
analyses. The British journal of nutrition 115(6): 1043–1060.
https://doi.org/10.1017/S0007114516000349
Teng, N. I. M. F., Juliana, N., Izlin, N. L., & Semaon, N. Z. (2020). Knowledge, attitude and practices of sugar-
sweetened beverages: A cross-sectional study among adolescents in Selangor, Malaysia. Nutrients,
12(12), 1–13. https://doi.org/10.3390/nu12123617
Thompson, H. R., Ritchie, L, Park, E, Madsen, K. A, Gosliner W. (2020) Effect of Removing Chocolate Milk on
Milk and Nutrient Intake Among Urban Secondary School Students. Preventing Chronic Disease,
17:200033. DOI: http://dx.doi.org/10.5888/pcd17.200033
252
Tung, S. E. H., Ch’ng, Y. Z., Karnan, T. V., Chong, P. N., Zubaidah, J. O., & Chin, Y. S. (2020). Fluid intake,
hydration status and its association with cognitive function among adolescents in Petaling Perdana,
Selangor, Malaysia. Nutrition Research and Practice, 14(5), 490–500.
https://doi.org/10.4162/nrp.2020.14.5.490
UNICEF. (2021). Review of national Food-Based Dietary Guidelines and associated guidance for infants,
children, adolescents, and pregnant and lactating women. New York: UNICEF, 2020.
https://www.unicef.org/media/102761/file/2021-Food-based-Dietary-Guidelines-final.pdf
Usai-Satta P., Scarpa M., Oppia F., &Cabras F. (2012). Lactose malabsorption and intolerance: What should
be the best clinical management? World Journal of Gastrointestinal Pharmacology and Therapeutics
3(3): 29-33. https://doi.org/10.4292/ wjgpt.v3.i3.29 PMID:22966480
Vanderhout S.M., Aglipay M., Torabi N., Jüni P., da Costa B.R., Birken C.S., O'Connor D.L., Thorpe K.E. &
Maguire J.L. (2020). Whole milk compared with reduced-fat milk and childhood overweight: a
systematic review and meta-analysis. The American journal of clinical nutrition 111(2): 266–279.
https://doi.org/10.1093/ajcn/nqz276
Wallace T.C., Bailey R.L., Lappe J., O’Brien K.O., Wang D.D., Sahni, S. & Meaver C.M. (2020). Dairy intake
and bone health across the lifespan: a systematic review and expert narrative. Critical Reviews in
Food Science and Nutrition 14: 1-47. doi:10.1080/10408398.2020.1810624
Wan Manan, W. M., Jomo, K. S., & Tan, Z. G. (2019). Addressing malnutrition in Malaysia. Kuala Lumpur: KM9
Khazanah Research Institute. Kuala Lumpur.

Watkins P.J., Jaborek J.R., Teng F., Day L., Castada H.Z., Baringer S. & Wick M. (2021). Branched chain fatty
acids in the flavour of sheep and goat milk and meat: A review. Small Ruminant Research 200,
106398.https://doi.org/10.1016/j.smallrumres.2021.106398.
WHO (2017). Guidance on ending the inappropriate promotions of foods for infants and young children:
implementation manual. World Health Organization, Geneva.
WHO. (2022). Food fortification. https://www.who.int/health-topics/food-fortification#tab=tab_1 (accessed

October 27, 2022).
Zhang, F., Ye, J., Zhu, X., Wang, L., Gao, P., Shu, G., Jiang, Q., & Wang, S. (2019). Anti-Obesity Effects of Dietary
Calcium: The Evidence and Possible Mechanisms. International Journal of Molecular Sciences, 20(12),
3072. https://doi.org/10.3390/ijms20123072
Zhang, X., Chen, X., Xu, Y. Yang, J., Du, L., Li, K. & Zhou, Y. (2021). Milk consumption and multiple health
outcomes: umbrella review of systematic reviews and meta-analyses in humans. Nutrition &
Metabolism, 18, 7, https://doi.org/10.1186/s12986-020-00527-y
253
Appendix 9.1: Nutrient composition of cow’s and goat’s milk (per 100g of milk)
Cow’s Milk Goat Milk
Average Range Average Average
Proximates
Energy (kJ) 262 247-274 270 243-289
Energy (kcal) 62 59-66 66 58-74
Water (g) 87.8 87.3-88.1 87.7 86.4-89.0
Total protein (g) 3.3 3.2-3.4 3.4 2.9-3.8
Total fat (g) 3.3 3.1-3.3 3.9 3.3-4.5
Lactose (g) 4.7 4.5-5.1 4.4 4.2-4.5
Minerals
Calcium (mg) 112 91-120 118 100-134
Iron (mg) 0.1 Tr-0.2 0.3 Tr-0.6
KM9 Magnesium (mg) 11 10-11 14 13-14
Phosphorus (mg) 91 84-95 100.4 90-111

Potassium (mg) 145 132-155 202 170-228
Sodium (mg) 42 38-45 44 32-50
Zinc (mg) 0.4 0.3-0.4 0.3 0.1-0.5

Vitamins
Retinol (μg) 35 29-45 45 35-56
Carotene (μg) 16 7-23 13 Tr-18
Vitamin A (μg RE) 37 30-46 48 30-74
Vitamin E (mg) 0.08 0.07-0.08 0.05 0.03-0.07
Thiamin (mg) 0.04 0.02-0.04 0.06 0.03-0.09
Riboflavin (mg) (vit B2) 0.20 0.17-0.20 0.13 0.04-0.18
Niacin (mg) 0.13 0.09-0.20 0.24 0.10-0.30
Pentothenic acid (mg) 0.43 0.34-0.58 0.3 0.31-0.41
Vitamin B6 (mg) 0.04 0.03-0.06 0.05 0.05-0.06
Folate (μg) 8.5 5.0-8.0 1.0 Tr-1.0
Vitamin B12 (μg) 0.51 0.25-0.90 0.07 0.04-0.10
Vitamin C (mg) 1.0 0.0-2.00 1.1 1.0-1.3
Vitamin D (μg) 0.2 0.1-0.3 0.1 0.1-0.1
Tr : traces.
Source: FAO, 2013
254
KM9

Key Message 10
Choose different types of fats and oils in appropriate

amounts
255
KM10
Choose different types of fats and oils in appropriate amounts
Key Message 10
Choose different types of fats and oils in appropriate

amounts
Assoc. Prof. Dr. Mohd Razif Shahril, Mr. Shahir Shamshuddin, Assoc. Prof. Dr. Zulfitri Azuan Mat Daud,
Dr. Khor Ban Hock and Prof. Dr. Tilakavati Karupaiah
10.1 Terminology
Blended oils Ghee

Blending of two oils to achieve SFA: PUFA balance Ghee is clarified liquid fat made from cow milk
requires mixing proportionate volumes of palm oil butter which was treated with low heat until water
and a LA-rich oil such as corn oil, soybean oil or evaporates and leaves behind milk solids.
sunflower oil.
Hydrogenation
Dietary fat classification Hydrogenation is a process intended to give highly
Chemically, dietary fats are composed of 3 fatty liquid vegetable oils, which are generally rich in
acids attached to a glycerol backbone. These fatty polyunsaturated fatty acids (PUFA), a semi-solid or
acids are built on carbon chains (C) of varying length solid texture. In the process, hydrogen is forced into
with either shared bonding (unsaturation) denoted the vegetable oil to change the shape of the
chemically as CX: 1/2/3 or single-bonding molecules, producing an oil called hydrogenated fat
(saturation) denoted chemically as CX: 0. Natural that mimics the texture of saturated fat. Some
vegetable-based oils and fats and animal-based fats margarine and shortenings contain hydrogenated or
contain varying proportions of saturated (SFA), hardened fat and these are used in making bakery
polyunsaturated (PUFA) and monounsaturated products, cookies and crackers.
(MUFA) fatty acids.
256
Monounsaturated fatty acids (MUFA) Polyunsaturated fatty acids (PUFA)

Monounsaturated fatty acids (MUFA) contain one Polyunsaturated fatty acids (PUFA) are fatty acids
double bond in the molecule of the fatty acids. The that contain more than one double bond in their
predominant MUFA in the diet is oleic acid (C18:1). molecules. PUFA consists of two groups, the omega-
Oils that are rich in MUFAs are naturally more liquid 3 polyunsaturated fatty acid (e.g. alpha-linolenic
at room temperature compared to fats rich in SFAs. acid [ALA, C18:3], eicosapentaenoic acid [EPA,
C20:5] and docosahexaenoic acid [DHA, C22:6]) and
Mediterranean diet the omega-6 polyunsaturated fatty acid (e.g. linoleic
Mediterranean Diet refers to a mainly plant-based acid [LA, C18:2] and arachidonic acid [AA, C20:4].
diet that emphasizes consumption of seasonal LA and ALA are known as essential fatty acids
vegetables, fruits, nuts, legumes and seeds, extra (EFA) as they cannot be synthesised by humans and
virgin olive oil, fermented dairy products, fish and therefore must be included in the diet.
lean meat, consumed in seasons when available and
grown and produced locally. Saturated fatty acids (SFA)
Saturated fatty acids (SFA) common to the human
Oils and fats diet are built of 12 to 18 carbon-chain lengths,
Humans consume fats as visible and invisible fats. namely lauric acid (C12:0), myristic acid (C14:0),
Visible fats come from cooking oils that are plant- palmitic acid (C16:0) and stearic acid (C18:0).
based (vegetable oils) and table spreads, which may
be either plant-based (margarine) or animal-based Shortening
(butter) fats. Invisible fats are natural constituents Shortening is a semisolid fatty product that is mostly
of foods ranging from cereals, vegetables, fruits, solid at room temperature, and is typically made
pulses, nuts and oilseeds, dairy products, meat, from hydrogenated and partially hydrogenated KM10
eggs, or fish. vegetable oils, such as corn, cottonseed, or soybean.

Omega-3 polyunsaturated fatty acids Trans fatty acids (TFAs)
Omega-3 polyunsaturated fatty acids are a family of Trans fatty acids (TFAs) are produced industrially
polyunsaturated fatty acids (PUFA) that confer high through partial hydrogenation of liquid plant oils to
liquidity and fluidity to the oil. Omega-3 fatty acids become solid fats. Elaidic acid (C18:1 trans-9), a
differ from the more common plant-source PUFAs, common industrial TFA is produced during
in the position of its first double bond, which starts formulation of margarine, vanaspati (vegetable
at the 3rd carbon when counted from the methyl (or ghee), shortenings and bakery products. Naturally
omega) end of the fatty acid molecule. occurring TFAs also occur as vaccenic acid (C18:1
trans-11) in the stomach of dairy cattle.
Omega-6 polyunsaturated fatty acids
Omega-6 polyunsaturated fatty acids are a family of Thermally oxidised fats
polyunsaturated fatty acids (PUFA) and differ from Lipid oxidation occurs when cooking oils are
the omega-3 in the position of its first double bond, repeatedly reheated for deep-frying of foods. High-
which starts at the 6th carbon when counted from temperature cooking of reused oil generates lipid
the methyl (or omega) end of the fatty acid molecule. peroxidation products.
Partially hydrogenated fats Vanaspati

In partial hydrogenation, only a portion of the Vanaspati is made from partially-hydrogenated
unsaturated fatty acids in the oils was hydrogenated vegetable oils and is commonly used as a substitute
so that the texture of the solid product will not be for ghee in India.
as hard as fully hydrogenated oils. While fully
hydrogenated oil completely saturates the
unsaturated fatty acids in the oils, partial
hydrogenation leaves some of the double bonds on
the unsaturated fatty acids intact. However, some
of these unsaturated fatty acids are transformed into
trans fatty acids (TFA).
257
10.2 Introduction
Fat is essential for children’s and adolescents’ coconut milk or locally known as santan is
health, growth and development. It is the primary commonly used in preparing meals. For instance,
source of energy due to its energy-dense properties. nasi lemak, curry, masak lemak, kuih muih and
One gram of fat yields 9 kcal, double the yield of one cendol are traditionally consumed foods that use
gram of protein or carbohydrate. Fat also stores extra santan. Soybean, corn, sunflower and safflower oils
energy in the form of body fat as a readily available are the main sources of the omega-6 fatty acids,
energy source when needed by the body during rest, namely linoleic acids (LA, C18:2). Omega-3 fatty
exercise or when food availability is limited. Besides acids include marine-based fatty acids such as
acting as an insulator to help retain body heat, eicosapentaenoic (EPA, C20:5) and
stored body fat pads the body and protects organs docosahexaenoic (DHA, C22:6) acids as well as
such as kidneys and liver from injury. The plant-based alpha-linolenic acid (ALA, C18:3). The
disparagement of fat obscures the fact that children types of fish rich in EPA and DHA commonly
and adolescents need fat in their diets. Without an consumed by Malaysians are Indian mackerel
appropriate amount of fat intake, the digestion, (kembong), anchovies (bilis), yellow-tail and yellow-
absorption, and transport of important fat-soluble stripe scads (selar kuning), tuna (tongkol), sardines
vitamins (A, D, E, and K) and phytonutrients which (sardin), torpedo scads (cincaru), Indian and short-
play many functions in the body will be impacted. fin scads (selayang), pomfret (bawal), red snapper
Additionally, fat provides essential fatty acids which (merah), king mackerel (tenggiri), marine catfish
are needed as the substrates for the synthesis of (jahan) and stingray (pari). ALA is found in soybean
local hormones called eicosanoids important in body and canola oils; seeds and nuts such as flaxseed,
KM10 metabolism, neurological development, and brain chia, and walnuts; and some green leafy vegetables
function in children. During digestion, fat depresses such as kale and spinach. Oleic acid (C18:1) is the
gastric secretions, slows gastric emptying and main MUFA and is found mainly in olive, peanut,
stimulates biliary and pancreatic secretions, thereby canola and palm oil/olein. The fatty acid
aiding the digestive process in the cell membrane, composition of various dietary fats and oils is
fat help determine what substances are transported provided in Table 10.1 (Appendices). Significant fat
in and out of the cell and regulate what substances content distribution of various food categories in
can bind to the cell, thus, strongly influencing the terms of total fat and fatty acid classes are provided
function of the cell. In addition, fat helps maintain in Table 10.2 (Appendices) and Table 10.3
cell fluidity and other physical properties of the cell (Appendices) provides the overall varying
membrane. distribution of total fat in local fish with omega-3
fatty acid distribution.
Fat has become crucial to domestic and commercial
utilization attributable to its flavour, taste and Restriction of energy intake from fat for children and
texture-enhancing properties. When choosing fats, adolescents may adversely affect their growth and
the choices consist of three types of fatty acids: development. On the other hand, excessive intake
saturated, monounsaturated and polyunsaturated of fat during childhood may lead to the development
fatty acids. Almost all sources of fats contain these of childhood obesity and other health complications
three major fatty acids, but in different proportions. in later years. For Malaysian children (above 2 years)
Selecting and preparing foods with the proper ratio and adolescents (up to the age of 18 years), who are
of these fatty acids is as important as the amount of more active than adults, the recommended range for
fats consumed by an individual. Vegetable-based fat intake is between 25 to 35% TEI (NCCFN, 2017).
oils and fats, and animal-based fats such as butter A balanced diet, which includes appropriate
contain varying proportions of saturated (SFA), amounts and types of fats, ensures optimal growth
monounsaturated (MUFA) and polyunsaturated and development. A balanced intake of saturated,
(PUFA) fatty acids, either naturally occurring or as monounsaturated and polyunsaturated fats is
commercially blended oils and fats. Palm oil or palm important in maintaining an optimal lipid profile.
olein has an almost equal amount of SFA and Dietary saturated fats should be limited to less than
unsaturated fatty acids as indicated by 40% of 10% TEI whereas trans fatty acids should be avoided
palmitic acid (C16:0), 4% of stearic acid (C18:0) and in the diet (< 1% TEI). NCCFN (2017) also suggests
43% of oleic acid (C18:1). Bakery items (pastries and that monounsaturated fat should be maintained at
cakes), ultra-processed foods, dairy cream toppings 12 to 15% TEI while polyunsaturated fat should be
and fried foods are preferred sources of saturated increased up to 7%.
fatty acid among children and adolescents. Besides,
258
10.3.1 Total daily fat recommendation Practice implications to diet
In line with global recommendations (FAO, 2010), Fat is an essential nutrient for children and
the Recommended Nutrient Intake (RNI) 2017 has adolescents, and its dietary level should not fall too
set fat intake for Malaysian children and adolescents low. Otherwise, the prepared diet becomes
from 25% to 35% TEI (NCCFN, 2017). The values are monotonous, has low palatability, low energy
set based on evidence that the consumption above density and the amount of essential fatty acid (EFA)
or below these ranges might be associated with can become limiting for health. However, the quality
nutrient inadequacy and an increased risk of of fat in the diet of children and adolescents bears
developing diet-related non-communicable different health implications which will be
diseases. Young healthy growing children and addressed separately in the following sections.
adolescents also need adequate amounts of fats and
energy to sustain their daily metabolism where 10.3.2 Rationale to limit foods high in
lower intake may confer as much unfavourable saturated fat
effect as excessive intake.
The rationale to limit saturated fat (SFA) intake
Given the rising prevalence of childhood obesity, among children and adolescent is primarily derived
and its high energy density, dietary fat is greatly from a well-establish evidence that dietary SFA are
scrutinised as a contributing factor. Naude et al., strongly correlated with increase in blood total
(2018) in their Cochrane review suggest that only a cholesterol and LDL-cholesterol level (Mensink,
small reduction in body mass index, total- and LDL- 2016; Brouwer, 2016), a major risk factors for KM10
cholesterol were observed in trials among children cardiovascular diseases (CVD). In general, the basis
aged 2 to 18 years where a lower fat intake (30% TEI of this recommendation stemmed from the fact that

or less) was provided compared with usual or the atherosclerotic process begins in childhood
modified fat intake. However, in two of the three (Hong, 2010), attributed to dyslipidemia and other
identified intervention studies, children were already CVD risk factors. In children and adolescence, very
having a high blood cholesterol level prior to the low incidence of cardiovascular events among this
intervention. In the same systematic review, mixed population undermine direct measurement on the
findings were observed when associating total fat impact of SFA on cardiovascular events (Te
intake with increased body weight and BMI as an Morenga & Montez, 2017), hence have to rely on
indicator of body fatness (Naude et al., 2018). CVD surrogates marker – blood lipids. Elevated total
and LDL cholesterol in childhood has been found to
Studies documenting the effects of limiting dietary be positively correlated with an increase in
fat below 25% TEI on health risks in the adult thickening of the carotid artery intima-media in
population are consistent, however, data on children adulthood (Lorenz et al., 2007), a marker of
and adolescents remain scarce. All epidemiological subclinical atherosclerosis and predictor of future
studies regarding dietary fat intake are focusing on cardiovascular.
adults since cardiovascular events as the main
outcome measure is only present in later life. In Several randomised controlled trials (RCTs)
adults, limiting dietary fat intake below 25% TEI conducted among children indicated that reduction
would be likely to increase the carbohydrate load in LDL-C can be achieved by replacing SFA with
(Siri-Tarino et al., 2010; Appel et al., 2005) which in polyunsaturated fatty acids (PUFA) (DISC study;
turn increases CVD risk (Jakobsen et al., 2009). STRIP Study). In fact, reduced intake of SFA have
Epidemiological data among adults also suggest been shown to be associated with significant
that there is no positive association between total reduction in risk of CVD in meta-analyses of
dietary fat intake and CVD risk (Zhu et al., 2019) and prospective cohort studies (Farvid et al., 2014) and
a further reduction in total fat intake had no effect RCTs (Mozaffarian et al., 2010). Results from a recent
on CVD risk (Skeaff & Miller, 2009). meta-analysis of RCTs and prospective cohort
259
studies (Te Morenga & Montez, 2017) indicated that examine the effect of a heart-healthy diet that is low
greatest benefit on blood cholesterol is achieved in saturated fat and high in unsaturated fat on
when SFA intake is less than 10% of total energy healthy children at a very young age for more than
intake, while no adverse effects on children growth two decades of follow up.
and development were noted. However, the role of
SFA in view of CVD incidence and mortality remain For omega-3 PUFA, a study showed that
inconclusive (de Souza et al., 2015; Hooper et al., consumption of 300g of oily fish per week reduced
2020). serum triglyceride and increased total and HDL-
cholesterol in healthy school-age children (Vuholm
Practice implication to diet et al., 2019). On the other hand, studies showed that
consumption of fish and/or omega-3 PUFAs in
The recommendation to limit SFAs are in view of its children had inconclusive findings (mixed or null
LDL-C raising effects. As such, reducing SFA from results) on cognitive development and treatment of
an early age may help to reduce the risk of CVD later allergic diseases, ADHD symptoms, and depressive
in life. Animal fat and full cream dairy products symptoms (Bernstein et al., 2019). Therefore, the
contain substantial amount of SFA and therefore recommendation to increase PUFA intakes among
should be targeted for reduction along with children is based on meeting the requirement for
replacing some SFA calories with PUFA by blending growth and development as well as for
palm oil with a PUFA-rich vegetable oil. cardiometabolic health.
10.3.3 Rationale to increase fats and oil rich Practice implication to diet
in polyunsaturated fat
KM10 Dietary sources of LA include soybean and
Polyunsaturated fatty acids (PUFA) are essential for vegetable oils (e.g., soybean oil, sunflower oil,
normal growth and development in children. PUFAs safflower oil, and corn oil). Dietary sources of ALA
with critical physiological role include omega-6 include nuts (e.g., walnut, cashew nut, and
PUFAs, namely linoleic acid (LA) and arachidonic pistachio), seeds (e.g., flaxseed, chia seed, and
acid, as well as omega-3 PUFAs, including ⍺- sesame), legume (e.g., soybean and soybean
linolenic acid (ALA), eicosapentaenoic acid (EPA), products), and vegetable oils (e.g., canola oil and
and docosahexaenoic acid (DHA). LA and ALA are soybean oil) while EPA and DHA are mainly found
essential fatty acids that cannot be synthesized by in oily fish.
humans and therefore must be obtained from the
diet. On the other hand, DHA is an important 10.3.4 Meeting the essential fatty acids
component of brain and retina (Huffman et al., 2011; requirement
Lee, 2013). The recommendation of total PUFA
intake for children 2 – 18 years old is 11% of TEI Clinical manifestations of essential fatty acid
(FAO, 2010). deficiency include reduced growth rate in infants
and children, a dry scaly rash, hair loss, impaired
For cardiometabolic health, a population-based wound healing, and increased susceptibility to
randomized controlled trial conducted in Finland infection (Gramlich et al., 2019). A dietary intake
demonstrated that families with seven-month-old consisting of 2 – 3% TEI from LA and > 0.5% TEI
infants receiving individualized dietary counselling from ALA is considered adequate to meet the
to achieve an SFA/MUFA/PUFA ratio of 1:1:1 requirement for these essential fatty acids (FAO,
resulted in reduced total cholesterol, LDL- 2010).
cholesterol, and apolipoprotein B concentrations, as
well as lower risk of metabolic syndrome in children Practice implication to diet
during the 20 years follow up. However, there was
no significant impact on insulin status. There were Dietary sources of ALA include nuts (e.g., walnut,
no adverse effects on growth, neurological or cashew nut, and pistachio), seeds (e.g., flaxseed, chia
pubertal development or psychosocial well-being seed, and sesame), legume (e.g., soybean and
(Hakanen et al., 2010; Kaseva et al., 2015; Lehtovirta soybean products), and vegetable oils (e.g., canola
et al., 2018; Niinikoski et al., 1996; Niinikoski et al., oil and soybean oil) while dietary sources of LA
2007; Nupponen et al., 2015; Oranta et al., 2013; include soybean and vegetable oils (e.g., soybean oil,
Rask-Nissilä et al., 2000). The main objective of this sunflower oil, safflower oil, and corn oil).
population-based randomized controlled trial was to
260
10.3.5 Rationale to maintain 10.3.6 Rationale to exclude trans-fat from the

monounsaturated fat intake diet
There are many studies done to look at the effects Studies documenting the detrimental effect of trans-
of monounsaturated fat intake (MUFA) on CVD risks fatty acids (TFA) on CVD risks in adults’ population
in adult population, however, there is lack of is consistent, however, data on children and
information from similar studies on children and adolescence remain scarce. All epidemiological
adolescents. Epidemiological studies on MUFA studies regarding TFA intake are focusing on adults
intake are focusing on adults due to the fact that due to the fact that cardiovascular event as a main
cardiovascular events as a main outcome measure outcome measure only present in later life (Te
only present in later life. In adults, replacing Morenga & Montez, 2017). In adults, TFA’s role in
saturated and trans fatty acids with unsaturated worsening CVD risk is attributed to increase in LDL-
fatty acids (including MUFA) has been shown to C, decrease HDL-C, heighten inflammation, worsen
give favourable effects on blood lipid parameters insulin sensitivity and promote endothelial
(Mensink et al., 2003). In an 8-week, diet intervention disfunction (Mozaffarian et al., 2006; Mozaffarian et
study (SFA was replaced with MUFA or al., 2009). In a meta-analysis of observational studies
Mediterranean Diet) found that LDL particles on the effects of TFA on CVD risk, total TFA intake
concentration decreased and ApoB/ApoA1 ratio was positively correlated and resulted in 16%
increased in both types of diet (Michielsen et al., increased risk of CVD (Chowdhury et al., 2014).
2019). The Canola Oil Multi-center Intervention Trial Meanwhile, in a meta-analysis of prospective cohort
II (COMIT II) similarly showed that the usage of studies involving a pool of 230,135 participants, an
conventional canola oil and High Oleic Canola Oil additional 2% TEI derived from TFA was associated
(HOCO) in the diet produced a positive effect on with a 25% and 31% increased risk of CHD and CHD KM10
lipids and lipoproteins among adult participants mortality, respectively (de Souza et al., 2015). TFA
(with metabolic syndrome risk factors) compared to intake among children and adolescent in studies

control blended oil (Bowen et al., 2019). A systematic from Spain (Scholz et al., 2016) and China (Liu et al.,
review and dose-response meta-analysis of 2015) reported predominantly from industrially
prospective cohort studies among adults concluded produce including fast food, processed baked goods,
that MUFA intake was inversely associated with risk and processed meat. TFA intake has been
of all-cause mortality, but not with mortality from recommended to not exceeding 1% of TEI by WHO
CVD or cancer (Lotfi et al., 2021). A network meta- Expert Consultation (2003) and the United States
analysis looking into oil comparison and lipid Institute of Medicine (IOM, 2005). This upper limit
profiles outcomes revealed that palm oil gave the has been reflected in the Malaysia’s RNI (NCCFN,
same TC, TG, LDL lowering effect and increase HDL 2017).
level as other types of oil (safflower, sunflower,
rapeseed, hempseed, flaxseed, corn, olive, soybean Practice implication to diet
coconut) among adults (Schwingshackl et al., 2018).
In general, TFA intake is expected to be low in
Practice implication to diet Malaysia as palm oil is the most common edible oil
used commercially and at home – as such, palm oil
Palm oil is the most widely used cooking oil in is readily usable in many food applications without
Malaysia. It has 44% saturated fat (palmitic acid), the need of hydrogenation. Commercial foods are
39% monounsaturated fat (oleic acid) and 11% likely sources of trans fats, if they are imported.
polyunsaturated acid (linoleic acid). Palm olein is a These may be stick margarines, Vanaspati
fractionation of palm oil which produces a more (vegetable ghee), partially hydrogenated edible oils,
liquid form of the oil can contain up to 44% oleic acid bakery products containing partially hydrogenated
and 13% linoleic acid (Choo & Nesaretnam, 2014). fats (pastries and cake) and cookies and biscuits.
Therefore, MUFA intake is not an issue in Malaysia
as most household consume/ use palm oil as the 10.3.7 Dietary cholesterol
main cooking oil.
The 2020-2025 USDA dietary guideline did not set
an upper limit for dietary cholesterol intake but had
recommended dietary cholesterol consumption to
be as low as possible without compromising the
nutritional adequacy of the diet. Similarly, The RNI
2017 recommends removing the restriction on
dietary cholesterol intake for a healthy population
261
but at the same time cautions against excessive Practice implication to diet
consumption (NCCFN, 2017). It must be cautioned
that dietary cholesterol-rich foods such as red meat It must be cautioned that dietary cholesterol-rich
mutton, lamb, beef, and pork also carry significant foods such as red meat mutton, lamb, beef and pork
content of SFA, which are known to increase LDL- also carry significant content of SFA. Cholesterol,
C levels. SFA, animal protein, and sodium also coexist in
certain foods such as processed foods.
10.4 Current Status
Visible fat consumption by Malaysians is mainly intakes for Malaysian is severely limited by the lack
palm oil for cooking, as this country is a primary of laboratory validated fatty acid compositional data
producer of palm oil. The intake of SFA for our of food intakes. It is assumed that the diet practices
population is expected to be high from palm oil by Malaysian’s adult would also apply to young
consumption. Current consumption of palm oil is children and adolescents. Therefore, it is noteworthy
14.02g/capita/day (FAO, 2019). On the other hand, it to look at a recent data from urban adult population
is estimated that human consumption of LA is in Kuala Lumpur which reports that the intake of fat
insufficient (Jakobsen et al., 2009) and therefore the TEIs is 31.6% and this was distributed to SFA
public health approach is to encourage increasing (14.1%), MUFA (12.6%) and PUFA (4.8%) (Karupaiah
LA consumption (NCCFN 2017; USDA 2015). et al., 2019). The actual trans-fat intake in
Malaysians does not exceed the 1% TEI limitation
The largest evidence on current status of fat intake because palm oil is the major edible oil used
KM10
among children aged 1 to 12 years comes from the commercially and domestically. It was reported that
SEANUTS Malaysia (Poh et al., 2013) and among 83.9% of urban population household uses palm oil
adolescents aged 13 to 17 years comes from the while the remaining small proportion are non-users
Adolescents Nutrition Survey 2017 (IPH, 2017). (Karupaiah et al., 2019). The percentage of palm oil
Mean total fat intake of Malaysian children as users are expected to be higher in rural areas.
reported by SEANUTS Malaysia for 1 to 3.9 years is However, children and adolescents are more
37.9 to 40.1 g/day or 31% of TEI from fat, for 4 to 6.9 exposed to the harmful effects of trans fats in the
years is 48.9 to 51.1 g/day or 30% of TEI from fat and form of imported cookies and biscuits (Norhayati et
for 7 to 12 years is 61.1 to 61.7 g/day or 28%. of TEI al., 2011) as well as from their frequent visits to fast
from fat These intakes are comparable between rural food outlets and snacking habits.
and urban localities but varies between boys and
girls with boys consuming slightly higher. Among Cooking oils should ideally be consumed fresh, as
adolescents aged 13 to 17 years, the median fat repeated heating of these oils will generate
intake as reported by Adolescents Nutrition Survey thermally oxidised products (Oboh et al., 2014).
2017 is 69.3 g/day or 33.4% of TEI from fat. RNI 2017 Unfortunately, it is a common practice in the
recommendation for total daily energy intake (TEI) Malaysian households, as well as in commercial
from fat for adolescents is between 25 to 35%. food production to use the same frying oil repeatedly
Almost half (46.9%) of the adolescent’s fat intake to save cost (Azman et al., 2013). Azman et al. (2013)
were within the recommended 25 to 35% of TEI from found that more than half of the 100 night market
fat, while 42.2% exceeded the 35% of TEI from fat food outlet operators in Kuala Lumpur (63.0%)
recommendation. The remaining 10.9% of the admitted using cooking oil repeatedly for deep
adolescents had lower than 25% of TEI from fat. The frying food and 7 of them reused cooking oil up to
median fat intake was also higher among boys, 16 four times or more. Another study found 43% of food
to 17 years age group, obese adolescents, and those operators in Pulau Pinang repeatedly heating
with normal height for age compared to their cooking oil more than 5 times or more (Aziz et al.,
counterparts. 2018). Due to repeated heating, the quality, colour,
smell and taste of cooking oil changes along with
When it comes to investigating the types of fat oxidation of lipid content to lipid peroxidation
intake distribution in the diet, no data is available products. Lipid oxidation is casually linked to a high
locally for the younger Malaysian population. risk for the development of CVD (Falade et al., 2017).
Reporting the distribution of SFA, PUFA and MUFA
262
Key Recommendation (KR) 1: Maintain total fat intake within 25-35% of total energy intake.


Reduce consumption Reduce the availability Reduce the availability Educate
of both deep-fried (e.g., of both deep-fried and of both deep-fried and parents/ caregivers,
keropok, french fries, batter-fried foods at batter-fried foods in teachers and
nuggets, sausages, home. the school environment. children/ adolescents
curry puffs, doughnuts, on healthier
vadai, yue char kuay, alternatives to deep-
keropok lekor) and fried and batter-fried
batter-fried (e.g., foods.
pisang goreng, fish
fillet, chicken chop/
fried chicken) foods.
KM10
Use a cooking method which requires less fat and Emphasise on Prepare relevant
oil such as stir-frying, grilling, pan-frying, appropriate amount education materials on

air-frying, baking and stewing. and types of fats and the cooking method
oils in the school which requires less fat
curriculum during and oil, recipe
Health Education modification to reduce
classes. excessive use of oils
and fats and practical
tips to remove excess
oil on food after
cooking. Make it
accessible through
various platforms such
as social media and
mass media.

Modify recipes to reduce excessive use of oils Get Parents Teachers Provide knowledge
and fats and replace it with ingredients with lesser Association (PTA)’s training and
fat. For example, replace santan with low fat milk involvement in various awareness on
to prepare nasi lemak or reduce ghee and health related programs healthier food
margarine in preparation of nasi briyani. at school level including preparation which
monitoring of foods high requires less fat and
in fat being sold in the oil for canteen
school environment. operators and school
administrators.
263
Key Recommendation (KR) 1: Maintain total fat intake within 25-35% of total energy intake.
(cont.)


Remove excessive oil after cooking once the Monitor foods high in
dishes are cooled to room temperature. For fat being sold in the
example, remove visible fat that floats in soup school environment
or sambals. (e.g., keropok, french
fries, nuggets,
sausages, curry puffs,
doughnuts, vadai, yue
char kuay, keropok
lekor, pisang goreng,
fish fillet, chicken
chop/ fried chicken).
KR1: HTA5: - -
Limit the usage of dressings e.g., mayonnaise,
KM10
thousand islands etc.
- KR1: HTA6: - -
Cook and prepare food

at home with your child
using low to moderate
fat ingredients and low
fat cooking techniques
to encourage good
eating habits.
- KR1: HTA7: - -
Empower children and
adolescents to limit
high fat food through
informal education at
home.
264
Key Recommendation (KR) 2: Limit the intake of saturated fats.


Limit intake of bakery items (biscuits with fillings, Ensure bakery items Educate parents/
pastries, cakes, muffins, cream filled buns) and and dairy cream caregivers, teachers
kuih (kuih talam, kuih lapis, kuih bingka, topping that are used and children/
kuih koci, akok) prepared with coconut milk/ for beverages, adolescents on
santan, butter, and ghee. cupcakes, dessert are healthier alternatives
not being sold in the to bakery items, kuih
school environment. prepared with santan,
butter and ghee, dairy
cream toppings, ultra
processed foods and
foods prepared with
coconut milk/ santan.

KM10
Limit dairy cream toppings that are used for Ensure ultra processed Prepare relevant
beverages, cupcakes, desserts etc. food such as nuggets, education materials on
luncheon meat, and how to increase intake

sausages are not being of omega-3 and
sold in the school omega-6
environment. polyunsaturated fatty
acid rich foods. Make
it accessible through
as social media and
mass media.

Limit consumption of processed meats such as Limit the availability of Provide knowledge
nuggets, luncheon meat, and sausages. foods prepared with training and
coconut milk/ santan, awareness on
butter, and ghee in the healthier food
school environment. preparation which
replaces the use of
santan, butter and
ghee fully or partially
for canteen operators
and school administrators.

Limit intake of foods prepared with coconut milk/ Get Parents Teachers Advocate to the public
santan (e.g masak lemak, nasi lemak, curries). Association (PTA)’s on the practice of
involvement in various blending an equal
health related programs amount (1:1) of palm
in school level including oil with any
monitoring of foods high polyunsaturated fat-
in saturated fat being rich oil (e.g., corn oil,
sold in the school soya bean oil, and
environment. sunflower oil) and use
it for all types of cooking
except deep-frying.
265
Key Recommendation (KR) 2: Limit the intake of saturated fats. (cont.)

KR2: HTA5: - -
Remove the skin and visible fat from poultry and
red meat during food preparation.
- KR2: HTA6: - -
Blend equal amounts
(1:1) of palm oil with any
polyunsaturated fat-rich
oil (e.g., corn oil, soya
bean oil, and sunflower
oil) and use it for all
types of cooking except
deep-frying.
KM10
Key Recommendation (KR) 3: Increase the intake of omega-3 and omega-6 polyunsaturated fatty
acid rich foods.


Include nuts (e.g., almond, walnut, cashew nut, Emphasise sources of Educate parents/
and pistachio), seeds (e.g., flaxseed, chia seed, omega-3 and omega-6 caregivers, teachers
and sesame) and legumes (soybean or soybean polyunsaturated fatty and children/
products such as tofu and tempeh) in daily diet acids rich local foods in adolescents on
according to recommended intake per day. the school curriculum healthier alternatives
during Health to deep-fried and
Education classes. batter-fried foods.

Choose fish containing omega-3 polyunsaturated Increase availability of Prepare relevant
fatty acids such as siakap, kembung, anchovies, nuts, seeds, legumes education materials on
tenggiri, or sardines. Canned sources of fish with rich in omega-6 and how to increase intake
low sodium such as tuna and sardines may also local fishes rich in of omega-3 and
be consumed. omega-3 omega-6
polyunsaturated fatty polyunsaturated fatty
acids in school acid rich foods. Make
environment. it accessible through
as social media and
mass media.
- KR3: HTA3: - KR3: HTA3:

Prepare food using a Provide knowledge
blended vegetable oil training and
rich in omega-6 awareness on how to
polyunsaturated fatty include omega-3 and
acids, which consists of omega-6
266
Key Recommendation (KR) 3: Increase the intake of omega-3 and omega-6 polyunsaturated fatty
acid rich foods. (cont.)

an equal amount (1:1) polyunsaturated fatty

of palm oil with any acid rich foods in food
polyunsaturated fat-rich preparation for
oil (e.g., corn oil, soya canteen operators and
bean oil, and sunflower school administrators.
oil) and use it for all
types of cooking except
deep-frying.
- - - KR3: HTA4:
Advocate to the public
on the practice of
blending an equal
amount (1:1) of palm
oil with any
KM10
polyunsaturated fat-
rich oil (e.g., corn oil,
soya bean oil, and

sunflower oil) and use
it for all types of
cooking except deep-
frying.
Key Recommendation (KR) 4: Limit intake of foods containing trans fatty acids


Read the nutritional information panel of Emphasize reading Educate parents/
processed foods for ingredients that may indicate nutrition information on caregivers, teachers
trans-fat such as “partially hydrogenated fats/ oils” the food label for and children/
or “shortening”. Avoid processed products that ingredients that may adolescents on how to
state “partially hydrogenated fats/ oils” or indicate trans-fat in the read nutrition
“shortening” on the ingredient listing. school curriculum information on food
during Health labels for ingredients
Education classes. that may indicate
trans-fat.

Limit intake of foods made with ingredients high in Ensure that foods made Prepare relevant
trans fat such as shortening, vanaspati, or with ingredients high in education materials on
partially dehydrogenated margarine. Such foods trans-fat such as limiting the intake of
are: a) Western: French fries, fast foods and shortening, vanaspati, foods made with
bakery products & b) Local: roti canai, paratha, or partially ingredients high in
curry puff, doughnuts. hydrogenated trans-fat. Make it
margarine are not accessible through
267
Key Recommendation (KR) 4: Limit intake of foods containing trans fatty acids (cont.)

being sold in the various platforms such

school environment. as social media and
mass media.

Get Parents Teachers Monitor foods
Association (PTA)’s containing trans fatty
involvement in various acids being sold in the
health related programs school environment.
at school level including
monitoring of foods
containing trans fatty
acids being sold in the
school environment.
KM10
Key Recommendation (KR) 5: Do not reuse cooking oil more than twice


Avoid purchasing deep-fried foods from outside Ensure deep-fried foods Educate parents/
food vendors which use cooking oil repeatedly. prepared using reused caregivers, teachers
cooking oil are not and children/
being sold in the school adolescents on the
environment. detrimental effects of
reusing cooking oil more
than twice and how to
dispose them safely.
- KR5: HTA2: KR5: HTA2: KR5: HTA2:

At home, oils for deep- Get Parents Teachers Prepare relevant
frying are not Association (PTA)’s education materials on
encouraged to be involvement in various how to safely dispose
reused for more than health related programs household cooking oil
two times. in school level including for recycling purposes.
monitoring reused Make it accessible
cooking oil in food through various
preparation in the platforms such as
school environment. social media and mass
media.
- KR5: HTA3: - KR5: HTA3:

Safely dispose of Monitor reused
household cooking oil cooking oil in food
for recycling purposes preparation in the
such as bio-fuels. school environment.
268
10.6 References
Abd Aziz, N., Azlan, A., Ismail, A., Mohd Alinafiah, S., Razman, M.R. (2013). Quantitative determination of
fatty acids in marine fish and shellfish from warm water of Straits of Malacca for nutraceutical
purposes. BioMed research international, 2013, 284329.
Alasalvar, C., Shahidi, F., Liyanapathirana, C.M. & Ohshima, T. (2003). Turkish tombul hazelnut (Corylus
avellana L.). 1. Compositional characteristics. Journal of Agricultural and Food Chemistry, 51(13),
3790-3796.
Appel, L.J., Sacks, F.M., Carey, V.J., Obarzanek, E., Swain, J.F., Miller, E.R., Conlin, P.R., Erlinger, T.P., Rosner,
B.A., Laranjo, N.M., Charleston, J., McCarron, P., Bishop, L.M., & OmniHeart Collaborative Research
Group (2005). Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure
and serum lipids: results of the OmniHeart randomized trial. JAMA, 294(19), 2455–2464.
Aziz, A.A., Elias, S.M. and Sabran, M.R. (2018). Repeatedly heating cooking oil among food premise operators
in Bukit Mertajam, Pulau Pinang and determination of peroxide in cooking oil. Malaysian Journal of
Medicine and Health Sciences, 14(SP2), 37-44.
Azman, A., Shahrul, S.M., Chan, S.X., Noorhazliza, A.P., Khairunnisak, M., Azlina, M.N., Qodriyah, H.M.,
Kamisah, Y. and Jaarin, K. (2012). Level of knowledge, attitude and practice of night market food outlet
operators in Kuala Lumpur regarding the usage of repeatedly heated cooking oil. Medical Journal of
Malaysia, 67(1), 91-101. KM10
Bernstein, A.S., Oken, E., de Ferranti, S., & Council on Environmental Health; Committee on Nutrition (2019).

Fish, shellfish and children’s health: an assessment of benefits, risks, and sustainability. Pediatrics.
Vol/pages ? doi: 10.1542/peds.2019-0999.
Brouwer, I.A. (2016). Effect of trans-fatty acid intake on blood lipids and lipoproteins: a systematic review
and meta-regression analysis. World Health Organisation, Geneva.
Choo Yuen, May, & Kalanithi, Nesaretnam. (2014). Research advancements in palm oil nutrition. Eur. J. Lipid
Sci. Technol.116, 1301–1315
Chowdhury, R., Warnakula, S., Kunutsor, S., Crowe, F., Ward, H.A., Johnson, L., Franco, O.H., Butterworth,
A.S., Forouhi, N.G., Thompson, S.G., & Khaw, K.T. (2014). Association of dietary, circulating, and
supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med
160(6): 398-406.
de Souza, R.J., Mente, A., Maroleanu, A., Cozma, A.I., Ha, V., Kishibe, T., Uleryk, E, Budylowski, P.,
Schünemann,H., Beyene, J., & Anand, S.S (2015). Intake of saturated and trans unsaturated fatty acids
and risk of all cause mortality, cardiovascular disease, and type 2 diabetes: systematic review and
meta-analysis of observational studies. BMJ 351: h3978.
Dubois, V., Breton, S., Linder, M., Fanni, J. & Parmentier, M. (2007). Fatty acid profiles of 80 vegetable oils
with regard to their nutritional potential. Euro J Lipid Science & Technology, 109, 710- 732.
Falade, A.O., Oboh, G. and Okoh, A.I. (2017). Potential health implications of the consumption of thermally-
oxidized cooking oils–a review. Polish Journal of Food and Nutrition Sciences, 67(2), 95-106.
FAO. (2010). Fats and Fatty Acids in Human Nutrition: Report of An Expert Consultation. FAO Food and
Nutrition Paper No. 91. Food and Agriculture Organization, Rome.
FAO. (2019). FAOStat. Retrieved from http://faostat.fao.org/
269
Farvid, M.S., Ding, M., Pan, A., Sun, Q., Chiuve, S.E., Steffen, L.M., Willett, W.C., & Hu, F.B. (2014). Dietary
linoleic acid and risk of coronary heart disease: a systematic review and meta-analysis of prospective
cohort studies. Circulation 130(18): 1568-1578.
Gramlich, L., Ireton-Jones, C., Miles, J.M. & Morrison, M. (2019). Essential fatty acid requirements and
intravenous lipid emulsions. J Parenter Enteral Nutr 43(6): 697-707.
Grundy, S.M. & Denke, M.A. (1990). Dietary influences on serum lipids and lipoproteins. J Lipid Res, 31,
1149-1172.
Gunstone, F.D., Harwood, J.L. & Dijkstra, A.J. (2007). The Lipid Handbook with CD-ROM. CRC Press, New
York.
Hakanen, M., Lagström, H., Pahkala, K., Sillanmäki, L., Saarinen, M., Niinikoski, H., Raitakari O.T, Viikari, J.,
Simell O & Rönnemaa, T. (2010). Dietary and lifestyle counselling reduces the clustering of
overweight-related cardiometabolic risk factors in adolescents. Acta Paediatr 99(6): 888-895.
Hooper, L., Martin, N., Jimoh, O.F., Kirk, C., Foster, E., & Abdel Hamid, A.S. (2020). Reduction in saturated fat
intake for cardiovascular disease. Cochrane Database of Systematic Reviews 5(5): CD011737.
Hong, Y. M. (2010). Atherosclerotic cardiovascular disease beginning in childhood. Korean circulation journal,
40(1), 1–9.
KM10
Huffman, S.L., Harika, R.K., Eilander, A., & Osendarp,S.J.M. (2011). Essential fats: how do they affect growth
and development in infants and young children in developing countries? A literature review. Matern
Child Nutr 7(S3): 44-65.
IOM (2005). Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein,
and amino acids. Institute of Medicine, National Acedemic Press 422-515.
IPH (2017). National Health and Morbidity Survey (NHMS) 2017: Adolescent Nutrition Survey 2017. Institute
for Public Health. Ministry of Health Malaysia, Putrajaya.
Karupaiah, T., Noor, M.I. & Sundram, K (2005). Dietary fatty acids and their influence on blood lipids and
lipoproteins. In. Akoh, C.C. & Lai O-M (eds). Healthful Lipids, pg. 171-203. Champaign, Illinois, AOCS
Press, USA.
Karupaiah, T., Tan, H.K., Ong, W.W., Tan, C.H. & Sundram, K. (2014). Trans fatty acid content in Malaysian
supermarket foods: a field-to-laboratory approach in assessing food risk. Food Additives &
Contaminants: Part A, 31, 1375-1384.
Karupaiah, T., Chuah, K.A., Chinna, K., Pressman, P., Clemens R.A., Hayes A.W., and Sundram, K. (2019). A
cross sectional study on the dietary pattern impact on cardiovascular disease biomarkers in Malaysia.
Scientific Reports 9, 13666.
Kaseva, K., Pulkki-Raback, L., Elovainio, M., Pahkala, K., Keltikangas-Jarvinen, L., Hintsanen, M., Hakulinen,
C., Lagstrom, H., Jula, A., Niinikoski, H., Ronnemaa, T., Viikari, J., Simell, O., & Raitakari, O. (2015).
Psychological wellbeing in 20-year-old adults receiving repeated lifestyle counselling since infancy.
Acta Paediatr 104: 815–22.
Kris-Etherton, P.M., Krummel, D., Russell, M.E., Dreon, D., Mackey, S., Borchers, J. & Wood, P.D. (1988). The
effect of diet on plasma lipids, lipoproteins and coronary heart disease. J Am Diet Assoc, 88, 1373-
1400.
Lee, J.H. (2013). Polyunsaturated fatty acids in children. Pediatr Gastroneterol Hepatol Nutr 16(3): 153-161.
270
Lehtovirta, M., Pahkala, K., Niinikoski, H., Kangas, A.J., Soininen, P., Lagström, H., Viikari, J.S., Rönnemaa, T.,
Jula, A., Ala-Korpela, M. and Würtz, P., (2018). Effect of dietary counseling on a comprehensive
metabolic profile from childhood to adulthood. The Journal of Pediatrics, 195,190-198.
Liu Ai, Dong., Li Jian, Wen., Liu Zhao, Ping., Zhou Ping, Ping, Mao Wei Feng, Li Ning, Zhang Lei.(2015). Trans
Fatty Acid Levels in Foods and Intakes among Population Aged 3 Years and above in Beijing and
Guangzhou Cities, China[J]. Biomedical and Environmental Sciences, 28(7): 477-485.
Lorenz, M.W., Markus, H.S., Bots, M.L., Rosvall, M., & Sitzer, M. (2007). Prediction of clinical cardiovascular
events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation,
115(4), 459–467.
Lotfi, K., Salari-Moghaddam, A., Yousefinia, M., Larijani, B., & Esmaillzadeh, A. (2021). Dietary intakes of
monounsaturated fatty acids and risk of mortality from all causes, cardiovascular disease and cancer:
a systematic review and dose-response meta-analysis of prospective cohort studies. Ageing Research
Reviews, 72, 101467.
Lukas, Schwingshackl., Berit Bogensberger,§ Aleksander Benčič., Sven, Knüppel., Heiner, Boeing., & Georg,
Hoffmann. (2018). Effects of oils and solid fats on blood lipids: a systematic review and network meta-
analysis. Journal of Lipid Research Volume 59:1771-1782
Mensink, R.P., Zock, P.L., Kester, A.D., & Katan, M.B. (2003). Effects of dietary fatty acids and carbohydrates
on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta- KM10
analysis of 60 controlled trials. Am J Clin Nutr, 77(5), 1146–1155.

Mensink, R.P. (2016). Effects of saturated fatty acids on serum lipids and lipoproteins: a systematic review
and regression analysis. World Health Organisation, Geneva.
Michielsen, C.C.J.R., Hangelbroek, R.W.J., Feskens, E.J.M., & Afman, L.A. (2019). Disentangling the effects
of monounsaturated fatty acids from other components of a Mediterranean diet on serum metabolite
profiles: a randomized fully controlled dietary intervention in healthy subjects at risk of the metabolic
syndrome. Molecular Nutrition & Food Research, 63(9), e1801095.
Muhamad, N.A. and Mohamad, J. (2012). Fatty acids composition of selected Malaysian fishes. Sains
Malaysiana, 41(1), 81-94.
Mozaffarian, D. (2006). Trans fatty acids - effects on systemic inflammation and endothelial function.
Atherosclerosis Supplements, 7(2), 29–32.
Mozaffarian, D., Aro, A., & Willett, W. C. (2009). Health effects of trans-fatty acids: experimental and
observational evidence. European Journal of Clinical Nutrition, 63 Suppl 2, S5–S21.
Mozaffarian, D., Micha, R., & Wallace, S. (2010). Effects on coronary heart disease of increasing
polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized
controlled trials. PLoS Medicine, 7(3), e1000252.
Naude, C.E., Visser, M.E., Nguyen, K.A., Durao, S., & Schoonees, A. (2018). Effects of total fat intake on
bodyweight in children. Cochrane Database Syst. Rev. 2, CD012960.
NCCFN (2017). Recommended Nutrient Intake (RNI) for Malaysian. A Report of the Technical Working Group
on Nutritional Guidelines. Putrajaya: Ministry of Health Malaysia
271
Niinikoski, H., Lagström, H., Jokinen, E., Siltala, M., Rönnemaa, T., Viikari, J., Raitakari, O.T., Jula, A., Marniemi,
J., Näntö-Salonen, K. & Simell, O.(2007). Impact of repeated dietary counseling between infancy and
14 years of age on dietary intakes and serum lipids and lipoproteins: the STRIP study. Circulation
116(9): 1032-1040.
Niinikoski, H., Viikari, J., Rönnemaa, T., Lapinleimu, H., Jokinen, E., Salo, P., Seppänen, R., Leino, A,, Tuominen,
J., Välimäki, I. & Simel,l O. (1996). Prospective randomized trial of low-saturated-fat, low-cholesterol
diet during the first 3 years of life. The STRIP baby project. Circulation 94(6): 1386-1393.
Norhayati, M., Azrina, A., Norhaizan, M.E., Muhmmad Rizal, R. (2011). Trans fatty acids content of biscuits
commercially available in Malaysian market and comparison with other countries. International Food
Research Journal, 18(3), 1097-1103.
Nupponen, M., Pahkala, K., Juonala, M., Magnussen, C.G., Niinikoski, H., Rönnemaa, T., Viikari, J.S., Saarinen,
M., Lagström, H., Jula, A. and Simell, O., 2015. Metabolic syndrome from adolescence to early
adulthood: effect of infancy-onset dietary counseling of low saturated fat: the Special Turku Coronary
Risk Factor Intervention Project (STRIP). Circulation, 131(7), 605-613.
Oboh, G., Falade, A.O. and Ademiluyi, A.O. (2014). Effect of thermal oxidation on the physico-chemical
properties, malondialdehyde and carotenoid contents of palm oil. Rivista Italiana Delle Sostanze
Grasse, 91(1), 59-65.
KM10 Oranta, O., Pahkala, K., Ruottinen, S., Niinikoski, H., Lagström, H., Viikari, J.S., Jula, A., Loo, B.M., Simell, O.,
Rönnemaa, T., Raitakari, O.T., (2013). Infancy-onset dietary counselling of low-saturated-fat diet
improves insulin sensitivity in healthy adolescents 15–20 years of age: the Special Turku Coronary
Risk Factor Intervention Project (STRIP) study. Diabetes care, 36(10), 2952-2959.
Orsavova, J., Misurcova, L., Ambrozova, J.V., Vicha, R. & Mlcek, J. (2015). Fatty acids composition of vegetable
oils and its contribution to dietary energy intake and dependence of cardiovascular mortality on
dietary intake of fatty acids. International Journal of Molecular Sciences, 16(6), 12871-12890.
Poh, B.K., Ng, B.K., Siti Haslinda, M.D., Nik Shanita, S., Wong, J.E., Budin, S.B., Ruzita, A.T., Ng, L.O., Khouw,
I., & Norimah, A.K. (2013). Nutritional status and dietary intakes of children aged 6 months to 12
years: findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia). British Journal of
Nutrition, 110 Suppl 3, S21–S35.
Rahman, S.A., Huah, T.S., Nassan, O. and Daud, N.M. (1995). Fatty acid composition of some Malaysian
freshwater fish. Food Chemistry, 54(1), 45-49.
Rask-Nissilä L, Jokinen E, Rönnemaa T, Viikari J, Tammi A, Niinikoski H, Seppänen R, Tuominen J & Simell
O (2000). Prospective, randomized, infancy-onset trial of the effects of a low-saturated-fat, low-
cholesterol diet on serum lipids and lipoproteins before school age: the Special Turku Coronary Risk
Factor Intervention Project (STRIP). Circulation 102(13): 1477-1483.
Scholz, A., Gimenez-Monzo, D., Navarrete-Muñoz, E.M., Garcia-de-la-Hera, M., Fernandez-Somoano, A.,
Tardon, A., Santa Marina, L., Irazabal, A., Romaguera, D., Guxens, M., Julvez, J., Llop, S., Lopez-
Espinosa, M.J., Vioque, J.. (2016). Dietary Intake of Trans Fatty Acids in Children Aged 4-5 in Spain:
The INMA Cohort Study. Nutrients.10;8(10):625.
Schwingshackl, L., Bogensberger, B., Benčič, A., Knüppel, S., Boeing, H., & Hoffmann, G. (2018). Effects of
oils and solid fats on blood lipids: a systematic review and network meta-analysis. Journal of Lipid
Research, 59(9), 1771–1782.
Siri-Tarino, P.W., Sun, Q., Hu, F.B., & Krauss, R.M. (2010). Saturated fat, carbohydrate, and cardiovascular
disease. Am J Clin Nutr 91(3): 502–509.
272
Skeaff, C.M., & Miller, J. (2009). Dietary fat and coronary heart disease: summary of evidence from prospective
cohort and randomised controlled trials. Ann Nutr Metab, 55(1-3), 173–201.
Te Morenga, L., Montez, J.M. (2017) Health effects of saturated and trans-fatty acid intake in children and
adolescents: Systematic review and meta-analysis. PLoS ONE 12(11): e0186672.
Tee, E.S., Mohd Ismail, N., Mohd Nasir, A. & Khatijah, I. (1997). Nutrient Composition of Malaysian Foods.
4th Edition. Institute for Medical Research, Kuala Lumpur
USDA. (2015). 2015-2020 Dietary Guidelines for Americans. 8th Edition. U.S. Department of Health and
Human Services and U.S. Department of Agriculture, December 2015. Available at
http://health.gov/dietaryguidelines/2015/guidelines/
Vuholm, S., Rantanen, J.M., Teisen, M.N., Stark, K.D., Mølgaard, C., Christensen, J.H., Lauritzen, L., &
Damsgaard, C.T. (2019). Effects of oily fish intake on cardiometabolic markers in healthy 8- to 9-y-old
children: the FiSK Junior randomized trial. Am J Clin Nutr 110(6): 1296-1305.
WHO (2003). Diet, nutrition, and the prevention of chronic diseases: report of a joint WHO/FAO expert
consultation (Vol. 916). World Health Organisation, Geneva:
Zhu, Y., Bo, Y., & Liu, Y. (2019). Dietary total fat, fatty acids intake, and risk of cardiovascular disease: a dose-
response meta-analysis of cohort studies. Lipids in Health and Disease, 18(1), 91.
KM10
273
KM10
Appendices
Table 10.1: Fatty acids composition of selected dietary fats and oils
SFA MUFA PUFA
Types of fats and

Lauric Myristic Palmitic Stearic Palmitoleic alpha- Others P/S ratio
oils Oleic acid Linoleic acid
<12:0 acid acid acid acid Total SFA acid Total MUFA linolenic acid Total PUFA
(18:1) (C18:2)
(C:120) (C14:0) (C16:0) (C18:0) (C16:1n7) (C18:3)
Coconut oil 14.9 48.5 17.6 8.4 2.5 91.9 - 6.5 6.5 1.5 - 1.5 0.1 0.02
Palm kernel oil 8.2 49.6 16 8 2.4 84.2 - 13.7 13.7 2 - 2 0.1 0.02
Cocoa butter - - 0.1 25.8 34.5 60.4 0.3 35.3 35.6 2.9 - 2.9 1.1 0.05
Beef fat 0.1 0.1 3.3 25.5 21.6 50.6 3.4 38.7 42.1 2.2 0.6 2.8 4.6 0.06
Shea butter - - - 5 41 46 - 48 48 5.1 - 5.1 0.9 0.11
Palm oil - 0.3 0.8 39.5 4.3 44.9 0.3 43.1 43.4 10.5 0.3 10.8 0.5 0.24
274
Palm olein - 0.2 0.8 37.2 4.2 42.4 0.4 43.6 44 11.5 0.3 11.8 0.3 0.28
Lard 0.1 0.1 1.4 24.8 12.3 38.7 3.1 45.1 48.2 9.9 1.1 11 3 0.28
Olive oil - - - 16.5 2.3 18.8 1.8 66.4 68.2 13 1.6 14.6 0 0.78
Groundnut oil - - 0.04 7.5 2.1 9.6 0.1 71.1 71.2 18.2 - 18.2 0.9 1.89
Corn oil - - - 12.3 1.9 14.2 0.1 27.7 27.8 56.1 1 57.1 0.9 4.02
Soybean oil - - 0.1 10.8 3.9 14.8 0.2 23.9 24.1 52.1 7.8 59.9 1.2 4.05
Canola oil - - - 5.6 1.8 7.4 - 56 56 25.8 9.8 35.6 1 4.81
Sunflower oil - 0.02 0.09 6.2 2.8 9.1 0.12 28 28.1 62.2 0.16 62.4 0.4 6.85
Safflower oil - - 0.1 6.7 2.4 9.2 0.1 11.5 11.6 79 0.15 79.2 0.1 8.6
Notes: values represent %/100g edible fat.Sources: Dubois et al. (2007), Grundy & Denke (1990), Kris-Etherton et al. (1988), Orsavova et al. (2015), Gunstone et al. (2007), and Karupaiah et al. (2005)
Table 10.2: Malaysian foods with significant content of dietary fats (g/100g)
Food Total fat SFA MUFA PUFA TFA*
Fishes
Black pomfret (bawal hitam) 1.79 0.94 0.14 0.71 N/A
Giant seaperch (siakap) 2.43 1.27 0.23 0.93 N/A
Golden snapper (Jenahak) 1.02 0.42 0.09 0.51 N/A
Indian Mackerel (kembong) 1.08 0.59 0.30 0.19 N/A
Silver Pomfret (Bawal Putih) 1.60 0.88 0.15 0.57 N/A
Yellowstripe scad (Selar Kuning) 2.54 0.83 0.29 1.42 N/A
Shellfish
Cockles (Kerang) 1.65 0.64 0.40 0.61 N/A
Cuttlefish (Sotong) 1.18 0.57 0.11 0.50 N/A
Oyster (Tiram) 0.98 0.56 0.08 0.34 N/A
Prawn (Udang) 0.88 0.31 0.11 0.46 N/A
Nuts and Seeds
KM10
Almond 48.8 4.5 33.1 11.1 N/A
Hazelnut 61.2 4.8 50.9 5.5 N/A

Peanut 41.8 7.6 20.7 12.9 N/A
Walnut 53.6 7.9 0.2 45.0 N/A
Confectionary
Chocolate wafer 27.3 17.0 7.6 1.7 0.74
Cooking chocolate 33.1 26.7 5.2 0.7 0.42
Fats, oils, spreads, dressing
Butter 80.6 46.6 25.6 4.8 1.06
Fat spread 73.4 26.6 28.9 17.0 0.16
Ghee 99.8 61.5 29.7 3.3 1.04
Margarine 80.0 35.5 34.6 6.4 0.28
Peanut butter 42.0 8.5 20.4 11.3 0.22
Hazelnut and chocolate spread 29.6 5.4 16.1 6.7 N/A
Cream cheese spread 31.9 20.4 8.9 0.9 N/A
Salad dressing 45.0 6.5 10.2 27.5 0.08
Shortening 99.8 57.0 33.6 8.8 0.20
Vanaspati 99.8 50.6 37.9 10.7 0.43
Dairy-based products
Adult milk powder 25.6 15.1 7.9 1.3 0.42
Cheese 21.5 12.9 6.8 1.0 0.17
Children’s milk >3 years 17.8 8.0 6.6 2.9 0.17
Children’s milk <1 year 27.4 10.9 11.2 5.0 0.04
Ice cream 11.0 7.5 2.6 0.5 0.23
275
Food Total fat SFA MUFA PUFA TFA*
Soups
Soup, canned 45.8 4.9 25.0 14.8 0.04
Soup, concentrates 17.0 8.8 6.2 1.5 0.33
Snacks
French fried 2.55 1.3 0.9 0.3 0.01
Frozen Chappati/paratha 9.1 4.7 3.1 1.1 0.06
Frozen dough 5.5 2.7 2.1 0.7 0.02
Potato chips 32.7 12.5 14.8 4.9 0.08
Meat & products
Beef lean 1.1 0.6 0.4 0 N/A
Burger patties 13 5.3 5.6 1.6 0.01
Chicken meat 19 5.7 9.2 4.1 N/A
Hen egg 8.1 2.6 4.7 0.8 N/A
Mutton 4.6 2.0 2.4 0.2 N/A
KM10 Nuggets 15 6.5 6.3 2.0 0.01
Pork fat 89.3 37.8 45.9 5.5 N/A
Pork lean 21 7.9 11.0 2.1 N/A

Prawn 0.3 0.1 0.1 0.1 N/A
Luncheon meats 28.8 11.0 13.5 2.9 0.04
Sausages 13.8 4.3 6.3 2.9 0.02
Popular Street Foods
Char Siew Pau 15.4 7.2 7.0 1.2 N/A
Chicken rice 4.6 1.8 2.1 0.7 N/A
Curry laksa 6.4 4.4 1.4 0.6 N/A
Dosai 0.7 0.4 0.2 0 N/A
Fried Kueh Tiau 9.7 3.9 4.5 1.3 N/A
Fried mee - Hokkien 6.6 2.7 3.0 0.9 N/A
Fried mee - Indian style 9.0 5.6 2.3 1.1 N/A
Lor Mai Kai 5.0 1.9 2.4 0.7 N/A
Nasi goreng cina 13.2 5.3 6.5 1.4 N/A
Nasi lemak 3.6 2.0 1.1 0.5 N/A
Satay 10.8 3.6 4.6 2.6 N/A
Sources: Abd. Aziz et al. (2013), Alasalvar et al. (2003), Dubois et al. (2007), Karupaiah et al. (2014), Orsavova et al.
(2015), Tee et al. (1997)
*relates to total TFA content as a sum of 18:1 n9t; 18:2 n6t; cis-9 t-12; t-9, cis-12; 18:3t1; 18:3t2; 18:3t4; and
18:3t5 excluding natural isomers of conjugated linoleic acid (cis-9,t-11).
N/A=not available
276
Table 10.3: Marine omega-3 fatty acids content in Malaysian fishes
Fish species Fat (g per 100 g) EPA (mg per 100 g) DHA (mg per 100 g)
High fat fish (>3 g fat per 100g)
Red pomfret (bawal merah) 34.0 2 1
Toli shad (terubuk) 13.8 137 35
Freshwater eel (belut air tawar) 10.7 37 9
Jelawat (jelawat) 7.9 1 6
Silver carp (kap perak) 7.1 2 6
Black siakap (siakap hitam) 6.5 3 25
Eel (belut) 6.3 17 1
Catfish (patin) 6.2 9 1
Indonesian carp (tebal sisik) 5.2 1 0
Indian mackeral (kembung) 4.5 48 22
Wild sepat (sepat ronggeng) 4.5 2 7 KM10

River catfish (keli bunga) 4.4 0 2

Catfish (keli) 4.3 3 0
Snakehead (haruan) 3.3 3 1
Anchovies (bilis) 2.4 11 25
Moderate fat fish (1-3 g fat per 100g)
African bream (tilapia) 2.8 2 0
Red african bream (tilapia merah) 2.4 1 0
Catla (catla) 1.9 1 0
Big head carp (kap kepala besar) 1.8 0 0
Rohu (rohu) 1.3 2 0
Seamese sepat (sepat siam) 1.2 1 2
Sources: Rahman et al. (1995); Muhammad & Mohamad (2012)
277
Table 10.4: Alternatives for fried foods
Fried Foods Alternatives
Pisang goreng (100g) Pisang (100g)

Kcal: 198 kcal Kcal: 103 kcal
Fat: 4.4 g Fat: 0.3 g
Fried chicken (100g) Grilled chicken (100g)
Fat: 19.9 g Fat: 11.8 g
Ikan goreng berlada (100g) Ikan masak asam (100g)
Fat: 28.2 g Fat: 12.7 g
Fried taukua (100g) Steam taukua (100g)
Fat: 15.2 g Fat: 5 g
KM10
Fried noodle (100g) Noodle soup (100g)
Fat: 5.3 g Fat: 2.6 g

Fried popia (100g) Popia basah (100g)
Fat: 12.3 g Fat: 6.8 g
Source: Tee et al. (1997)
278
Key Message 11
Limit intake of salt and sauces in daily meals

KM11
Key Message 11
Assoc. Prof. Dr. Wong Jyh Eiin, Dr. Siti Raihanah Shafie, Ms. Munirah Nasir, Ms. Rozalina Ismail,
Ms. Siti Farrah Zaidah Mohd Yazid and Prof. Dr. Suzana Mohd Shahar
11.1 Terminology
Discretionary salt Iodised salt

Salt added during cooking or at the table. A form of salt that has been added with iodine in the
form of potassium iodide or sodium iodide or iodate
Healthier Choice Logo (HCL) equivalent to not less than 20mg/kg and not more
This is a front label of food packages to assist than 40 mg/kg of iodine (MOH, 1985).
consumers in making informed food choices. Food
products may carry the HCL if they meet the Low sodium food
nutrient criteria specified by the Ministry of Health A food with a sodium concentration of not more
Malaysia (MOH, 2020). Food products with HCL than 0.12g/100g for solids or 0.06g/100ml for liquid
generally contain relatively lower sodium content (MOH, 2010).
compared to other products within the same
category of food.
280
MyChoice Sauces
An initiative by the Ministry of Health Malaysia to Sauce shall be a liquid or semi-liquid savoury
encourage the food services industry to provide preparation of food with or without spices and
healthier meals and enable Malaysians to make intended to be eaten with food as a relish. Sauces
healthier dining choices easily. To meet criteria for also include soy sauce or ‘kicap’, chili sauce, tomato
MyChoice logo endorsement, sodium content needs sauce or ketchup, salad dressing, mayonnaise, fish
to be ≤650mg in ≤500 kcal food (set menu) and for sauce, budu and cincalok (MOH, 1985).
beverage (ala carte) no addition of sodium or salts,
except for beverages that have obtained the Sodium-free food
Healthier Choice Logo (HCL) (MOH, 2021). A food with a sodium concentration of not more
than 0.005 g/100g for solids or 0.005 g/100ml for
Reduced/ Less/ Light sodium food liquid (MOH, 2010).
A product that has a new formulation with lower or
reduced sodium content compared to another Tolerable Upper Intake Level (UL)
version of the same food or similar product. The The highest average daily intake level of a nutrient
sodium content between compared foods must that is likely to pose no risk of adverse health effects
differ by at least 25% (MOH, 2010). to almost all individuals in the general population.
Salt and sodium The UL for sodium is dependent on age, ranging
Salt is an inorganic compound consisting of sodium from 1000 mg/day for 1-3 year olds, 1400 mg/day for
(Na+) and chloride (Cl-) ions i.e., NaCl. 1 g sodium is 4-8 year olds, 2000 mg/day for 9-13 year olds to 2300
equivalent to 2.55 mg NaCl, whilst 1 mmol Na is mg/day for 14-18 year olds (NCCFN, 2017).
equivalent to 23 mg Na (NaCl consists of Na at 40%).
Thus, 1 teaspoon of 5g salt provides 2000 mg or 88 Universal Salt Iodization (USI) KM11
mmol sodium. In addition to sodium chloride (NaCl), Addition of iodine (20-40 mg/kg) to all salt for
sodium may also be present in other forms, such as human and animal consumption, including salt for

monosodium glutamate, sodium nitrate and sodium food processing. An initiative to eliminate iodine
benzoate (MOH, 1985). deficiency disorder at the population level.
Salt substitute Very low sodium food

Salt with reduced sodium and enriched with A food with a sodium concentration of not more
potassium or other similar components such as than 0.04 g/100g for solids or 0.02 g/100ml for liquid
magnesium and aluminum. Potassium chloride (KCl) (MOH, 2010).
is the most common mineral salt used to partially
replace sodium chloride in salt substitutes. This is
sometimes known as low sodium salt or light salt.
11.2 Introduction
The words salt and sodium are often used absorption and transport of nutrients, maintaining
interchangeably, in which the public understands blood pressure, transmitting nerve signals and
the term dietary salt better than sodium (WHO, contracting and relaxing muscle. For infants aged 0
2012). Sodium is a mineral element also known as - 6 months old, the adequate intake (AI) for sodium
natrium, from which the symbol Na was derived. It is based on amounts found in breast milk. The WHO
is one of the principal positive ions, or electrolytes (2012) emphasizes that there is no recommended
in the body fluids (NCCFN, 2017). Sodium is found amount of salt that should be added to food
naturally in a variety of foods, such as milk, meat, prepared for infants and toddlers throughout their
shellfish and certain types of vegetables and fruits. early years or during the period of complementary
Whereas many processed foods contain sodium in feeding.
the form of sodium chloride (NaCl), or generally
known as salt. In addition, sodium is also used as Salt is an inorganic compound consisting of sodium
flavouring, preservative, sweetener and leavening and chloride ions i.e., NaCl. 1 g sodium is equivalent
agent such as monosodium glutamate, sodium to 2.55 mg NaCl whilst 1 mmol Na is equivalent to
nitrite, sodium saccharin, baking soda (sodium 23 mg Na (NaCl consists of Na at 40%). Thus, 1
bicarbonate), and sodium benzoate. teaspoon of 5g salt provides 2000 mg or 88 mmol
sodium. In addition to NaCl, sodium may also be
Sodium is required in a minute amount in the present in other forms, such as monosodium
human body for the regulation of electrolyte, glutamate, sodium nitrate and sodium benzoate.
281
High amounts of salt were found in most processed intake. Thus, in line with the prevention and control
and pre-packed foods (i.e bread, confectionery, of non-communicable diseases, sodium intake
butter, processed meat, sauces and flavour should be less than 2g/ day in adults and is adjusted
enhancers), and in many condiments (e.g soy and downward based on energy requirements of
fish sauces). Likewise, one gram of sodium therefore children relative to those of adults (WHO, 2012). The
equals approximately 2.5 g salt (WHO, 2012). recommendation of maximum intake for children
and adolescents is up to 2g/ day (Table 11.1). On the
In food industries, salt is used to add flavour, other hand, babies get enough salt from the formula
preserve foods to prevent spoilage, improve texture milk or breastmilk. Hence, salt is not required for
and keep foods like ready-to-eat meats and cheeses babies less than 1 year old (Gowrishankar, et,al,
safe to eat. Salt is also used in fermentation 2020). Their kidneys are unable to process a high
processes for foods like tempoyak (Ahmad et al., amount of added salt. Too much salt from sources
2018), pickles and noodles (Yeoh et al., 2020). In other than natural foods like vegetables and fruits,
addition, processed and ultra-processed foods, such breast milk and/or infant formula may affect a baby’s
as ready-to-eat meals, bacon, ham and salami kidneys and possibly even cause other organ
cheese, salty snack foods and instant noodles, soy damage.
sauce, fish sauce (budu), shrimp sauce (cencaluk),
bread and processed cereal products also contain Drawing from a general population
high amounts of salt. Based on a systematic review recommendation, reduction of sodium intake may
in several low-and-middle-income countries, major be achieved through the reformulation of
food sources of salt are breads, meat and meat manufactured foods or replacing discretionary salt
products, bakery products, instant noodles, salted with salt substitutes (WHO, 2012). Salt substitutes
KM11 preserved foods, milk and dairy products, are referred to as light salts, in which all or some of
condiments and sodium glutamate (Menyanu et al., the sodium is replaced with other minerals such as
2019; NCCFN, 2017; Ilyanie et al., 2020). In Malaysia, potassium or magnesium (MOH, 1985). Salt
a market survey of food label information revealed substitutes like potassium salt have up to 70% less
that the highest salt content was in sauces, namely sodium than standard table salt and therefore do not
fish/ shrimp sauce (budu/cencalok) (5192 ± carry the same health consequences as sodium-
3228mg/100g), followed by the light/thin soy sauce based salts (Service et al., 2016). Using salt
(5116 ± 2084mg/100 g), and salty soy sauce (4780 ± substitutes containing potassium chloride (KCl) is a
988mg/100 g) (Shahar et al., 2019). potential strategy to reduce sodium intake (WHO,
2012). KCl is considered the most effective salt
There is a variety of salt in the market and this (NaCl) substitute as it is able to perform many of the
includes sea salt, himalayan pink salt, kosher salt, functional roles of NaCl. However, KCl may leave a
bamboo salt, and french salt. These salts are bitter, chemical, and metallic aftertaste that reduces
frequently used or added to food during cooking in its palatability and limits its use (Sinopoli and
home kitchens or at the table. Regardless of the Lawless 2012). For individuals living with kidney
types, all salts contain equal amounts of sodium as diseases and using certain medications that raise
table and cooking salt. For example, garlic salt and their potassium levels, concerns have been raised
celery salt are popular and perceived as alternatives about the expanded use of potassium chloride
to standard table salt. However, these products are because of the risk of hyperkalemia and its
made predominantly of table, rock or sea salt consequences include arrythmias and cardiac arrest
combined with small amounts of dried garlic or posed by high intake of potassium in these salt
celery. The salt component is still sodium chloride, substitutes (Greer et al., 2020). Several studies
and therefore these too should be sparingly used as showed that potassium intake could reduce high
with rock and sea salt (Service et al., 2016). blood pressure among adults especially those with
hypertension (Bernabe-Ortiz et al., 2020;
Studies have shown that habitual high salt intake is Lichtenstein et al., 2021). However, data among non-
one of the risk factors for non-communicable diet hypertensive adults, children and adolescents are
related diseases and premature death. Salt scarce.
consumption among children in many countries of
the world exceeds the level recommended by WHO Sodium requirement for all age groups
(5 g/ day) (Núñez-Rivas et al., 2020; Farapti et al.,
2019; Levyraz et al., 2018). These studies revealed Sodium requirement estimated from Adequate
that children and adolescents also experience Intake (AI) for all age groups is presented in Table
diseases such as high blood pressure, obesity, 11.1. Generally, children and adolescents require
cancer, and asthma as a result of excessive salt less than adults.
282
Table 11.1: Sodium requirement (AI mg/ day) for all age groups
Age group Sodium requirement (AI mg/ day) Salt equivalent (teaspoon)
Infants
0 - 6 months 120 mg/ day (5mmol/ day) From breastmilk
7 - 12 months 370 mg/ day (16 mmol/ day) From natural food and breastmilk
Children and adolescents
1 - 3 years 1000 mg/ day (42mmol/ day) ½ (0.5)
4 - 8 years 1200 mg/ day (53 mmol/ day) ½ *** (0.6)
9 - 13 years 1500 mg/ day (65 mmol/ day) ¾ (0.75)
14 - 18 years 1500 mg/day (65 mmol/day) ¾ (0.75)
AI = Adequate intake; * Including sodium from natural foods and added salt; ** estimation of sodium intake from natural foods and
added salt (1 teaspoon of salt = 2g of sodium); *** round down figure
Source: NCCFN (2017)

KM11
In general, children and adolescents are pressure tended to be stronger among children with
recommended to limit the intake of salt and sauces overweight status and a low potassium intake

in daily meals. The recommendation is based on the (Leyvraz et al., 2018). Overall, the small 1 mmHg
scientific evidence described below. reduction in both systolic and diastolic blood
pressure for a difference of 1 g of sodium, is deemed
Sodium and blood pressure in children substantial from the population viewpoint.
Dietary sodium intake has a direct effect on blood The pathophysiologic mechanism linking high
pressure. It has been established that high sodium sodium intake to high blood pressure has not been
intake is a cause of elevated blood pressure in fully elucidated yet (Genovesi et al., 2021). Excessive
healthy children and adolescents. In intervention sodium intake may lead to transient increase in
studies, modest reduction in dietary sodium intake plasma sodium concentration which modify
leads to a small reduction in blood pressure among systemic vascular resistance and arterial stiffness,
children. The first meta-analysis which included 10 and in turn increase blood pressure (Grillo et al.,
controlled trials in children and adolescents aged 8 2019). In addition, the blood pressure response to
to 16 years demonstrated that, reduction of salt dietary sodium seems to vary among individuals. It
intake by 42% in median duration of four weeks has been suggested that sodium sensitivity is more
lowered systolic blood pressure by 1.2 mmHg and common in children born premature, small for
diastolic blood pressure by 1.3 mmHg (He & gestational age and overweight or obese (Lava et al.,
MacGregor, 2006). Similarly, another meta-analysis 2015).
of nine controlled trials with 14 comparisons in
children (n=1384) found that decreasing sodium There is strong evidence of blood pressure tracking
intake for three or more weeks reduced resting from childhood into adulthood (Chen & Wang, 2008).
systolic blood pressure by 0.84 mmHg (95% CI 0.25 High sodium intake during childhood is related to
– 1.43 mmHg, moderate quality of evidence) (Aburto higher blood pressure, which predisposes children
et al., 2013; World Health Organization, 2012). Based to higher risk of hypertension and its related
on the most recent meta-analysis of 18 experimental morbidities in adulthood. Based on results of seven
and observational studies, systolic and diastolic childhood cohorts, raised blood pressure from age
blood pressure increase by 0.8 mmHg and 0.7 10 and 16 years increased the likelihood for adult
mmHg respectively, with each additional gram of hypertension, especially among overweight and
sodium intake per day in children. The dose- obese children (Urbina et al., 2019).
response between sodium intake and blood
283
Globally, it is estimated that 4.0% of children are 2008). In addition, a high sodium intake may be a
living with childhood hypertension and the marker of overall poor quality diets because children
prevalence is on an upward trend (Song et al., 2019). who consumed foods high in sodium, for example
Since hypertension is a major risk factor for processed foods, tend to overeat foods that are high
cardiovascular and chronic kidney diseases, it in calories, sugar and fat (Poti et al., 2015). The
becomes important to limit sodium intake as part of evidence from neuropsychiatric study suggests that
a healthy diet in children for primordial prevention salty foods may be an addictive substance that
of childhood hypertension over the life course signal the opiate and dopamine receptors in the
(Falkner & Lurbe, 2020). brain to stimulate reward and pleasure centers to
increase appetite, caloric consumption, augmenting
Sodium and obesity in children the incidence of overeating, obesity, and related
illness (Cocores & Gold, 2009). A study suggested a
Emerging evidence suggests an association reduction of salt intake by half would decrease by
between high sodium intake and childhood obesity an average of approximately 2.3 sugar-sweetened
(Lee & Kim, 2016; Rafie et al., 2017; Yoo et al., 2021; soft drinks weekly per child assuming the average
Zhao et al., 2021). Studies across populations size of the soft drink is 250g (He et al., 2008). A
reported a positive association between sodium reduction in salt intake could, therefore, play a role
intake and BMI/BMI-Z score (Grimes et al., 2016; in helping to reduce childhood obesity through its
Zhu et al., 2014). Australian school children who effect on sugar-sweetened soft drink consumption.
consumed an additional of 1 gram of sodium per day
has been associated with 0.10 increased in BMI-Z Salt taste preference in children
score, 23% increased odds of being overweight or
KM11 obese and 15% higher risk to be centrally obese Among children, preference for salty taste, similar to
(Grimes et al., 2016). Similarly, the sodium intake of that for sweet taste, is elevated during periods of
adolescents in the US was positively linked with growth. Preference for salty taste appears at around
BMI, waist circumference and adiposity (Zhu et al., four months of age and is influenced by exposure to
2014). It is notable that the adolescent’s sodium salty foods (Beauchamp & Mennella, 2011). In
intake is two-fold higher than the recommendation addition to food exposure, salty taste threshold may
by the American Heart Association (< 1500mg/day) influence salt taste preference and sodium intake
(Zhu et al., 2014). In Indonesia, higher risk of among children. A study among children aged 9 to
overweight and obesity was found in children from 11 years old of different ethnicities in Malaysia has
rural areas who have higher daily consumption of found that Chinese children had a significantly
salty foods and grilled foods, which was associated higher salty taste threshold compared with Malay
with higher increases in mean daily energy intake and Indian Children (Dora et al., 2021).
(Esti et al., 2019).
As salt taste preference is malleable and easily
Besides dietary measurement, high intake of sodium influenced in children, it is important to reduce salt
is also reflected in the urinary sodium excretion of exposure in infancy and childhood (Appel et al.,
the children. Positive association between urinary 2015). Repeated exposure to salty food has been
sodium excretion and dietary sodium was found shown to increase children’s liking for a particular
among children in Korea (Lee et al., 2018; Lee & Kim, salted food (Bouhlal et al., 2014). While repeated
2016), Iran (Rafie et al., 2017), Japan (Kim et al., 2018; exposure to a low-salt food does not seem to shift
Okuda et al., 2017) and Australia (Grimes et al., 2016, children’s preference for salt, it may increase their
2017). Placing salt/soy sauce at dining tables and acceptance of low-salt food in their diets. For
out-of-home behaviour are related to urinary sodium instance, a randomised controlled trial in the United
excretion in Japanese students. The students who States among 6-to-14-year-old-children showed
frequently bought foods at convenience stores or that children readily ate low-sodium cereal for 8
visited restaurants excreted more sodium in urine consecutive weeks despite no change in their salt
than those who seldom bought foods (Okuda et al., preference (Bobowski & Mennella, 2019). The
2017). The association clearly shows that foods findings highlight the potential for incorporating
bought outside of home contributed to higher salt low-sodium foods or modifying family foods to limit
intake in children. salt intake in the home environment. It has been
suggested that an overall low-sodium diet may be
The sodium-obesity link may be explained by the required to change children’s salt preference.
observation that children with high sodium
consumption are more likely to drink sugar-
sweetened beverages (Grimes et al., 2021; He et al.,
284
Iodised salt in prevention of iodine deficiency
Iodine is an essential nutrient needed by the human Universal salt iodization has been recommended as
body in small quantities and plays an important role a safe, cost-effective, and sustainable strategy to
in the production of thyroid hormone. Adequate ensure sufficient intake of iodine by all individuals
thyroid hormone is critically important for normal (World Health Organisation (WHO), the United
growth and neurodevelopment in fetal life, infancy Nations Children’s Fund (UNICEF) and Iodine
and childhood (Pearce, 2014). Iodine deficiency may Global Network (IGN) (WHO, 2012). Based on a
result in goiter, hypothyroidism, miscarriage, latest systematic review, 81.8% of studies that had
stillbirth, congenital anomalies, infant and neonatal an adequate median of urinary iodine concentration
mortality, and impaired growth including stunting. (UIC) had a good impact in their respective salt
iodisation programmes (Machamba et al., 2021).
Salt is considered an appropriate vehicle for
fortification with iodine as it is widely consumed, A proper handling of iodized salt needs to be
inexpensive and does not affect the taste and smell ensured to prevent iodine loss as it is volatile. First,
of the salt or foods (WHO, 2012). In November 2018, when buying iodized salt, choose packaging that is
Malaysia gazette to make iodine salt mandatory for not exposed to direct sunlight. As for the storage of
household use and had enforced the iodized salt, store it in a closed and airtight container
implementation of the Universal Salt Iodization (USI) and make sure it closes tightly. Keep the container
Program since 1st January 2021 (UNICEF, 2015). This away from heat, window sills, extreme cold, and
salt iodisation has also taken into account sunlight. While cooking, add iodized salt after
Malaysia’s salt reduction strategy, which is to turning off the stove and cover the dish to prevent
recommend the use of iodized salt not exceeding 5 iodine from being volatile. If salt is not used for a KM11
grams (1 teaspoon) per day in line with the long period, shake first before adding to cooking to
recommendations of the World Health Organisation ensure iodine return evenly (MOH, 2020).

(WHO, 2012).
11.4 Current Status
Excessive salt consumption among children and adolescent in Malaysia using the gold standard, i.e.
adolescents have been reported in both a 24 hour urinary excretion.
international and local studies. In a comparison
study of national surveys from Australia, China, Several studies indicated that Malaysian children
Mexico and the United States, it was found that high and adolescents tended to consume snacks and fast
intake of sodium, in addition to sugar, was a foods, which are usually high in salt, sugar and fat.
common characteristic in dietary intake for children For instance, a recent study showed that 69.3% of
aged 4 to 13 years old across the four countries. The adolescents aged 10 to 18 years consumed fast food
study showed that 60% of Chinese children had 1 to 3 days per week (Man et al., 2021). Furthermore,
excessive sodium intake and the mean sodium 91.2% of adolescents aged between 13 and 14 years
intake in the US school age children was over 3000 old have family meals away from home at least once
mg/day. High sodium intake may be contributed by a week in an urban area in Selangor, where 41.6% of
salt-dense foods such as savoury snacks where them visited fast-food outlets when they eat out
there is an increasing trend of savoury snacks with their families (Cynthia et al., 2013). Another
consumption in older children (Wang et al., 2018). study by Abdullah et al. (2016) reported that among
In line with the global statistics, the Adolescents adolescents in Kelantan, the Malays showed a
Nutrition Survey (2017) reported that the sodium higher frequency of eating out and consuming fast
intake among Malaysian adolescents aged 13 to 17 food as compared to Chinese adolescents. Findings
years old was 2959 mg/day, higher than the from the Adolescents Nutrition Survey (2017) also
recommended levels (NCCFN 2017). A study by found that nearly 40 to 47% of Malaysian
Majid et al. (2016) showed that the sodium intake in adolescents consumed fast food between one to six
children and adolescents aged 9 to 18 years was days in a week, with the top four most consumed
2290 mg/ day, where it exceeded the recommended fast foods being fried chicken, burger, French fries
daily sodium intake of 1500 mg/ day. It should be and nuggets. High consumption of fast food and
borne in mind sodium intake in these studies were food outside the home is a concern as this dietary
estimated from dietary intake assessment which is pattern is often energy dense, high in fat and sodium
not the gold standard for sodium intake. There is a while low in dietary fibre (Palaniveloo et al., 2021).
need to determine sodium intake of children and Apart from fast foods, some local dishes are also
285
known to contain high amount of sodium or salt. Sodium labeling in food products can help
Sources and content of sodium in selected foods are consumers to choose products with lower salt and
presented in Table 11.2. Some of the examples make informed food choices (Pietinen et al., 2008).
include fried instant noodles, dishes prepared with The Ministry of Health has implemented Healthier
soup or thick gravy, or heavily seasoned with soy Choice Logo and MyChoice Logo as part of the
sauce and fish sauce (Omar & Omar, 2018; Salleh et initiatives to encourage the stakeholders to provide
al., 2021). healthier foods and beverages options to the
consumers including food and beverages low in
In combating the high consumption of salt among sodium. Another salt reduction strategy is the
Malaysians, including children and adolescents, the establishment of Mandatory Sodium Declaration on
Ministry of Health, Malaysia has come out with a Food Label for Selected Food Commodities that has
Salt Reduction Strategy to Prevent and Control NCD been gazette under the Food Act (1983) and Food
for Malaysia 2021-2025. The policy document Regulation (1985) which will be fully implemented
outlines 3 main strategies namely Monitoring (M), in 2024. Currently, a rather high percentage of high
Awareness (A) and Products (P) Strategy. Under the salt foods such as soy sauce (50%) (Shahar et al.,
strategy of awareness, the activity that involves 2019) and instant noodles (48%) (Devaraj et al., 2019)
children and adolescents is by incorporating salt were not labeled with sodium or salt.
education components as part of school healthy
eating curriculum, facilitating implementation of salt
reduction initiatives in school or higher learning
institutions and facilitating a health-promoting
environment through healthy cafeteria, canteen and
KM11 school meal programmes (MOH, 2021).
286
Key Recommendation (KR) 1: Instil preference for low-salts foods
General Health Professional/

& Parents/ Caregiver Civil Organisation

Modify family food to limit salt Educate children to be involved Educate parents, caregivers,
intake by serving home-cooked in purchasing, preparation and teachers, children and
or fresh food with reduced salt cooking of low-salt foods at adolescents on tips for
content to children and home. purchasing, preparation and
adolescents. cooking of low-salt foods at
home.

Encourage children’s Educate about sodium content of Prepare relevant education
involvement in purchasing, condiments. Discourage adding materials about sources of
preparation and cooking of salt, sauces and salty condiments sodium and their content in
low-salt foods. such as soy sauce, tomato sauce, natural and processed foods. KM11
and chilli sauces at the table. Make these education materials
accessible through various

platforms.

Limit adding salt, sauces and Provide tips on how to avoid
salty condiments such as soy excess salt (sodium) when
sauce, tomato sauce, budu and having takeaways, food
chilli sauces at the table. deliveries or eating out.
KR1: HTA4: - -
Eat home-cooked meals more
frequently to control intake of
salt.
287
Key Recommendation (KR) 2: Choose and consume foods with less salt and sauces


Read food labels and nutrition Educate children to be involved Monitor the labelling of salt
information on sodium (salt) and in purchasing, preparation and content for all packaged food.
choose lower salt products that cooking of low-salt foods at
are packed with good nutrients. home.

Choose products with no added/ Educate about food labels and Guide parents, caregivers,
reduced/less/ light/ low/ nutrition information on sodium teachers, children and
very low/free sodium (salt), (salt). Promote healthier choice adolescents on Healthier Choice
or those with Healthier Choice products that contains lower salt Logo (HCL) and nutrient claims
Logo (HCL) if available. and packed with good nutrients. related to sodium.

KM11 Eat more fresh foods and avoid Educate about products with no Educate parents, caregivers,
ultra-processed or ready-to-eat added/ reduced/ less/ light/ low/ teachers, children and
foods. very low /free sodium (salt), or adolescents on MyChoice logo.
those with Healthier Choice

Logo (HCL).

Request for less salt or food Educate about the sodium Promote the adoption of
with MyChoice logo, if available contained within natural and MyChoice logo among Food
when having takeaways, food processed foods. Advocate for and Beverage providers to
deliveries or eating out. serving of more fresh foods and prepare lower-sodium meals.
less ultra-processed or ready-to-
eat foods in schools.

Limit intake of salty snacks and Collaborate with food industries
foods, including gravy and on food reformulation to
sauce, canned soups, increase the availability of lower
processed meat, sausages and sodium foods and meals.
nuggets, salted nuts, instant
noodles, crackers, salted fish,
salted eggs, pickles and
preserved foods.
288
Key Recommendation (KR) 3: Prepare and cook foods with less salt and sauces


Limit preparing foods with flavor enhancers that are high in salt, Provide training on healthier
such as ready-to-use seasonings, stock cubes, soy sauce, oyster food preparation to preschool/
sauce, monosodium glutamate (MSG), fish or prawn sauce school caterers and
(budu, cencaluk). administrators.

Enhance the flavour of food Limit availability of high-sodium Encourage preschool/ school
using fresh and dry herbs and (salt) foods sold at the school caterers to use fresh and dry
spices such as lemon, garlic, canteen, vending machines, and herbs and spices such as
ginger, onions, lemongrass and shops. Monitor foods sold within lemon, garlic, ginger, onions,
others. the school environment. lemongrass and others as
flavour enhancers when
preparing foods.
KM11

Key Recommendation (KR) 4: Use iodised salt appropriately as recommended.


Add iodised salt as a food seasoning, only after turning off the heat. Educate school caterers about
Cover the pan before serving to avoid loss of iodine. heat sensitivity of iodised salt.
Add iodised salt as a food
seasoning, only after turning off
the heat. Cover the foods before
serving to children and
adolescents.

Store iodised salt away from heat and direct sunlight. Educate school caterer the
proper storage of iodised salt.
289
11.6 References
Abdullah, N. F., Teo, P. S., & Foo, L. H. (2016). Ethnic differences in the food intake patterns and its associated
factors of adolescents in Kelantan, Malaysia. Nutrients, 8(9), 1–14. https://doi.org/10.3390/nu8090551
Aburto, N. J., Ziolkovska, A., Hooper, L., Elliott, P., Cappuccio, F. P., & Meerpohl, J. J. (2013). Effect of lower
sodium intake on health: Systematic review and meta-analyses. BMJ (Online), 346(7903), 1–20.
https://doi.org/10.1136/bmj.f1326
Ahmad, A., Yap, W. B., Kofli, N. T., & Ghazali, A. R. (2018). Probiotic potentials of Lactobacillus plantarum
isolated from fermented durian (Tempoyak), a Malaysian traditional condiment. Food science &
nutrition, 6(6), 1370-1377.https://doi.org/10.1002/fsn3.672
Appel, L. J., Lichtenstein, A. H., Callahan, E. A., Sinaiko, A., Van Horn, L., & Whitsel, L. (2015). Reducing
Sodium Intake in Children: A Public Health Investment. Journal of Clinical Hypertension, 17(9), 657–
662. https://doi.org/10.1111/jch.12615
Beauchamp, G. K., & Mennella, J. A. (2011). Flavor perception in human infants: Development and functional
significance. Digestion, 83(Suppl.1), 1–6. https://doi.org/10.1159/000323397
Bernabe-Ortiz, A., Sal y Rosas, V. G., Ponce-Lucero, V., Cárdenas, M. K., Carrillo-Larco, R. M., Diez-Canseco,
F., & Miranda, J. J. (2020). Effect of salt substitution on community-wide blood pressure and
KM11 hypertension incidence. Nature Medicine 26(3): 374-378. https://doi.org/10.1038/s41591-020-0754-2
Bobowski, N., & Mennella, J. A. (2019). Repeated exposure to low-sodium cereal affects acceptance but
does not shift taste preferences or detection thresholds of children in a randomized clinical trial.
Journal of Nutrition, 149(5), 870–876. https://doi.org/10.1093/jn/nxz014
Bouhlal, S., Issanchou, S., Chabanet, C., & Nicklaus, S. (2014). “Just a pinch of salt”. An experimental
comparison of the effect of repeated exposure and flavor-flavor learning with salt or spice on vegetable
acceptance in toddlers. Appetite, 83, 209–217. https://doi.org/10.1016/j.appet.2014.07.032
Chen, X., & Wang, Y. (2008). Tracking of blood pressure from childhood to adulthood: A systematic review
and meta-regression analysis. Circulation, 117(25), 3171–3180.
https://doi.org/10.1161/CIRCULATIONAHA.107.730366
Cocores, J. A., & Gold, M. S. (2009). The Salted Food Addiction Hypothesis may explain overeating and the
obesity epidemic. Medical Hypotheses, 73(6), 892–899. https://doi.org/10.1016/j.mehy.2009.06.049
Cynthia, J., MS, Z., & My, L. (2013). Relationship between Family Meals away from Home and. Malaysian
Journal of Nutrition, 19(1), 25-35.
Devaraj NK, He FJ, MacGregor MA, Chia YC. 2019. Salt content of instant noodles in Malaysia: a cross-
sectional study. BMJ Open, 9e024702. Doi: 10.1136/ bmjopen-2018-024702.
Dora, R., Lim, S. Y., Haron, H., Wong, J. E., Yatiman, N. H., & Poh, B. K. (2021). Salty taste threshold among
children of different ethnicities. Journal of Sensory Studies, 36(1). https://doi.org/10.1111/joss.12623
Esti N, Hadi H, Chang JS, Chao JCJ, Paramashati BA, Gittelsohn J, Bai CH. (2019). Rural – Urban Di fferences
in Dietary Behavior and and Obesity: Results of the Riskesdas Study in 10–18-Year-Old Indonesian
Children and Adolescents Nutrients, 11(2813), 1–14. www.mdpi.com/journal/nutrients
Falkner, B., & Lurbe, E. (2020). Primordial prevention of high blood pressure in childhood an opportunity not
to be missed. Hypertension, 1142–1150. https://doi.org/10.1161/HYPERTENSIONAHA.119.14059
290
Farapti, F., Sulistyowati, M., Artanti, K. D., Setyaningtyas, S. W., Sumarmi, S., & Mulyana, B. (2019). Highlighting
of urinary sodium and potassium among indonesian schoolchildren aged 9–12 years: the contribution
of school food. Journal of Nutrition and Metabolism, 1028672. https://doi.org/10.1155/2019/1028672
Genovesi, S., Giussani, M., Orlando, A., Orgiu, F., & Parati, G. (2021). Salt and sugar: Two enemies of healthy
blood pressure in children. Nutrients, 13(2), 1–15. https://doi.org/10.3390/nu13020697
Gowrishankar, M., Blair, B., & Rieder, M. J. (2020). Dietary intake of sodium by children: why it matters.
Paediatrics & Child Health 25(1): 47-53. https://doi.org/10.1093/pch/pxz153
Greer, R. C., Marklund, M., Anderson, C. A., Cobb, L. K., Dalcin, A. T., Henry, M., & Appel, L. J. (2020).
Potassium-enriched salt substitutes as a means to lower blood pressure: benefits and risks.
Hypertension, 75(2), 266-274. https://doi.org/10.1161/HYPERTENSIONAHA.119.13241.
Grillo, A., Salvi, L., Coruzzi, P., Salvi, P., & Parati, G. (2019). Sodium intake and hypertension. Nutrients, 11(9),
1–16. https://doi.org/10.3390/nu11091970
Grimes, C. A., Bolton, K. A., Booth, A. B., Khokhar, D., Service, C., He, F. H., & Nowson, C. A. (2021). The
association between dietary sodium intake, adiposity and sugar-sweetened beverages in children
and adults: A systematic review and meta-analysis. In British Journal of Nutrition 126 (3), 409-427.
https://doi.org/10.1017/S0007114520004122
Grimes, C. A., Riddell, L. J., Campbell, K. J., Beckford, K., Baxter, J. R., He, F. J., & Nowson, C. A. (2017). Dietary KM11
intake and sources of sodium and potassium among Australian schoolchildren: Results from the
cross-sectional Salt and Other Nutrients in Children (SONIC) study. BMJ Open, 7(10), 1–10.

https://doi.org/10.1136/bmjopen-2017-016639
Grimes, C. A., Riddell, L. J., Campbell, K. J., He, F. J., & Nowson, C. A. (2016). 24-h urinary sodium excretion
is associated with obesity in a cross-sectional sample of Australian schoolchildren. British Journal of
Nutrition, 115(6), 1071–1079.
https://doi.org/10.1017/S0007114515005243
He, F. J., & MacGregor, G. A. (2006). Importance of salt in determining blood pressure in children: Meta-
analysis of controlled trials. Hypertension, 48(5), 861–869.
https://doi.org/10.1161/01.HYP.0000245672.27270.4a
He, F. J., Marrero, N. M., & MacGregor, G. A. (2008). Salt intake is related to soft drink consumption in children
and adolescents: A link to obesity? Hypertension, 51(3), 629–634.
https://doi.org/10.1161/HYPERTENSIONAHA.107.100990
Ilyanie, H. Y., Huda-Faujan, N., & Ida Muryany, M. Y. (2020). Comparative Proximate Composition Of
Malaysian Fermented Shrimp Paste. Malaysian Applied Biology.
https://doi.org.jms.mabjournal.com/index.php/mab/article/view/1557.
Kim, Y. M., Kim, S. H., & Shim, Y. S. (2018). Association of sodium intake with insulin resistance in Korean
children and adolescents: The Korea National Health and Nutrition Examination Survey 2010. Journal
of Pediatric Endocrinology and Metabolism, 31(2), 117–125. https://doi.org/10.1515/jpem-2017-0362
Lava, S. A. G., Bianchetti, M. G., & Simonetti, G. D. (2015). Salt intake in children and its consequences on
blood pressure. Pediatric Nephrology, 30(9), 1389–1396. https://doi.org/10.1007/s00467-014-2931-3
Lee, J., Hwang, Y., Kim, K. N., Ahn, C., Sung, H. K., Ko, K. P., Oh, K. H., Ahn, C., Park, Y. J., Kim, S., Lim, Y. K., &
Park, S. K. (2018). Associations of urinary sodium levels with overweight and central obesity in a
population with a sodium intake. BMC Nutrition, 4(1), 1–14. https://doi.org/10.1186/s40795-018-0255-
6
291
Lee, S. K., & Kim, M. K. (2016). Relationship of sodium intake with obesity among Korean children and
adolescents: Korea National Health and Nutrition Examination Survey. British Journal of Nutrition,
115(5), 834–841. https://doi.org/10.1017/S0007114515005152
Lee, Y. Y., Hassan, S. A., Ismail, I. H., Chong, S. Y., Affendi, R., Ali, R., Lee, W. S., & Majid, N. A. (2017). Gut
microbiota in early life and its in fl uence on health and disease: A position paper by the Malaysian
Working Group on Gastrointestinal Health. 53, 1152–1158. https://doi.org/10.1111/jpc.13640
Leyvraz, M., Chatelan, A., da Costa, B. R., Taffé, P., Paradis, G., Bovet, P., Bochud, M., & Chiolero, A. (2018).
Sodium intake and blood pressure in children and adolescents: A systematic review and meta-
analysis of experimental and observational studies. International Journal of Epidemiology, 47(6), 1796–
1810. https://doi.org/10.1093/ije/dyy121
Lichtenstein, A. H., Appel, L. J., Vadiveloo, M., Hu, F. B., Kris-Etherton, P. M., Rebholz, C. M., Sacks, F. M.,
Thorndike, A. N., Van Horn, L., & Wylie-Rosett, J. (2021). 2021 Dietary Guidance to Improve
Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation,
144(23), e472–e487. https://doi.org/10.1161/CIR.0000000000001031.
Machamba, A. A. L., Azevedo, F. M., Candido, A. C., Macedo, M. D. S., Priore, S. E., & Franceschini, S. D. C.
C. (2021). Assessment of the Impact of Salt Iodisation Programmes on Urinary Iodine Concentrations
and Goitre Rates: A Systematic Review. Journal of Nutrition and Metabolism, 2021.
https://doi.org/10.1155/2021/9971092
KM11
Majid, H. A., Ramli, L., Ying, S. P., Su, T. T., & Jalaludin, M. Y. (2016). Dietary intake among adolescents in a
middle-income country: An outcome from the Malaysian health and adolescents longitudinal research
team study (the myhearts study). PLoS ONE, 11(5), 1–14. https://doi.org/10.1371/journal.pone.0155447
Man, C. S., Hock, L. K., Ying, C. Y., Cheong, K. C., Kuay, L. K., Huey, T. C., Baharudin, A., & Aziz, N. S. A. (2021).
Is fast-food consumption a problem among adolescents in Malaysia? An analysis of the National
School-Based Nutrition Survey, 2012. Journal of Health, Population and Nutrition, 40(1), 1–9.
https://doi.org/10.1186/s41043-021-00254-x
Menyanu, E., Russell, J., & Charlton, K. (2019). Dietary sources of salt in low-and middle-income countries:
a systematic literature review. International Journal of Environmental Research and Public Health,
16(12), 2082. https://doi.org/10.3390/ijerph16122082
MOH (1985). Food Regulation 1985. Ministry of Health Malaysia, Putrajaya.
MOH (2010). Guide to Nutrition Labelling and Claims (as at December 2010). Food Safety and Quality
Division, Ministry of Health Malaysia, Putrajaya.
MOH (2020). Guidelines on Healthier Choice Logo Malaysia. Nutrition Division, Ministry of Health Malaysia,
Putrajaya.
MOH (2021). Guidelines on MyChoice Logo Malaysia. Nutrition Division, Ministry of Health Malaysia,
Putrajaya.
NCCFN (National Coordinating Committee on Food and Nutrition) (2017). Recommended Nutrient Intakes
for Malaysia (RNI). A Report of the Technical Working Group on Nutrition Guidelines. Ministry of
Health Malaysia, Putrajaya.
Núñez-Rivas, H., Holst-Schumacher, I., Blanco-Metzler, A., de los Angeles Montero-Campos, M., Campos-
Saborío, N., & Benavides-Aguilar, K. (2020). Salt/Sodium Intake Estimation in Children and
Adolescents of Costa Rica. Food and Nutrition Sciences, 11(10), 919.
https://doi.org/10.4236/fns.2020.1110065
292
Okuda, M., Asakura, K., & Sasaki, S. (2017). Placing salt/soy sauce at dining tables and out-of-home behavior
are related to urinary sodium excretion in Japanese secondary school students. Nutrients, 9(12).
https://doi.org/10.3390/nu9121290
Omar, S. R., & Omar, S. N. (2018). Malaysian Heritage Food (MHF): A Review on Its Unique Food Culture,
Tradition and Present Lifestyle. International Journal of Heritage, Art and Multimedia, 1(3), 1–15.
Palaniveloo, L., Salleh, R., Baharudin, A., Man, C. S., Ahmad, M. H., Aziz, N. S. A., & Sallehudin, S. (2021).
Associations of gender and BMI-for-age status (BAZ) with nutrient intake among adolescents in
Malaysia: Findings from adolescent nutrition survey (ANS) 2017. Malaysian Journal of Medicine and
Health Sciences, 17(1), 10–16.
Pearce, E. N. (2014). Iodine deficiency in children. Endocrine Development, 26, 130–138.

https://doi.org/10.1159/000363160
Pietinen, P., Valsta, L. M., Hirvonen, T., & Sinkko, H. (2008). Labelling the salt content in foods: A useful tool
in reducing sodium intake in Finland. Public Health Nutrition, 11(4), 335–340.
https://doi.org/10.1017/S1368980007000249
Poti, J. M., Mendez, M. A., Ng, S. W., & Popkin, B. M. (2015). Is the degree of food processing and convenience
linked with the nutritional quality of foods purchased by US households? American Journal of Clinical
Nutrition, 101(6), 1251–1262. https://doi.org/10.3945/ajcn.114.100925
KM11
Rafie, N., Mohammadifard, N., Khosravi, A., Feizi, A., & Safavi, S. M. (2017). Relationship of sodium intake
with obesity among Iranian children and adolescents. ARYA Atherosclerosis, 13(1), 1–6.

Salleh, R., Ganapathy, S. S., Ibrahim Wong, N., Cheong, S. M., Ahmad, M. H., Palaniveloo, L., & Aris, T. (2021).
Is socio-demographic status, body mass index, and consumption of food away from home associated
with high sodium intake among adults in Malaysia?: Findings from the Malaysian Community Salt
Survey (MyCoSS). Journal of Health, Population and Nutrition 40(1): 1-9.
Service, C., Grimes, C., Riddell, L., He, F., Campbell, K., & Nowson, C. (2016). Association between parent
and child dietary sodium and potassium intakes as assessed by 24-h urinary excretion. Nutrients
8(4): 191.
Shahar, S., You, Y. X., Zainuddin, N. S., Michael, V., Ambak, R., Haron, H., & MacGregor, G. A. (2019). Sodium
content in sauces—A major contributor of sodium intake in Malaysia: A cross-sectional survey. BMJ
Open, 9(5), e025068.
Sinopoli, D. A., & Lawless, H. T. (2012). Taste properties of potassium chloride alone and in mixtures with
sodium chloride using a check all that apply method. Journal of food science, 77(9), S319-S322.
Song, P., Zhang, Y., Yu, J., Zha, M., Zhu, Y., Rahimi, K., & Rudan, I. (2019). Global Prevalence of Hypertension
in Children: A Systematic Review and Meta-analysis. JAMA Pediatrics, 173(12), 1154–1163.
https://doi.org/10.1001/jamapediatrics.2019.3310
Tee ES, Ismail MN, Mohd Nasir A, Khatijah I (1997). Nutrient Composition of Malaysian Foods (4th Edition).
Institute for Medical Research, Kuala Lumpur, Malaysia.
United Nation Child's Fund (2015). Universal_Salt_Iodisation_in_South_and_East_Asia_and_Pacific (Issue

July).
Urbina, E. M., Khoury, P. R., Bazzano, L., Burns, T. L., Daniels, S., Dwyer, T., Hu, T., Jacobs, D. R., Juonala, M.,
Prineas, R., Raitakari, O., Steinberger, J., Venn, A., Woo, J. G., & Sinaiko, A. (2019). Relation of Blood
Pressure in Childhood to Self-Reported Hypertension in Adulthood. Hypertension (Dallas, Tex. : 1979),
73(6), 1224–1230. https://doi.org/10.1161/HYPERTENSIONAHA.118.12334
293
Wang, D., Van Der Horst, K., Jacquier, E. F., Afeiche, M. C., & Eldridge, A. L. (2018). Snacking patterns in
children: A comparison between Australia, China, Mexico, and the US. Nutrients, 10(2), 1–14.
https://doi.org/10.3390/nu10020198
WHO (2012). Guideline: Sodium intake for adults and children. World Health Organization.
Yeoh, S. Y., Lubowa, M., Tan, T. C., Murad, M., & Easa, A. M. (2020). The use of salt-coating to improve
textural, mechanical, cooking and sensory properties of air-dried yellow alkaline noodles. Food
chemistry, 333, 127425. https://doi.org/10.1016/j.foodchem.2020.127425
Yoo, B. M., Kim, M., & Kang, M. J. (2021). Association between childhood obesity and familial salt intake:
Analysis of data from Korean national health and nutrition examination survey, 2014–2017. Endocrine
Journal, 68(9), 1127–1134. https://doi.org/10.1507/endocrj.EJ21-0111
Zhao, L., Ogden, C. L., Yang, Q., Jackson, S. L., Loria, C. M., Galuska, D. A., Wiltz, J. L., Merritt, R., & Cogswell,
M. E. (2021). Association of Usual Sodium Intake with Obesity Among US Children and Adolescents,
NHANES 2009-2016. Obesity, 29(3), 587–594. https://doi.org/10.1002/oby.23102.
Zhu, H., Pollock, N. K., Kotak, I., Gutin, B., Wang, X., Bhagatwala, J., Parikh, S., Harshfield, G. A., & Dong, Y.
(2014). Dietary sodium, adiposity, and inflammation in healthy adolescents. Pediatrics, 133(3).
https://doi.org/10.1542/peds.2013-1794.
KM11
294
Appendices
Table 11.2: Sources and content of sodium in selected foods

LOW MODERATE HIGH
(<120 mg Natrium (Na) (120 - 360 mg Natrium (Na) (>360 mg Natrium (Na)
per standard serving) per standard serving) per standard serving)
Cereal & Cereal Products
Rice, plain, cooked Rice porridge, instant -

1 cup - 8mg Na 1 packet - 294mg Na
Rice, husked, unpolished - -

1 cup - 100mg Na
- Noodle, rice Noodle, instant

1 flat piece (1/2 cup) - 138mg Na 1 packet - 1340mg Na
- Noodle, wet Noodle, dry

1 cup - 177mg Na 1 round piece (11x3.5cm) -
431mg Na
- Noodle snack, flavoured - KM11

1 medium packet - 184mg Na

Bread, white - -
1 slice (10.5x9.3x1.1) - 64mg Na
Bread, wholemeal - -
1 slice - 78mg Na
Biscuit, cream crackers Biscuit, soda/ plain -

(6.5x6.5x0.5cm) (6.5x6.5x0.5cm)
<10 square pieces - 104mg Na 5 square pieces - 206mg Na
Crackers, low-salt - -
1 piece - 19mg
Cookies, sesame seed Cookies, oats -

(6.0x5.5x0.5cm) (6.0x1.0cm)
5 pieces - 6mg 5 round pieces - 218mg Na
Starchy Roots, Tubers & Products
Potato Potato chips Potato chip

1 whole large, oval (8.5x4.5cm) 1 small packet - 128mg Na 1 big packet - 655mg Na
- 55mg Na
Legumes & Legumes Product
Soya bean, white Soya bean paste, fermented Soya sauce "thick"
1 cup - 81mg Na (Tau-ceo) 1 tablespoon - 564mg Na
1 tablespoon - 341mg Na
Soya bean cake, fermented Soya bean curd, strands (Fucok) Soya sauce "thin"
(Tempeh) 1 cup - 188mg Na 1 tablespoon - 1255mg Na
1 rectangular piece
(12.0x9.0x0.5cm) - 5mg Na
295
Table 11.2: Sources and content of sodium in selected foods (cont.)
LOW MODERATE HIGH

Soya bean curd, sheet/ film Soya bean noodle -

1 cup - 11mg Na 1 piece (11.5x6cm) - 127mg Na
- Appalam (8.5x0.2 cm) Baked bean, canned

5 pieces - 349 mg Na 1/2 cup (beans only) - 365mg
Na
Nuts, Seeds & Products
Mixed nuts, without salt added Peanut butter Mixed nuts, salt added
1 cup - 16mg Na 3 tablespoon - 177mg Na 1 cup - 917mg Na
- Watermelon seeds, dried, black -

3 cups - 168mg Na
Vegetable & Vegetable Products
KM11 Fresh vegetables Chilli sauce, bottle Canned vegetables

1 tablespoon - 224mg Na 1 cup - 777mg Na
- Pickled vegetables
1 cup - 938mg Na
- Cabbage, Chinese, salted

(Hum-choy)
1 cup (chopped) - 2763mg Na
Tomato juice, canned Tomato soup, canned

1/2 cup - 226mg Na 1/2 cup - 804mg Na
Tomato ketchup (Sos tomato) -

Seaweed, dried (Hai-tai) Peas, salted, fried

1/2 cup - 308mg Na 1 cup - 402mg Na
Fruits & Fruits Products
Fresh fruits Guava, with "asam boi" Banana, smoked

(12.0x8.0x1.5cm) 100g - 840mg Na
2 slice without skin & seeds -
184mg Na
Fruit cocktail in syrup, - Fruit, mixed, spicy pickled 100g

canned 1 tin (450ml) - 19mg Na - 1480mg Na
Durian cake (Lempuk) Durian, fermented (Tempoyak) -

1 cylindrical piece (17.0x2.5cm) 2 tablespoon - 178mg
- 20mg Na
296
LOW MODERATE HIGH

Meat and Poultry Products
Chicken, breast meat Chicken, fried Chicken, fried, fast food

1/2 cup (131g) -55mg Na 1 piece (90g) - 145mg Na franchise
1 piece (140g) - 664mg Na
Chicken, thigh Chicken burger patty Chicken curry, canned

1 medium (12.5x11.3x3.2cm) - 1 round piece - 185mg Na 1 can - 385mg Na
71 mg Na
- Chicken frankfurter Chicken, broth cubes,

("Frankfurter" daging ayam) proprietary brand (Pati ayam)
(12.0x1.5cm) 1 cube - 1152mg Na
2 pieces, 4 inch long - 186mg Na
Beef, lean Beef burger patty Beef, corned, canned

1/2 cup (122.8g) - 82mg Na 1 round piece - 309mg Na 1/2 cup - 777mg Na KM11
- Beef frankfurter (12.0x2.0cm) Beef rendang, canned

2 long piece - 186mg Na 1 can - 862mg Na
Beef, extract, proprietary brand Beef, extract, proprietary brand

(Pati daging lembu) (Pati daging lembu)
1 teaspoon - 337mg Na 1 teaspoon - 337mg Na
Beef burger Beef burger
1 whole - 554mg Na 1 whole - 554mg Na
- - Beef, broth cubes, proprietary

brand
1 cube - 864mg Na
Goat meat, lean Mutton, lean Mutton curry, canned

1 cup (223g) - 110mg Na 1 cup (198.6g) - 180mg Na 1 can (167g) - 708mg Na
Fresh rabbit, duck (100g) - Pork (Khinzir) -

46mg Na 1 bowl (410g) - 189mg Na
- Pork, medium fat -

1 cup (205.8g) - 195mg Na
Eggs
Hen egg, whole 56mg Na Duck egg, salted, whole 249mg Na -
Fish, Shellfish & Products
Fresh fish (except stated in Fish ball (Bebola ikan) (D, 2cm) Fish ball (Bebola ikan) (D, 3cm)
moderate column) 5 whole, small - 296mg Na 2 whole, large - 378mg Na
- Bream, threadfin, Japanese Fish, unspecified, dried, salted -

(Kerisi) Scad, hairtail, dried (Cencaru,
1 whole, medium kering)
(22.0x8.0x2.5cm) - 179mg Na 1 piece, tail portion - 889mg Na
297
LOW MODERATE HIGH

- Carp, big head 1 slice Trevally, yellow-banded, dried

(11.8x6.4x8.2cm) - 151mg Na (Selar kuning, kering)
1 whole medium
(16.0x4.5x1.5cm) - 1113mg Na
1 piece (7.0x3.5x0.4cm) -
433mg Na
- Mackerel, Spanish Fish curry, canned (Kari ikan

1 slice (8.0x2.0x15cm) - dalam tin)
155mg Na 1 tin - 1056mg Na
- Snapper, red Fish "satay" snack ("Satay"

1 slice (6.0x2.0x15.0cm) - ikan)
128mg Na 5 sticks - 380mg Na
- Fish crackers, fried Fish sauce (Budu)

(15.0x7.5x0.2cm) 1 tablespoon - 1032mg Na
KM11 5 oval piece - 241mg Na
- Carp, common (Lee Koh) Anchovy, dried, without head

1 slice (10.5x5x11.6cm) - and entrails

134mg Na 1/2 cup - 758mg Na
Sardine (18.0x3.5x2.0cm) - Sardine, canned

2 whole, small - 60mg Na 1 small can - 476mg Na
Prawn, pink (11.0x1.4cm) Prawn, salted, dried Shrimp, fermented

5 whole, medium - 34mg Na 1 tablespoon - 255mg Na 1 tablespoon - 897mg Na
- Prawn crackers Shrimp paste

1 small packet - 187mg Na 1 piece (3.5x3.2x3.0cm) -
629mg Na
- Prawn paste (Hay-Ko) -

Cuttlefish, fresh Cuttlefish, dried Cuttlefish crackers

1 whole, medium (12.5x6.0cm) 1 whole, small (14.5x9.5x0.5cm) 1 large packet - 421 mg Na
- 78mg Na - 314mg Na
- Clam (Lala) Crab, blue/ sea crab

10 clam - 121mg Na 1 whole (128g) - 377mg Na
- - Crab, swimming/live crab,

1 whole (g) - 392mg Na
Oyster, sauce
Milk & Milk Products
Low sodium cheese, cheddar Cheese, processed, cheddar Cheese burger

1 slice - 21mg Na 1 slice - 261mg Na 1 whole - 864mg Na
298
LOW MODERATE HIGH

Oils & Fats
Margarine, without salt 0mg Na Margarine -

- Butter 2 tablespoon - 172mg Na -
Beverages
Carbonates beverage, Carbonated beverage, -

cream soda isotonic sports drink
1 bottle (500ml) - 59mg Na - 1 bottle (1500ml) - 315mg Na
Carbonated beverage, - -
isotonic sports drink
- 1 bottle (500ml) - 105mg Na
Condiments & Spices KM11
All natural condiments - All types of instant flavouring or

(eg : cloves, cinnamon, anise seasoning
seeds, cumin seeds, asam ≥ 1 1/2 teaspoon - >360mg Na
gelugor, cardamom, chilli or
dried etc). ≥ 1/4 cube - >360mg Na
- - Tamarind, paste
Sources:
1. Tee ES, Ismail MN, Mohd Nasir A, Khatijah I (1997). Nutrient Composition of Malaysian Foods (4th Edition). Institute for
Medical Research, Kuala Lumpur, Malaysia.
299
KM11
300
Key Message 12
Consume foods and beverages low in sugar

KM12
Key Message 12
Dr. Hanapi Mat Jusoh, Prof. Dr. Ruzita Abd Talib, Dr. Norliyana Aris, Assoc. Prof. Dr. Siti Sabariah Buhari,
Dr. Nurul Hayati Anwar, Dr. Nur Dayana Shaari and Ms. Norwati Sakiram
12.1 Terminology
Added sugars Artificial sweeteners

Added sugars are not naturally found in the food Artificial sweeteners, also known as non-nutritive
product and are added to foods during processing, sweeteners, are food additives that, when added to
culinary preparation, or meals. These include brown food, can impart a sweet taste (Yebra-Biurrun, 2005).
sugar, corn sweeteners, corn syrup, dextrose, Non-nutritive sweeteners have few or no calories,
fructose, glucose, sucrose, high-fructose corn syrup, and little or no nutritional value (Wilson et al., 2019).
honey, invert sugar, lactose, maltose, malt syrup, The permitted artificial sweeteners in Malaysia
molasses, and raw sugar (Mela & Woolner, 2018). In include saccharin (2-sulphobenzoic imide), sodium
pre-packaged foods, no added sugar does not mean saccharin (sodium salt of 2– selphobenzoic imide),
that no sugar is present. It means that no sugars and acesulfame potassium, neotame and aspartame
have been added during the manufacturing process which contain low or no calorie (MOH, 1985).
since most foods contain sugars in some form
(Rachel et al., 2017). The classifications of added Free sugars
sugar, free sugar and total sugar are shown in Figure Free sugars include all sugars added by the
12.1. manufacturer, cooked, or consumed, as well as
sugars naturally present in honey, syrups, fruit and
vegetable juices, concentrates, purées, pastes and
302
similar products. These exclude sugars in whole Sugar sweetened beverages (SSBs)
(intact, cooked, or dried) fruits and vegetables or Sugar-sweetened beverages include drinks
dairy products (Swan et al., 2018). containing added sugars, including soft drinks, fruit-
flavoured or fruit-based drinks and high-energy
Hidden sugars drinks, sweetened milk drinks and sweetened teas
Hidden sugars are sugars added in foods and drinks, and coffees, but excluding pure fruit juices and ‘diet’
although they are not labeled as ‘sugar’. The hidden drinks (zero or very-low-calorie drinks with artificial
sugars can be identified by reading the food label. sweeteners) (Winpenny et al., 2017).
Some foods may not have the word ‘sugar’ in the
food and beverage packaging ingredients list. Sweeteners
However, they could still have sugars labelled in Sweeteners are substances with a sweet taste used
different names such as sucrose, dextrose, maltose, as alternatives to sucrose. Sweeteners are classified
fructose, lactose, glucose and honey (US FDA, 2014). as high intensity or bulk based on their sweetness
Significant sources of hidden sugar are soft drinks, level compared to sucrose. The classification and
sweets and candies, cakes, fruit drinks and juices examples of sweeteners are shown in Figure 12.2.
(not homemade), flavoured waters, dairy desserts
and several milk products, soups and sauces (not Total sugars
homemade), processed breakfast foods and Total sugars consist of all mono and disaccharides
smoothies, tea and coffee drinks, canned vegetables, that include glucose (dextrose), fructose, galactose,
industrial bread, hamburger buns, salad dressings, lactose (milk sugar), sucrose (table sugar) and
noodles and some alcoholic beverages (Marí, 2017). maltose. It is present in food, derived from any
source, including naturally occurring and free
Naturally occurring sugars sugars. KM12
Naturally occurring sugar is an integral component
of food, e.g., sugar in whole fruits, vegetables and

dairy products (Erickson and Slavin, 2015).
Total Sugar
All mono-and disaccharides present in food,
derived from any source including naturally
occurring (sugar in whole fruits, vegetables as
well as dairy product) and free sugar.
Free Sugar
Sugars added by the manufacturer, cook,
or the consumer as well as sugars that are
naturally present in honey, syrups, fruit/
vegetables juices and concentrates.
Added Sugar
Sugar that are not naturally found
in the food product and are added
to foods during processing,
culinary preparation, or during
meals.
Figure 12.1: Classification of sugars

[Source: Erickson & Slavin, 2015; Swan et al., 2018]
303
Sweeteners
Bulk High intensity (non

(nutritive sweeteners) nutritive sweeteners)
Low-caloric Synthethic
Caloric Natural
(sugar alcohols) (artificial)
Eg.: Sucrose, Eg.: Sorbitol, Eg.: Aspartame,

molasses, xylitol, acesulfame
KM12 honey, gula erythitol, potassium Eg.: Stevia
melaka, glucose, isomalt, (Ace-K), neotame,
fructose lacititol saccharin,
sucralose
Figure 12.2: Classification of sweeteners

[Source: Yebra-Biurrun, 2005; MOH, 1985]
12.2 Introduction
Malaysian dietary guidelines for children and fruit juice concentrates should be consumed less
adolescents was first published in 2013. (NCCFN, than 10% of total calorie intake. For example,
2013). Sugars are mono- or disaccharides, the children and adolescents with a calorie intake of
simplest form of carbohydrate. Monosaccharides 1600 kcal/day should limit their “free sugar” intake
include glucose, fructose, and galactose, while to only 40 grams or 160 kcal per day (one gram of
disaccharides include sucrose, lactose, and maltose. sugar equals 4 kcal).
Since sugars are carbohydrates, they provide energy
to virtually all cells in the body including the brain, Estimating and monitoring sugar intake at the
muscle, nervous system and red blood cells. For population level is challenging, partly because the
example, muscle cells take up blood sugar (known national foods composition database lacks data on
as blood glucose) and break it down in a series of free or added sugars. Hence, studies investigating
chemical reactions that create energy to fuel the sugar intake among the Malaysian population are
cells. In addition, the breakdown of sugar could also usually underreported and do not represent the
produce specific chemical structures for other actual amount consumed. For example, a
molecules in the cells such as DNA and RNA. nationwide survey such as Adolescent Nutrition
Survey (ANS) 2017 reported that, on average,
Sugars can be classified as “naturally occurring” or adolescents consumed only about 40.7 gram or 8
“free sugars”. Unlike naturally occurring sugars, free teaspoons of total sugar per day (IPH, 2018). This
sugars intake is more significant to health and well- value, however, could be well below the actual
being because exceeding the recommended intake as several sugar-containing foods or
amount could lead to health problems. According to beverages with unknown sugar contents were not
WHO (2015) guideline, the consumption of free included in the calculation of total sugar intake.
sugars that include “added sugars” and sugars Nevertheless, recent studies have evaluated sugar
naturally present in honey, syrups, fruit juices and contents in various local foods and beverages. These
304
data can be helpful when estimating total sugar in July 2019. These include i) Beverages including
intake of the population in future surveys. carbonated drinks containing added sugar or
flavoured and other sweetening matter which
Sugars are a common element in many foods and contains sugar exceeding 5g per 100 ml; ii) Fruit
food products. However, introducing new foods, juices and vegetable juices which contains sugar
especially with high sugar content, such as soft exceeding 12g per 100ml, and iii) Flavoured UHT
drinks, bubble tea, boba tea, sweets, cakes, and milk- based drinks which contain sugar exceeding
chocolates can encourage excessive sugar intake. It 7g per 100ml (Ministry of Finance Malaysia, 2018).
is where the health problems arise because the
excessive sugar intake can lead to weight gain, In the following sections, scientific evidence is
dental caries, poor diet quality, diabetes, outlined to show the linking between excess sugar
cardiovascular disease, and other metabolic intake and health problems as well as the status of
diseases. Cognizant of these problems, the sugar intake among children and adolescents. At
Malaysian government has taken a preventive step the end of this chapter, the Key Recommendations
to limit sugar intake by introducing an excise duty are presented with practical considerations on how
of RM0.40/litre on sweetened beverages to achieve them.
manufactured in the form of ready-to-drink starting
The focus of scientific evidence on sugars guidelines Dental caries is a multifactorial infectious disease
concerning health revolves around four main health involving teeth. Evidence has shown that even
issues: Sugar is the leading cause of dental caries, though multifactorial factors contribute to dental KM12
and a lower absolute sugar intake would result in an caries, sugars are the most important dietary factor
appreciable decrease in caries incidence. Sugar in developing dental caries. The interaction of acid-

increases overall energy intake, where producing bacteria in the oral cavity and
overconsumption could lead to weight gain, fermentable carbohydrates is the leading cause of
increased risk of metabolic syndrome, and type 2 dental caries (Tinanoff, 2019).
diabetes (T2DM). Sugar is also thought to have a
role in causing hyperactivity and other behavioural A systematic review on the relationship between
problems in children. In addition, overconsumption sugar and caries risk recommended the restriction
of sugar may reduce the intake of foods containing of sugar to prevent caries (Moynihan et al., 2019).
more nutritionally adequate calories and could The restriction should include the amount and
displace micronutrient-dense foods from the diet, frequency of sugar intake (van Loveren, 2019).
resulting in poor diet quality. This section also Limiting free sugars intake to less than 10% of total
discusses the relationship between artificial energy intake and ideally even further, to less than
sweeteners consumption and health outcomes. 5% may minimise the risk of dental caries
throughout the life course (WHO, 2017). As for
12.3.1 Dental caries frequency of intake, sugar intake more than four
times daily leads to an increased risk of caries
Dental caries remain a significant health problem (Rodrigues & Sheiham, 2000; WHO, 2015).
among Malaysian children and adolescents. Caries
prevalence among preschool children is still high Even though overwhelming evidence shows that
even though there is a continuous declining trend frequent consumption of sugars is associated with
from 76.2% in 2005 to 71.3% in 2015 (Oral Health the prevalence of dental caries, the relationship
Division, 2017). between dietary factors and dental caries is not
straightforward. Poor oral hygiene and the absence
The same declining trend is seen in the results of of fluoride also contribute to a higher incidence of
National Oral Health Survey for School children dental caries (Gomes Silva Cerqueira, 2021).
where caries prevalence among 12-year-old school
children had reduced from 41.5 % in 2007 to 33.3%
in 2017 (Oral Health Division, 2018). Carious tooth
leads to pain and infection, consequently affecting
the quality of life. Studies have shown that the daily
performance of children can be affected by dental
problems (Ruff et al., 2019).
305
12.3.2 Obesity overweight/ obese children but none of the normal-

weight children in a case-control study conducted
The Global Burden of Disease (GBD) Research in among 402 children living in metropolitan Kuala
2015 indicates the prevalence of obesity among Lumpur (Bee et al., 2011). While the Malaysian
children worldwide was only 5 percent, and Health and Adolescents Longitudinal Research
overweight and obesity combined is 23 percent Study (MyHeARTs) done among Form 1 students
(GBD, 2015; Ng et al., 2014). Whilst WHO reported aged 13 years old revealed that the prevalence of
that overweight and obesity among children and metabolic syndrome in this population was 2.6%.
adolescents aged 5-19 had risen dramatically from The prevalence was higher among males (3.4%)
4% in 1975 to over 18% in 2016. The rise has than females (2.1%). The study found no difference
occurred similarly among boys and girls, in which in the prevalence of metabolic syndrome in rural and
18% of girls and 19% of boys were overweight. The urban areas. Among the overweight and obese
prevalence of childhood obesity is increasing rapidly participants, the prevalence of metabolic syndrome
in Malaysia in tandem with increasing global was 10.0%. Overweight and obese males had a
prevalence. In Malaysia, childhood obesity (children higher rate of metabolic syndrome (11.9%) than
under 18 years) increased from 6.1 to 11.9 per cent females (8.7%) (Fadzlina et al., 2014).
between 2011 and 2015 (IPH, 2011; IPH, 2015). The
National Health and Morbidity Survey (NHMS) (IPH, Insufficient data specific to children and adolescents
2019) showed that 15.0% were overweight, with regarding the association of sugar consumption and
14.8% being obese among children 5-17 years of metabolic syndrome, but drawing from the general
age. Similarly, the Southeast Asian Nutrition Study population observation, high sugar intake may relate
(SEANUTS) revealed 14.4% overweight and 20.1% to a high risk of metabolic syndrome. It is unclear
KM12 obese among urban children aged 7 to 12 in six whether consuming sugar-sweetened beverages
regions in Malaysia (Poh et al., 2013). In the (SSB) is independently associated with the
MyBreakfast Study among 6-12 year-olds, the development of the metabolic syndrome. A
prevalence of overweight and obesity was 13.2% systematic review and meta-analysis from a total of
and 15.1%, respectively, whereas, among the 12 studies (eight cross-sectional, four prospective
adolescents, the prevalence of overweight and cohort studies) with 56 244 participants (age range
obesity were 15.5% and 13.2%, respectively (Tee et 6 to 98 years) revealed that soft drinks or sugar-
al.,2018). sweetened beverages (SSB) and artificially
sweetened beverages (ASB) intake are both
There is no clear evidence that sugar consumption associated with MetS (Narain et al., 2017). In
per se affects food intake and weight gain among contrast, the role of other important food sources of
children and adolescents. However, several studies fructose-containing sugars in the development of
have suggested that consuming soft drinks and MetS remains unclear. The meta-analysis suggests
other sweetened beverages, including fruit juices that the negative association of SSBs with MetS
with added sugars, may play a vital role in the does not extend to other food sources of fructose-
aetiology of obesity. A meta-analysis revealed that containing sugars, such as yoghurt, 100% fruit juice
even Sugar-Sweetened Beverages (SSB) are accused and mixed fruit juices (Semnani-Azad et al., 2020).
of being the leading cause of childhood obesity.
However, this subject requires a broader approach The multicentric European Childhood Obesity
that includes a thorough diet and lifestyle analysis Project Trial (CHOP) aimed to characterize the
and a more substantial body of scientific evidence association of dietary sugar intake with blood lipids
based on epidemiological studies conducted in and glucose-related markers in childhood at eight
different populations (Nissensohn et al., 2018). In years of age. The study concluded that increasing
contrast, another systematic review of prospective dietary total sugar intake in children, primarily from
cohort studies and randomized controlled trials sweetened beverages, was associated with
(RCTs) relating SSBs to weight measures indicates unfavourable effects on HDL-C, which might
that SSB consumption positively affects obesity increase the long-term risk for dyslipidemia and
indices in children and adults (Luger et al., 2017). cardiovascular disease (Aumueller et. al.,2021)
12.3.3 Metabolic syndrome 12.3.4 Prediabetes and Type 2 Diabetes

Mellitus
The prevalence of metabolic syndrome (MetS) in
children and adolescents is increasing, in parallel The childhood obesity epidemic has led to an
with the increasing trends in obesity rates. The increased incidence and prevalence of type 2
prevalence of MetS was found in 5.3% of the diabetes mellitus (T2DM) and prediabetes in youth
306
(Magge et al., 2020). There is limited prevalence data out and preferences for big portions of snack foods
on T2DM and prediabetes among children and and sugar-sweetened beverages had become a
adolescents in Malaysia. The Malaysian national trend among Malaysian children and adolescents
registry on children and adolescents with diabetes which proved to be a contributing factor to obesity.
reported that 17.5% had T2DM (Fuziah et al., 2008). Recent findings from ANS 2017 showed nearly 40-
Diet recommendation, including eliminating SSB, is 47% of Malaysian adolescents consumed fast food
essential in preventing and treating prediabetes and between one to six days a week (Lalitha et al., 2021).
T2DM (Magge et al., 2020; Kristen et al., 2016). Children are exposed to an ever-increasing number
of convenience and fast foods high in fat and sugar
12.3.5 Behaviour and cognitive function and are vulnerable to their appeal which may
contribute to the increased prevalence of
Dietary sugars (mainly sucrose) have been overweight and obesity among children (Leung et
considered a possible cause of hyperactivity and al., 2018). Children who consume SSBs have poorer
other behavioural problems in children. The possible diet quality and higher total energy intake than
explanations for the association between sucrose children who do not consume SSBs (Leung et al.,
and hyperactivity include a rise in blood sugar 2018).
shortly after ingestion, reactive hypoglycaemia
several hours after ingestion and an allergic In conclusion, public health interventions should
response (Wolraich et al., 1994). focus on reducing high sugar consumption of
children and adolescents which may contribute to
Nevertheless, the adverse effects of sucrose excess calories and poor diet quality. Consumption
consumption and their impact on behaviour among of sweetened dairy products and presweetened
children and adolescents have been inconclusive cereals was positively associated with the number KM12
and not consistently proved. A recent meta- analysis of dairy servings consumed per day for both age
suggests that an unhealthy diet which is high in groups. On average, consumption of sweetened

refined sugar and saturated fat can increase the risk dairy foods and beverages and presweetened
of attention deficit hyperactivity disorder (ADHD), cereals had a positive impact on children and
whereas a healthy diet, characterized by high adolescents' diet quality, whereas sugar-sweetened
consumption of fruits and vegetables, would protect beverages, sugars and sweets, and sweetened
against these outcomes. (Del-Ponte et al., 2019). grains had a negative impact on their diet quality.
Another meta-analysis found that carbohydrate
administration was associated with higher levels of 12.3.7 Relationship between non-nutritive
fatigue and less alertness compared with placebo sweeteners (NNS) consumption and
within the first hour post- ingestion (Mantantzis et health outcomes
al., 2019)
Non-nutritive sweeteners (also known as artificial
The lack of consistent data demonstrating the sweeteners and non-caloric sweeteners) are
behavioural or cognitive effects of sugar should frequently used in foods and beverages as a
warrant further investigation. This is important as complement to or replacement for sugar. NNS are
sucrose is a common component of children’s diets popular as they provide a lot of sweetness with little
and with the increasing trend of sugar consumption to no energy. People of all ages, particularly children
worldwide, any possible relation between sugar and are now using NNS (Schiano et al., 2021). According
behaviour is a major health concern. to the Malaysian Food Regulation 1985, there are
five artificial sweeteners that are permitted as
12.3.6 Poor dietary quality described in the Section 12.1.8. Although permitted,
increasing consumption with a larger quantity
Poor diet quality is a major cause of the global among children and adolescents requires
burden of disease. As a direct contributor to scrutinization of scientific evidence to refute or
maternal and child undernutrition, inadequate support their safety and benefits. It is important to
maternal and child dietary intakes are linked to 45% note that research on NNS is still scarce especially
of child deaths (Black et al., 2013). Throughout the in children and findings are inconsistent due to
entire life course, energy-dense and nutrient-poor methodological and reporting quality of studies
diets drive the global obesity epidemic (Popkin et al., conducted in humans (Toews et al., 2019). Besides,
2012). Several studies have found significant measuring the amount of NNS consumed at the
associations between the intake of added sugar and individual and population levels is difficult since the
micronutrient dilution in various populations manufactured products are not required to specify
(González-Padilla et al., 2020). The practice of eating the content of NNS in a product (Baker-Smith, 2019).
307
A recent review has suggested that consumption of sweet taste and subsequently caloric consumption.
NNS may contribute to poor metabolic Humans have an innate preference for sweet foods
consequences such as weight gain and obesity and repeated exposure and familiarization of NNS
(Shum & Georgia, 2021). Another systematic review use in children may be associated with a greater
and meta-analysis showed that NNS intake during preference for sweet foods (Ventura & Mennella,
childhood had a small but significant association 2011).
with increased body mass index (Karalexi et al.,
2018). Ironically, increased prevalence of childhood The effects of acute NNS ingestions on glucose
obesity is coincident with increasing trends in NNS homeostasis in clinical studies were inconsistent.
intake suggesting that NNS may promote the intake One study reported NNS intake impaired glucose
of sugary foods and drinks by affecting taste tolerance as indicated by higher peak plasma
preferences (Baker-Smith, 2019). Animal studies glucose concentration and insulin secretion rate.
suggest that alteration of cephalic phase in response Whilst two other studies reported either no
to sweet taste leading to overeating could explain differences in blood glucose and insulin level or
the possible mechanisms for the increased body lower blood glucose when ingesting NNS,
weight and obesity (Shum & Georgia, 2021). respectively (Shum & Georgia, 2021). Longitudinal
studies, however, did show increased risk of type 2
Sweet taste receptors on the tongue are activated diabetes with NNS consumption (Schiano et al.,
by sugar consumption. This signals the brain that 2021). In vitro models showed that acute exposure
calories are expected, triggering the cephalic phase of pancreatic beta cells to NNS boosted insulin
response. The cephalic phase response is a series of secretion in response to a glucose load (Shum &
anticipatory hormonal signals that increase insulin Georgia, 2021).
KM12 secretion, gastric enzyme production, and signalling
for satiety (Shum & Georgia, 2021). The same sweet On the flip side, there are also studies suggesting
taste receptors are activated by NNS, which also that NNSs can reduce weight gain or promote small
triggers the cephalic phase response. However, amounts of weight loss in children when NNS was
unlike sugar, the normal physiological response is substituted for caloric-sweetened foods or
disrupted because the sweet taste stimulus by NNS beverages. However, the reduction in body weight
is not followed by caloric intake. NNS consumption was only reported among those with the highest
does not satisfy the anticipatory Pavlovian baseline BMI. It is proposed that the use of NNS in
conditioning of the cephalic response, resulting in isolation is unlikely to lead to substantial weight
sweet signal activation and increased energy intake loss. In addition, NNS consumption has been
(Shum & Georgia, 2021). A study among students associated with reduced incidence of dental caries
aged 18-22 years old who were given one of three (Baker-Smith, 2019). Recent epidemiological studies
drinks (NNS-containing beverages, mineral water, or in healthy adults suggest that artificial sweeteners
regular beverages) reported that those who may have beneficial effects such as in reducing
consumed NNS felt less satisfied and were more hyperglycemia, improving lipid metabolism as well
likely to subsequently look for high-calorie foods as having antioxidant effects (Schiano et al., 2021).
(Hill et al., 2014). In another study, young adults While these seem to be promising, there are still
demonstrated preference for sweet snacks relative limited studies available on the benefits of artificial
to salty or savory snacks after consuming NNS- sweeteners in children and adolescents. In addition,
containing beverages than regular SSB-containing further research is also needed to determine the
beverages (Casperson et al., 2017). The possible long-term safety of NNS intake and provide future
explanation for this could be that the alteration of directions in research and policy.
cephalic response may lead to increased craving for
12.4 Current Status
The per capita sugar intake is defined as the raw has the highest per capita sugar consumption for
sugar consumption per person of a given country or the past twenty years (Figure 12.3). However,
territory (Weeratunga et al., 2014). In Malaysia, the sugar’s domestic consumption among Malaysians
sugar consumption per capita has increased about is considered lower compared to other Southeast
6.88kg from 2001 to 2021. Despite lower increment Asia countries as shown in Figure 12.4.
compared to other neighbouring countries, Malaysia
308
Sugar (RSE) Consumption Per Capita (kg)
60
51.99
50.54
49.72
50 47.58 48.26
45.11
42.97
39.05
40
36.14
32.88
31.11
30 23.61 27.53
25.71
23.42 23.02 22.46
20.01
22.93
20 18.52
16.77 16.20
15.05 14.75
11.62
10 KM12
2001 2006 2011 2016 2021
Thailand Philippines Vietnam Malaysia Indonesia

Figure 12.3: Sugar (Raw Sugar Equivalent, RSE) Consumption Per Capita (kg).
Source: OECD-FAO Agricultural Outlook 2012-2021 (2021)
Human Domestic Consumption (1,000 Metric Tan, Raw value

7,445 7,500
7,500 7,356
7,055
7,000
6,375
6,500
6,000
2,580
2,480 2,470
2,500
2,360 2,380
2,300 2,300
2,250 2,275
2,300
1,991 2,164 2.185

2,000 1,877
1,833 1,895
1,823
1,747 1,597 1,560
1,500
2017/18 2018/19 2019/20 2020/21 2021/22
Thailand Philippines Vietnam Malaysia Indonesia
Figure 12.4: World Centrifugal Sugar: Human Domestic Consumption (1,000 Metric Tons, Raw Value).
Source: USDA Foreign Agricultural Service (2021)
309
Table 12.1: Consumption of sugary confectionery and snacks among Malaysian adolescents
Median Intake
Percent
No. Food Items
Consumed (%) Serving Gram
(per day) (per day)
1. Candy 68.2 0.57 2.28
2. Dairy ice cream 64.3 0.10 5.91
3. Chocolate bar 57.5 0.07 2.85
4. Doughnut 55.7 0.14 7.83
5. Cake 55.6 0.07 6.89
6. Cream cookies 50.7 0.43 4.27
7. Ice beans/ cendol 48.9 0.05 13.13
8. Pau 48.8 0.14 7.12
9. Non-dairy ice cream 45.8 0.13 7.88
10. Kuih lapis 41.6 0.14 9.97
KM12 11. Kuih keria 24.2 0.16 7.38
Source: IPH, 2017

Sugar was the top five most consumed food items consumed sugary confectionery and snacks among
(77.9%) among adolescents in Malaysia (IPH 2017). adolescents in Malaysia are shown in Table 12.1.
A nationwide study of Adolescent Nutrition Survey
(ANS) 2017 found that sugars intake in adolescents There has been an increasing interest in sugar-
increased from 29.5 g/day in 2012 to 40.7 g/day in sweetened beverages (SSBs) consumption among
2017. The habitual intake of sugars was once daily Malaysian children and adolescents in recent years.
at an average of about 6 grams per day (IPH, 2018). In terms of standard measures, one serving of SSBs
Furthermore, it was reported that the mean intake is equal to one cup or 250 ml. Findings from ANS
for sugar in 999 adolescents aged 13 to 17 years old 2017 showed that about 98.0% Malaysian
was (51.1 g/day), with the male having significantly adolescents (n=2021) aged 10 to 17 years consumed
higher sugar intakes (55.4 g/day) than female some SSB with the median intake was 345.1 ml/day
adolescents (47.4 g/day) (Palaniveloo et al., 2021). (1.4 cups/day). In this study, male adolescents
However, findings from MyHeARTs Study significantly consumed more SSBs than females (1.5
(Malaysian Health and Adolescents Longitudinal vs. 1.3 cups/day) (Salleh et al., 2021). Surprisingly, a
Research Team Study) involving 794 adolescents study among 421 adolescents (12 - 16 years) in
aged 13 years old indicated lower mean intake for Gombak, Selangor reported a higher mean of SSBs
sugar (34.3 g/day). In addition, both male and female consumption (1038 ml/day) with the most popular
adolescents in this study had similar amounts of SSBs was malted drinks followed by milk and tea
sugar intakes with 34.7 and 34.1 g/day, respectively (Gan et al., 2019). In contrast, a lower mean of SSBs
(Abdul Majid et al., 2016). consumption (177.5 ml/day) was reported in the
earlier study among 873 adolescents (aged 13 years)
In MyBreakfast study, total sugar intakes in 1819 in Kuala Lumpur (Loh et al., 2017). Research on SSBs
children aged 6 to 12 years appeared to be consumption among preschoolers (n=590, aged 3 –
significantly higher in children who consumed 6 years) in Kota Bharu, Kelantan showed that about
ready-to-eat cereals (RTEC) than those who did not 61.2% of the children consumed SSBs weekly with
(41.7 g/day vs. 32.5 g/day) (Nasir et al., 2017). A the frequency of 5.0 times/week. The most common
small-scale study by Tan et al. (2020), reported that SSBs were sugar-added drinks (coffee, tea, flavoured
the average daily sugar intake from ready-to drink & malted drinks) followed by carbonated soda
sugar-sweetened beverages (RTD- SSB) was 26.6 g beverages, fruit-flavoured drinks (concentrated fruit
among 126 adolescents aged between 9-11 years juices with sweetener, juice cordial), and flavoured
old. Percentage and median intake of mostly milk drinks.
310
A report from ANS 2017 demonstrated that one in It has been recommended that free sugars intake be
three Malaysian students had carbonated soft drinks reduced at all stages of life to less than 10% of total
at least once daily. The report also showed that energy intake (WHO, 2015). At 1600 calorie intake,
malted drinks, ready-to-drink tea, flavoured the recommended intake of free sugars equals a
carbonated and cordial drinks were the most maximum of 40 g or 8 teaspoons (tsp) of sugars per
consumed beverages among adolescents (IPH, day (1 tsp = 5 gram = 20 kcal). Table 12.3 shows the
2017). These findings suggest that the trends in recommended free sugar limits which are estimated
SSBs consumption among Malaysian children and from energy requirements as recommended for
adolescents are at an alarming rate. These drinks are Malaysian children and adolescents. For children
known to contain high amount of sugars and aged 4 – 6 years, PAL 1.4 is recommended to be
therefore, may increase the risks of non- used for the general population. Meanwhile for
communicable diseases at an early age. List of children above 7 years and adolescents, PAL of 1.6
commonly consumed beverages by Malaysian (i.e. moderately active) is recommended to be used
adolescents are shown in Table 12.2. for the general population (NCCFN, 2017).
Table 12.2: Consumption of beverages among Malaysian adolescents
Median Intake
Percent
No. Food Items
Consumed (%) Serving Gram
(per day) (per day)
1. Malted drinks 80.0 0.85 99.66

KM12
2. Tea, ready to drink 75.2 0.85 85.42
3. Carbonated drinks 60.8 0.20 34.45

4. Various flavoured cordial drinks 54.6 0.57 71.18
5. Fruit juice 48.7 0.28 35.59
6. 3 in 1 ready to drink 35.4 0.14 4.27
7. Ice blended 34.8 0.20 19.69
8. Coffee, ready to drink 26.4 0.28 28.47
Source: IPH, 2017
Table 12.3: Recommended free sugars limit
Male Female
Age group Energy Energy

Gram Gram
Requirement Requirement
(teaspoon) (teaspoon)
(kcal/day)a (kcal/day)a
Children
1 – 3 years 980 24.5 g (5 tsp)b 900 22.5 g (4 ½ tsp)b
4 – 6 years 1490 37.3 g (7 ½ tsp) 1380 34.5 g (7 tsp)
7 – 9 years 1750 43.8 g (8 ¾ tsp) 1610 40.3 g (8 tsp)
Adolescents
10 -12 years 1930 48.3 g (9 ¾ tsp) 1710 42.8 g (8 ½ tsp)
12 – 15 years 2210 55.3 g (11 tsp) 1810 45.3 g (9 tsp)
16 – 18 years 2340 58.5 g (11 ¾ tsp) 1890 47.3 g (9 ½ tsp)
RNI 2017, bbased on PAL of 1.4 (low active). 1 teaspoon = 5 grams sugar = 20 kcal.
a
311
It is important to note that, since free sugars include Currently, the information about sugar content of
added sugars and sugars that are naturally present foods particularly local and traditional foods in
in honey, syrups, fruit and vegetable juices, Malaysia are still limited. Most data are obtained
concentrates and purées, thus, the intake of added from published articles since the national nutrient
sugars should be lower than free sugars. Sugars database (Malaysian Food Composition Database,
intake can be estimated using a teaspoon where 1 MyFCD) only covered a limited number of foods and
teaspoon equals to 5 grams of sugar. Figure 12.5 nutrients of which does not include sugar. Appendix
illustrates the proportion of free sugar ingredients, 12.1 to 12.5 provide list of sugar content of selected
sweeteners, a combination of both or neither in foods and beverages that were adopted from
prepackage foods and beverages based on major Malaysian Dietary Guideline 2020 which based on
food group and overall (Bernstein et al., 2016). several published articles conducted in Malaysia
(Sabeetha, Amin & Barakatun Nisak, 2017; Norhayati
et al., 2018; Rosmawati et al., 2018; Chong et al.,
2019).
100%
12% 21% 23% 12% 28% 27% 43% 44% 46% 54% 58% 64% 70% 82% 83% 33%
80%
Proportion ( % )
KM12
60%
40%
20%
94% 91% 83% 78% 77% 72% 72% 72% 57% 55% 49% 46% 39% 31% 29% 18% 17% 64%
0%
Vegetables
Bakery Products
Beverages
Meat & Alt.

Desserts
Sugars & Sweets
Mixed Dishes
Fish & Seafood

Soups
Sauces & Dips
Snacks
Others
Fruits
Fats & Vinegars
Cereals & Grains
Nuts & Seeds

Dairy & Alt.
Total
Major food group

Free Sugar Ingredients Sweetener Both Neither
Figure 12.5: Distribution of free sugar ingredients, sweeteners, a combination of both or neither in
prepackage foods and beverages
Source: Bernstein et al. (2016)
312
Key Recommendation (KR) 1: Instill a preference for a less sweet taste.
Civil Society
General Organization/
Parents/ Caregiver Health Professional
(to children and adolescents) Non-Governmental
Organization

Reduce sugar during Do not add sugar when Educate and provide Refrain from giving
food preparation. preparing training on preparation sugary foods and
complementary foods. of complementary foods beverages such as ice
with no added sugar. cream, chocolate,
candy, cotton candy,
cupcakes, bubble tea
and boba drinks as
rewards to children.
KR1: HTA2: KR1: HTA2: KR1: HTA2: - KM12

Request for beverages Do not introduce sugary Educate and provide
low in sugar when foods and beverages training on preparation

eating out. such as ice cream, of foods and beverages
chocolate, cakes, with low sugar.
doughnuts, cordial
drinks, flavoured drinks,
tea and coffee to
children below the age
of 2.
- KR1: HTA3: - -
Provide or prepare
packed foods and
beverages with low
sugar for school
children.
- KR1: HTA4: - -
Refrain from giving
sugary foods and
beverages such as ice
cream, chocolate, candy,
cotton candy, cupcakes,
bubble tea and boba
drinks as rewards to
children.
313
Key Recommendation (KR) 2: Eat foods low in sugars.
Civil Society
Parents/ Health
(to children and Teacher Non-
adolescents) Caregiver Professional
Governmental
Organization

Choose or prepare cereals, biscuits, Do not allow ultra-processed and sugary Educate on
cookies, kuih and cakes with less sugar. foods to be sold in the school compound different types of
(such as sweets, chocolates, sweet sweeteners such
pickle, food with cream/ coated with as total sugars,
sugar, ice confectionery product and ice free sugar,
cream). added sugar,
hidden sugar
and artificial
sweeteners.

KM12 Replace sweet desserts such as sweet Advocate for serving more fresh foods
puddings, cookies and cakes with fresh such as fruits and boiled/ steamed
fruits, yogurt, steamed corn, boiled groundnuts in the school compound.
chickpeas, or steamed groundnuts.
KR2: HTA3: KR2: HTA3: KR2: HTA3: -

Reduce the frequency of consuming Educate on Encourage
sugary foods (such as ice cream, different types of involvement of
chocolate, biscuit, bun with cream/ sweeteners such Parents Teachers
filling/ icing, spreads such as kaya and as total sugars, Association (PTA)
jam) and limit them to smaller portions. free sugar, added in monitoring of
sugar, hidden sugar sugary foods sold
and artificial in the school
sweeteners. compound.

Avoid adding table sugar/ honey/ Educate and
syrup to your meal. provide training on
preparation of
foods less in sugar
for canteen/
restaurant
operators.

Avoid consuming sugary foods as a Educate on how to
snack. read food labels
and Healthier
Choice Logo (HCL).
KR2: HTA6: - - -
Avoid stocking up foods that are high in
sugar at home such as ice cream,
chocolate and candy.
314
Key Recommendation (KR) 2: Eat foods low in sugars. (cont.)
Civil Society
Parents/ Health
(to children and Teacher Non-
adolescents) Caregiver Professional
Governmental
Organization
KR2: HTA7: - - -
Read food labels to choose foods that
are low in sugar or look for Healthier
Choice Logo (HCL).
KR2: HTA8: - - -
Avoid intake of foods that sugar is listed
as the first ingredient in the ingredient
list on the food label and look for hidden
sugar such as glucose, sucrose,
maltose and corn syrup.
KM12
Key Recommendation (KR) 3: Drink beverages low in sugars.

General Parents/ Caregiver Health Professional Teachers


Always choose plain water. Educate on how to Advocate to drink plain
read food labels and water in schools by
Healthier Choice Logo providing water
(HCL). dispensers.

Choose milk and soy milk with no added sugar or Do not allow sweetened Encourage
cultured milk that are lowin sugar. beverages to be sold in involvement of Parents
the school compound Teachers Association
(such as prepared or (PTA) in monitoring of
topped with cordial/ sugary beverages sold
flavoured syrup/ in the school
sweetened creamer/ compound.
instant 3 in 1 powder/
sweetened powder/
whipping cream).
KR3: HTA3: -
Avoid intake of sugar-sweetened beverages such
as bubble tea, boba drinks, energy drinks, coffee,
teh tarik, chocolate drinks, carbonated drinks,
cordial drinks, premix.
KR3: HTA4: -
Avoid consuming sugary beverages between
meals.
315
Key Recommendation (KR) 3: Drink beverages low in sugars. (cont.)
General Parents/ Caregiver Health Professional Teachers

KR3: HTA5:
Avoid stocking up beverages that are high in - -
sugar at home such as carbonated drink,
energy drinks and packed sugary drinks.
KR3: HTA6:
Read food labels to choose beverages that are - -
low in sugar or look for Healthier Choice Logo
(HCL).
KR3: HTA7:
Avoid intake of beverages that sugar is listed as - -
the first ingredient in the ingredient list on the food
label and look for hidden sugar such as glucose,
sucrose, maltose and corn syrup.
KM12
12.5.1 Additional Recommendations
AR1: Avoid consuming foods and beverages with non-nutritive sweeteners (NNS) to instill a
preference for a less sweet taste.
AR2: Practise good and proper oral hygiene habits to prevent dental caries.
Practise good and proper oral hygiene habits
While sugar consumption pattern (amount and time of the day. Toothbrushing should be done with
frequency) has been shown to be associated with fluoridated toothpaste and proper brushing
dental caries formation, poor oral hygiene and technique. When using fluoridated toothpaste for
absence of fluoride in toothpaste are also factors young children, parents should ensure that the
that contribute to the development of tooth decay amounts given are suitable to the children's age.
(Moynihan et al., 2019). Since young children have limited hand dexterity,
parents are encouraged to brush their children’s
Good and proper oral hygiene should start at the teeth until the age of 8 (AAPD, 2017).
very beginning of a child’s life to prevent tooth
decay and good oral hygiene practice remains Parents play an important role to ensure their
important as children grow into adolescence. Proper children's dental health. Parents are recommended
and good oral hygiene habits can be achieved by to take their children for dental check-ups as early
ensuring that children brush their teeth at least as 6 months old and schedule yearly regular dental
twice daily, once before bedtime and once at any visits for preventive care (AAPD, 2017).
316
12.6 References
AAPD (2017) American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient.
Pediatr Dent. 39(6):246–259.
Abdul Majid, H., Ramli, L., Ying, S.P., Su, T.T., Jalaludin, M.Y. and Abdul Mohsein, N.A.S., (2016). Dietary intake
among adolescents in a middle-income country: an outcome from the Malaysian Health and
Adolescents Longitudinal Research Team Study (the MyHeARTs Study). PloS one, 11(5), p.e0155447.
Aditya Narain, Chun Shing Kwok,Mamas A. Mamas (2017). Soft drink intake and the risk of metabolic
syndrome: A systematic review and meta-analysis. Clinical Practice. Vol 71(2).
https://doi.org/10.1111/ijcp.12927
Aumueller N, Gruszfeld D, Gradowska K, Escribano J, Ferré N, Martin F, Poncelet P, Verduci E, · ReDionigi A,

Koletzko B, Grote V. (2021) Infuence of total sugar intake on metabolic blood markers at 8 years of
age in the Childhood Obesity Project. European Journal of Nutrition. 60:435–442.
Baker-Smith CM, de Ferranti SD, Cochran WJ, (2019) AAP Committee on Nutrition, Section on
Gastroenterology, Hepatology, and Nutrition. The Use of Nonnutritive Sweeteners in Children.
Pediatrics. 2019;144(5):e20192765.
Bee S Wee, Bee K Poh, Awang Bulgiba, Mohd N Ismail, Abdul T Ruzita & Andrew P Hills. (2011). Risk of
metabolic syndrome among children living in metropolitan Kuala Lumpur: A case control study. BMC KM12
Public Health, 11:333.

Bernstein JT, Schermel A, Mills CM, L'Abbé MR. (2016) Total and Free Sugar Content of Canadian
Prepackaged Foods and Beverages. Nutrients. Sep 21;8(9):582. doi: 10.3390/nu8090582. PMID:
27657125; PMCID: PMC5037566.
Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., De Onis, M., Ezzati M, McGregor S. G.,
Katz J., Martorell R., Uauy R. & Maternal and Child Nutrition Study Group. (2013). Maternal and child
undernutrition and overweight in low-income and middle-income countries. The Lancet, 382(9890),
427-451.
Casperson SL, Johnson L, Roemmich JN. (2017) The relative reinforcing value of sweet versus savory snack
foods after consumption of sugar- or non-nutritive sweetened beverages. Appetite. 2017; 112:143–
149.
Channel News Asia (2020). https://www.channelnewsasia.com/news/singapore/bubble-tea-sugar-content-

sweeter-than-coke-soda-11063316. Accessed on 6th February 2020.
Chong CP, Hasnah H Suzana S & Mohd Fairulnizal MN (2019). Individual sugars contents in cooked dishes,
processed foods, fruits and beverages commonly consumed by Malaysian. J Food Composition and
Analysis.
Del-Ponte, B., Quinte, G. C., Cruz, S., Grellert, M., & Santos, I. S. (2019). Dietary Patterns and Attention
Deficit/Hyperactivity Disorder (ADHD): A Systematic Review And Meta-Analysis. Journal Of Affective
Disorders, 252, 160-173.
Erickson J & Slavin J (2015). Total, added, and free sugars: Are restrictive guidelines science-based or
achievable? Nutrients 7(4):2866-2878.
Fadzlina AA, Fatimah Harun , Nurul Haniza MY, Al Sadat N, Murray L, Cantwell MM, Tin Tin Su, Majid HA,
Jalaludin MY. (2014) Metabolic syndrome among 13 year old adolescents: prevalence and risk factors.
BMC Public Health, 14(Suppl 3):S7.
317
Fuziah, M. Z., Hong, J. Y., Zanariah, H., Harun, F., Chan, S. P., Rokiah, P., & Adam, B. (2008). A national database
on children and adolescent with diabetes (e-DiCARE): results from April 2006 to June 2007. Med J
Malaysia, 63(Suppl C), 37-40.
Gan, W.Y., Mohamed, S.F. and Law, L.S., (2019). Unhealthy lifestyle associated with higher intake of sugar-
sweetened beverages among Malaysian school-aged adolescents. International Journal of
environmental research and public health, 16(15), p.2785.
GBD (2015). Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79
behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: A
systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016, 388, 1659.
Gomes Silva Cerqueira, A., Barauna Magno, M., Barja Fidalgo, F., Vicente Gomila, J., Cople Maia, L., &
Fonseca Gonçalves, A. (2021). Recommendations From Paediatric Dentistry Associations Of The
Americas On Breastfeeding And Sugar Consumption And Oral Hygiene In Infants For The Prevention
Of Dental Caries: A Bibliometric Review. International Journal of Paediatric Dentistry.
González-Padilla, E., A. Dias, J., Ramne, S. (2020). Association between added sugar intake and micronutrient
dilution: a cross-sectional study in two adult Swedish populations. Nutr Metab (Lond) 17, 15 (2020).
https://doi.org/10.1186/s12986-020-0428-6
Hill, S.E., Prokosch M.L., Morin, A., & Rodeheffer. 204. The effect of non-caloric sweeteners on cognition,
KM12 choice, and post-consumption satisfaction. Appetite. Vol 83. Page: 82-88.
IPH (2011). National Health and Morbidity Survey (NHMS) 2011: Vol. II: Non-Communicable Diseases
Technical Report; National Institutes of Health, Ministry of HealthMalaysia. Selangor Darul Ehsan,
Malaysia,
IPH (2015). National Health and Morbidity Survey (NHMS) 2015: Vol. II: Non- Communicable Diseases, Risk
Factors & Other Health Problem; Technical Report; National Institutes of Health, Ministry of Health
Malaysia. Selangor Darul Ehsan, Malaysia..
IPH (2017). National Health and Morbidity Survey (NHMS) 2017: Adolescent Nutrition Survey 2017, Institute
of Public Health (IPH)Malaysia. Kuala Lumpur, Malaysia. Available at:
http://iku.gov.my/images/IKU/Document/REPORT/NHMS2017/NutritionSurveyNHMS2017.pdf
IPH (2018). National Health and Morbidity Survey 2017: Key Findings from the Adolescent Health and
Nutrition Surveys. Institute for Public Health (IPH)Kuala Lumpur, Malaysia. Available at:
http://iku.gov.my/images/IKU/Document/REPORT/NHMS2017/NHMS2017Infographic.pdf
IPH (2019). NHMS (2019). National Health and Morbidity Survey Vol. I: NCDs-Non- Communicable Diseases:
Risk Factors and Other Health Problem; Technical Report; National Institutes of Health, Ministry of
Health Malaysia.Selangor Darul Ehsan, Malaysia.
Karalexi, M. A., Mitrogiorgou, M., Georgantzi, G. G., Papaevangelou, V., & Fessatou, S. (2018). Non-nutritive
sweeteners and metabolic health outcomes in children: A systematic review and meta-analysis. The
Journal of pediatrics, 197, 128-133.
Kristen J. Nadeau, Barbara J. Anderson, Erika G. Berg, Jane L. Chiang, Hubert Chou, Kenneth C. Copeland,
Tamara S. Hannon,Terry T.-K. Huang, Jane L. Lynch, Jeff Powell, Elizabeth Sellers, William V.
Tamborlane, and Philip Zeitler. (2016). Youth-Onset Type 2 Diabetes Consensus Report: Current Status,
Challenges, and Priorities Diabetes Care;39:1635–1642.
Lalitha Palaniveloo, Ruhaya Salleh, Azli Baharudin, Cheong Siew Man, Mohamad Hasnan Ahmad, Nur
Shahida Abd Aziz, Syafinaz Sallehudin. (2021). Associations of Gender and BMI- for-age Status (BAZ)
With Nutrient Intake Among Adolescents in Malaysia: Findings From Adolescent Nutrition Survey
(ANS) 2017 Malaysian Journal of Medicine and Health Sciences (eISSN 2636-9346)
318
Leung CW, DiMatteo SG, Gosliner WA, Ritchie LD. (2018). Sugar-Sweetened Beverage and Water Intake in
Relation to Diet Quality in U.S. Children. Am J Prev Med; 54(3):394-402.
Loh, D.A., Moy, F.M., Zaharan, N.L., Jalaludin, M.Y. and Mohamed, Z., (2017). Sugar sweetened beverage
intake and its associations with cardiometabolic risks among adolescents. Pediatric obesity, 12(1),
pp.e1-e5.
Luger, M., Lafontan, M., Bes-Rastrollo, M., Winzer, E., Yumuk, V., & Farpour-Lambert, N. (2017). Sugar-
sweetened beverages and weight gain in children and adults: a systematic review from 2013 to 2015
and a comparison with previous studies. Obesity facts, 10(6), 674-693.
Magge, S. N., Silverstein, J., Elder, D., Nadeau, K., & Hannon, T. S. (2020). Evaluation and treatment of
prediabetes in youth. The Journal of pediatrics, 219, 11-22.
Mantantzis, K., Schlaghecken, F., Sünram-Lea, S. I., & Maylor, E. A. (2019). Sugar rush or sugar crash? A
meta-analysis of carbohydrate effects on mood. Neuroscience & Biobehavioral Reviews, 101, 45-67.
Malmö University (2020). (https://capp.mau.se/country-areas/) (Accessed on 4 October 2020
Marí JAT (2017). Hidden sugar in food: A risk for health. J Clin Nutr Diet 3:5.
Mela, D. J., & Woolner, E. M. (2018). Perspective: total, added, or free? What kind of sugars should we be
talking about?. Advances in Nutrition, 9(2), 63-69 KM12
MOF (2018). Budget 2019. Ministry of Finance Malaysia. Percetakan Nasional Malaysia Berhad. 1-90.

Mortensen A (2006). Sweeteners permitted in the European Union: safety aspects. Scandinavian Journal of
Food and Nutrition, 50:3, 104-116, DOI:10.1080/17482970600982719
MOH (1985). Food Regulation 1985. Department of Public Health, Ministry of Health Malaysia, Kuala Lumpur.
Moynihan, P., Tanner, L. M., Holmes, R. D., Hillier-Brown, F., Mashayekhi, A., Kelly, S. A. M., & Craig,
D. (2019). Systematic Review of Evidence Pertaining To Factors That Modify Risk of Early Childhood
Caries. JDR Clinical & Translational Research, 4(3), 202-216.
Narain, A., Kwok, C. S., & Mamas, M. A. (2017). Soft drink intake and the risk of metabolic syndrome: A
systematic review and meta analysis. International journal of clinical practice, 71(2), e12927.
Nasir, M.T.M., Nurliyana, A.R., Norimah, A.K., Mohamed, H.J.B.J., Tan, S.Y., Appukutty, M., Hopkins, S.,
Thielecke, F., Ong, M.K., Ning, C. and Tee, E.S., 2017. Consumption of ready-to-eat cereals (RTEC)
among Malaysian children and association with socio-demographics and nutrient intakes– findings
from the MyBreakfast study. Food & nutrition research, 61:1, DOI: 10.1080/16546628.2017.1304692
NCCFN (2017). Recommended Nutrient Intakes for Malaysia (RNI, 2017). National Coordinating Committee
on Food and Nutrition Ministry of Health Malaysia, Putrajaya. Available at:
https://nutrition.moh.gov.my/wp-content/uploads/2017/05/FA-Buku-RNI.pdf`
Ng, M.; Fleming, T.; Robinson, M.; Thomson, B.; Graetz, N.; Margono, C.; Mullany, E.C.; Biryukov, S.; Abbafati,
C.; Abera, S.F (2014). Global, regional, and national prevalence of overweight and obesity in children
and adults during 1980–2013: A systematic analysis for the Global Burden of Disease Study 2013.
Lancet 2014, 384, 766–781.
Nissensohn, M., Fuentes-Lugo, D., & Serra-Majem, L. (2018). Sugar-sweetened beverage consumption and
obesity in children's meta-analyses: wrong answers to right questions. Nutrición Hospitalaria, 35(2),
474-488.
319
Norhayati MK, Mohd Fairulnizal MN, Mohd Naeem MN, Nazline MK, Aswir AR, Wan Sulong WO, Norliza
AH, Janarthini S & Rusidah S (2018). Individual and total sugar contents of 83 Malaysian foods.
Journal of Food Research, 7: 3.
Oral Health Division, Ministry of Health Malaysia. (2017) National Health and Morbidity Survey 2017:
National Oral Health Survey of Schoolchildren 2017 (NHMS 2017: NOHSS 2017). Vol. II:Oral Health
Status of 12-year-old Schoolchildren. September 2017.
Oral Health Division. (2018). National Oral Health Survey for School children 2017. Putrajaya: Ministry of
Health.
Palaniveloo, L., Salleh, R., Baharudin, A., Man, C.S., Ahmad, M.H., Abd Aziz, N.S. and Sallehudin, S.. (2021).
Associations of Gender and BMI-for-age Status (BAZ) With Nutrient Intake Among Adolescents in
Malaysia: Findings From Adolescent Nutrition Survey (ANS) 2017. Mal J Med Health Sci 17(1): 10-16.
Poh, B.K.; Ng, B.K.; Haslinda, M.D.S.; Shanita, S.N.; Wong, J.E.; Budin, S.B.; Ruzita, A.T.; Ng, L.O.; Khouw, I.;
Norimah, A.K. (2013). Nutritional status and dietary intakes of children aged 6 months to 12 years:
Findings of the Nutrition Survey of Malaysian Children (SEANUTS Malaysia). Br. J. Nutr. 2013, 110,
S21–S35. [CrossRef].
Popkin, B. M., Adair, L. S., & Ng, S. W. (2012). Global nutrition transition and the pandemic of obesity in
developing countries. Nutrition reviews, 70(1), 3-21.
KM12
Rachel BA, Lana V, Erin PH & David H (2017). Added sugar in the packaged foods and beverages available
at a major Canadian retailer in 2015: A descriptive analysis. CMAJ Open, 5(1).
Rodrigues, C. S., & Sheiham, A. (2000). The relationships between dietary guidelines, sugar intake and caries
in primary teeth in low income Brazilian 3-year-olds: A longitudinal study. International Journal of
Paediatric Dentistry, 10(1), 47–55.
Rosmawati D, Hasnah H, Suzana S, Chong CP, Muhamad Fikri MF & Mohd Fairulnizal MN (2018).
Macronutrients and sugar content in foods and beverages from three selected zones in Peninsular
Malaysia. Sains Malaysiana, 47(7):1557–1562.
Ruff, R.R., Senthi, S., Susser, S.R. and Tsutsui, A., (2019). Oral Health, Academic Performance, And School
Absenteeism In Children And Adolescents: A Systematic Review And Meta-Analysis. The Journal of
the American Dental Association, 150(2), pp.111-121.
Sabeetha S, Amin I & Barakatun Nisak MY (2017). Physico-chemical characteristics of watermelon in

Malaysia. J. Trop.Agric. and Fd. Sc 45(2):209-223.
Salleh, R., Zainuddin, A.A., Yusof, S.M., Man, C.S., Ahmad, M.H., Aziz, N.S.A., Palaniveloo, L., Baharudin, A.
and Wong, N.I., (2021). Factors associated with sugar-sweetened beverages consumption among
Malaysian adolescents: findings from the Adolescent Nutrition Survey 2017. Malaysian Journal of
Nutrition, 27(1).
Schiano, C., Grimaldi, V., Scognamiglio, M., Costa, D., Soricelli, A., Nicoletti, G. F., & Napoli, C. (2021). Soft
drinks and sweeteners intake: Possible contribution to the development of metabolic syndrome and
cardiovascular diseases. Beneficial or detrimental action of alternative sweeteners? Food Research
International, 142, 110220.
Semnani-Azad, Z., Khan, T. A., Mejia, S. B., de Souza, R. J., Leiter, L. A., Kendall, C. W., ... & Sievenpiper, J. L.
(2020). Association of major food sources of fructose-containing sugars with incident metabolic
syndrome: a systematic review and meta-analysis. JAMA network open, 3(7), e209993-e209993.
Sheela N. Magge, Janet Silverstein, Deborah Elder, Kristen Nadeau,Tamara S. Hannon. (2020). Evaluation
and Treatment of Prediabetes in Youth. J Pediatr. 2020 April; 219: 11–22.
320
Shum, B., & Georgia, S. (2021). The Effects of Non-Nutritive Sweetener Consumption in the Pediatric
Populations: What We Know, What We Don’t, and What We Need to Learn. Frontiers in Endocrinology,
12, 272.
Swan GE, Powell NA, Knowles BL, Bush MT and Levy LB (2018). A definition of free sugars for the UK.
Public Health Nutrition: 21(9), 1636–1638.
Tan, S. T., Zaini, N. A. N. A., Tan, S. S., & Tan, C. X. (2020). Gender and body weight status differences in the
consumption frequency, choice and sugar intake of ready-to-drink sugar-sweetened beverages.
British Food Journal, 122 (10).
Tee ES, Nurliyana AR, Norimah AK, Mohamed HJBJ, Tan SY, Appukutty M et al. Breakfast consumption
among Malaysian primary and secondary school children and relationship with body weight status
– Findings from the MyBreakfast Study. Asia Pac J Clin Nutr 2018; 27 (2):421-432.
Tinanoff, N. (2019). Dental Caries. Pediatric Dentistry (pp. 169-179).
Toews, I., Lohner, S., Küllenberg de Gaudry, D., Sommer, H., & Meerpohl, J. J. (2019). Association between
intake of non-sugar sweeteners and health outcomes: Systematic review and meta-analyses of
randomised and non-randomised controlled trials and observational studies. BMJ, 364, Article k4718.
https://doi.org/10.1136/bmj.k4718.
US FDA (2014). How to Understand and Use the Nutrition Facts Label. U.S. Food and Drug Administration, KM12
US.

USDA Foreign Agriculture Service (2021). Sugar: World Markets and Trade. Available at: The USDA
Economics, Statistics and Market Information System, ESMIS
https://usda.library.cornell.edu/concern/publications/z029p472x?locale=en (Accessed on 11 January
2022).
van Loveren, C., (2019). Sugar restriction for caries prevention: amount and frequency. Which is more
important? (, 53(2), pp.168-175.
Ventura AK, Mennella JA. Innate and learned preferences for sweet taste during childhood. Curr Opin Clin
Nutr Metab Care. 2011;14(4):379–384
Yebra-Biurrun MC (2005). Sweeteners: Encyclopedia of Analytical Science. 2nd ed. Elsevier.
Weeratunga, P., Jayasinghe, S., Perera, Y. et al. Per capita sugar consumption and prevalence of diabetes
mellitus – global and regional associations. BMC Public Health 14, 186 (2014).
https://doi.org/10.1186/1471-2458-14-186.
WHO (2015). Guideline: Sugars Intake for Adults and Children. World Health Organization, Geneva.
World Health Organization. (2017). Sugars and dental caries (No. WHO/NMH/NHD/17.12). World Health
Organization.
WHO (2021) Obesity and Overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-

overweight.
Wilson T, Murray B, Price T, Atherton D, Hooks T (2019). Non-Nutritive (Artificial) Sweetener Knowledge
among University Students. Nutrients 11, 2201.
Winpenny EM, Penney TL, Corder K, White M, Van Sluijs EMF (2017). Changes in consumption of added
sugars from age 13 to 30 years: A systematic review and meta-analysis of longitudinal studies. Obesity
Reviews 18, 1336.
321
Wolraich, M. L., Wilson, D. B., & White, J. W. (1994). The Effect Of Sugar On Behavior Or Cognition In Children:
A Meta-Analysis. JAMA, 274(20), 1617-1621.
Zhila Semnani-Azad, Tauseef A. Khan, Sonia Blanco Mejia, Russell J. de Souza, Lawrence A. Leiter, Cyril W.
C. Kendall, Anthony J. Hanley, John L. Sievenpiper. (2020). Association of Major Food Sources of
Fructose-Containing Sugars With Incident Metabolic Syndrome A Systematic Review and Meta-
analysis. JAMA Network Open. 2020;3(7): e209993. doi:10.1001/jamanetworkopen.2020.9993.
KM12
322
Appendices
Appendix 12.1: Total sugars content in selected local kuih
Household Household
Total Total
measurement measurement
Type of food Sugars Type of food Sugars
equivalent equivalent
(g/100g) (g/100g)
Local Kuih Local Kuih
Kuih keria 24.8 4.96 Putu piring 12.7 2.54
Bingka ubi 21.5 4.3 Kuih koci 12.1 2.42
Cekodok pisang 21.1 4.22 Cucur badak 11.9 2.38
Pau Kaya 19.2 3.84 Kuih tepung pelita 11.4 2.28
Kuih peneram 18.6 3.72 Pengat pisang 11.3 2.26
Cek Mek Molek 17.5 3.5 Kuih akok 10.1 2.02
Kuih apam 17.2 3.44 Putu mayam 9.9 1.98
Kuih kasturi 16.9 3.38 Pengatubi keledek 9.5 1.9

KM12
Kuih bakar 16.2 3.24 Buahmelaka 8.9 1.78
Kuih Apam balik 16.0 3.2 Kuih ketayap 8.7 1.74

Lepat ubi 15.8 3.16 Kuih talam 8.3 1.66
Kuih sagu 15.8 3.16 Pau ayam 7 1.4
Kuih kasui 14.8 2.96 Kuih lopes 5.5 1.1
Pau kacang merah 14.8 2.96 Cucur bilis 4.7 0.94
Pau kelapa 14.3 2.86 Cucur bawang 3.8 0.76
Pau goreng 14.2 2.84 Pulut panggang 2.2 0.44
Kuih lapis 13.7 2.74 Cakoi 1.2 0.24
Lepat pisang 13.5 2.7 Ketupat 0.5 0.1
Kuih sri muka 13.3 2.66
Source: Chong et al. (2019)
323
Appendix 12.2: Total sugars content in selected local cooked dishes
Household Household
Total Total
(g/100g) (g/100g)
Cooked dishes Cooked dishes
Mee rebus 6.2 1.24 Mee-hoon goreng 2.4 0.48
Roti canai 4.6 0.92 Kuey teow goreng 2.1 0.42
Mee bandung 4 0.8 Nasi ayam 1.9 0.38
Capati 3.3 0.66 Nasi lemak 1.5 0.3
Roti telur 3.1 0.62 Lontong 1.2 0.24
Murtabak 3 0.6 Idli 1.1 0.22
Mee goreng 2.7 0.54 Tosai 1.1 0.22
Mee Kari 2.6 0.52 Kuey teow sup 1.1 0.22
Lempeng 2.6 0.52 Mee sup 0.9 0.18

KM12
Source: Chong et al. (2019)
Appendix 12.3: Total sugars content in selected cereals based products & tubers, legumes, nuts & seed and
other processed products
Household Household
Total Total
(g/100g) (g/100g)
Cereal products Starchy root & tuber products
Wafer, chocolate, full 39.13 7.83 Tapioca chips, spicy 12.64 2.53
coated
Biscuit, cream filled 25.65 5.13 Tapioca chips, plain, 7.61 1.52
unsalted
Biscuit, raisin 24.56 4.91 Sweet potato, red, chips 5.09 1.02
Biscuit, chocolate chip 24.17 4.83 Tapioca chips, black 4.92 0.98
pepper
#Cake, banana 24 4.8 Potato chips, spicy 2.75 0.55
Bun, kaya 22.82 4.56 Legume, nut & seed products
Cookies, butter 21.62 4.32 Soya sauce, sweet 42.23 8.45
Biscuit, milk 19.06 3.81 Peanut, crush 40.97 8.19
Muesli 18.75 3.75 Peanut/ Groundn ut, 8.06 1.61

flour coated
Biscuit, shortbread 17.80 3.56 Pistachio nut 6.41 1.28
324
Appendix 12.3: Total sugar contents in selected cereal, starchy & tuber, legume, nut & seed and other
processed products. (cont.)
Household Household
Total Total
(g/100g) (g/100g)
Biscuit, oatmeal 16.43 3.29 Soya flour 6.33 1.27
Biscuit, cracker with sugar 14.92 2.98 Macadamia nut 4.28 0.86
#Bun, coconut filling 14.9 2.98 Sunflower seed 2.38 0.48
#Bun, chocolate filling 14.6 2.92 Hazelnut 1.72 0.34
#Bun, red bean filling 14.4 2.88 Flaxseed 1.69 0.34
Biscuit, corn 14.02 2.80 Pumpkin seed 1.10 0.22
Bun, potato 13.55 2.71 Other processed products
#Bun, corn cream filling 12.5 2.5 *Palm sugar 86.7 17.34
KM12
Biscuit, crackers, 9.72 1.94 *Seri kaya 47.3 9.46
vegetable flavor

Corn flakes 8.58 1.72 #Sweetened creamer 45.9 9.18
*Bun, plain 6.8 1.36 #Chili, sauce 27.9 5.58
*Bread, white 4.4 0.88 #Tomato, sauce 20.5 4.1
*Bread, wholemeal 3.7 0.74 Thousand island, sauce 15.47 3.09
*Instant noodles, curry 2.3 0.46 *Peanut butter 12.2 2.44
*Biscuit, cream cracker 2.1 0.42 Mayonnaise 8.59 1.72
Oatmeal cereal, dry 1.2 0.24
Sources: Norhayati et al. (2018); *Rosmawati et al. (2018); #Chong et al. (2019)
325
Appendix 12.4: Total sugars content in selected sugar & syrup products and beverages
Household Household
Total Total
(g/100g) (g/100g)
Sugar & syrup products #Pre-mixed cocoa, 46.4 9.28

powder
Cordial, pineapple 65.52 13.1 #Malted milk, powder 44.8 8.96
Cordial, guava 64.63 12.93 #Full cream milk, powder 40.7 8.14
Jam, blueberry 54.78 10.96 #Low fat milk, powder 39.9 7.98
Jam, apricot 53.65 10.73 Ready-to-drink Beverages
Jam, strawberry 52.67 10.53 #Cocoa flavoured drink 10.7 2.14

with sweetened creamer
Jam, grape 52.43 10.49 #Coffee with 9 1.8

sweetened creamer
KM12
Cordial, roselle 51.03 10.2 #Tea with sweetened 8.8 1.76
creamer
Cordial, soursop 45.39 9.08 #Orange flavoured 7.7 1.54

cordial drink
Cordial, mango 43.46 8.69 #Orange juice, fresh 7.6 1.52
Cordial, orange 41.41 8.28 #Soymilk, fresh 7 1.4
Cordial, grape 34.9 6.98 #Coffee with sugar 6.9 1.38
Cordial, sarsi 32.91 6.58 #Barley drink, fresh 6.6 1.32
Cordial, lime 31.22 6.24 #Chrysanthemum 5.7 1.14

tea, fresh
Cordial root beer 15.00 3 Total

Sugar (g/500ml)
Powdered Beverages §Bubble milk tea 102.5 20.5
#Pre-mix 48.6 9.72 Brown sugar Boba

§ 92.5 18.5
coffee, powder milk tea
Source: Norhayati et al. (2018); #Chong et al. (2019); §Channel News Asia (2020)
326
Appendix 12.5: Total sugars content in selected fruits
Household Household
Total Total
(g/100g) (g/100g)
Fruits Fruits
#Pisang berangan 20.4 4.08 Green pear 10.1 2.02
Rambutan 17.9 3.58 #Soursop 9.2 1.84
#Ciku 17.1 3.42 #Pineapple 8.6 1.72
Longan 16.7 3.34 §Dragon fruit, white 8.5 1.7
Mangosteen 15.1 3.02 §Dragon fruit, red 8.4 1.68
Langsat 14.1 2.82 #Papaya 7.8 1.56
#Durian 13.9 2.78 Yellow pear 7.7 1.54
‡Watermelon, red, seeded 11.4 2.28 Tangerine 7.1 1.42 KM12
§Pomegranate 10.7 2.14 #Mandarin orange 7.0 1.4

‡Watermelon, Yellow 10.1 2.01 #Guava 6.7 1.34
Sources: ‡Sabeetha et al. (2017); §Norhayati et al. (2018); Rosmawati et al. (2018); #Chong et al. (2019)
327
KM12
328
Key Message 13
Drink plenty of water daily

KM13
Key Message 13
Prof. Dr. Loh Su Peng, Dr. Nor Baizura Md Yusop, Ms. Nor Hasyimah Khalid,
Ms. Nur Wahidda Azmi and Ms. Noor Faezah Abdul Jalil
13.1 Terminology
Alkaline water Dehydration

Water with a higher pH than normal drinking water Dehydration is an excessive loss of body water.
(pH 8 or 9) and contains alkaline minerals and There are several causes of dehydration including
negative oxidation reduction potential. heat exposure, prolonged vigorous exercise,
vomiting, diarrhoea, kidney disease and medications
Beverage (diuretics).
A beverage refers to any one of the various liquids
suitable for drinking, excluding plain water. This Drinking water
may include tea, coffee, liquids, beer, milk or soft Drinking water is water that is safe to drink or use
drinks. An alcoholic beverage is liquor containing for food preparation. The amount of drinking water
more than 2 percent v/v (2% by volume) of alcohol required to maintain good health varies, and it
but does not include denatured spirit or any liquor depends on the physical activity level, age, health-
or any preparation containing more than 2 percent related issues, and environmental conditions.
v/v of alcohol for which medicinal properties are
claimed (MOH, 1985).
330
Electrolyte Reverse osmosis (RO) water

An electrolyte is a substance that will dissociate into Water that uses purification methodology that
ions in solution and acquire the capacity to conduct removes ions, molecules and other larger particles
electricity. The electrolytes include sodium, from drinking water using a semipermeable
potassium, chloride, calcium and phosphate. membrane and pressure to reverse the natural flow
of water.
Energy drink
An energy drink is a fluid that typically contains Sports drink
stimulants, such as caffeine and guarana, with A sports drink is a fluid that contains carbohydrate
varying amounts of carbohydrate, protein, amino (6 to 8%), electrolytes (sodium and potassium),
acids, vitamins, sodium and other minerals. flavour and vitamins. A sports drink replaces water
and electrolytes during physical activities
Fluid
Fluid is a substance that has no fixed shape and Water/ plain water
yields easily to external pressure. Water is a substance with the chemical formula
H2O: one molecule of water has two hydrogen
Hydration atoms covalently bonded to a single oxygen atom.
Hydration is a process of providing adequate Water/ plain water is a tasteless, odourless liquid at
amounts of liquid to body tissues. room temperature and pressure and appears
colourless without any calories. Example of water/
Oxygenated water plain water include; mineral water, drinking water,
Drinking water that contained extra dissolved filtered water, boiled water, oxygenated water,
oxygen (from 30 to 120 mg/L). reverse osmosis (RO) water, alkaline water. KM13

13.2 Introduction
Water is one of the body's most essential nutrients. is tap water, bottled drinking water, and bottled
It is made up of two hydrogen atoms and one mineral water. Our main water sources for drinking
oxygen atom. Most of the water in the body comes can come from raw/ spring water, alkaline water,
from diet which is not only from water but from oxygenated water, reverse osmosis water and
other liquids and solid food such as drinking water mineral water. Popular functional waters include
and the water content of soft drinks, juices, milk, alkaline water, oxygenated water, caffeinated water
coffee, tea and alcohol. A constant supply of water and reverse osmosis water. While not a functional
without excess or deficiency is needed in the body. water, sparkling/ raw water is often compared with
It is essential for metabolism, substrate transport oxygenated water due to its gaseous nature and it’s
across membranes, cellular homeostasis, difficult to compare oxygenated water with other
temperature regulation, and circulatory function types of functional water, as their ingredients vary.
(Armstrong & Johnson, 2018) For example, naturally alkaline water occurs when
water passes over rocks like springs and picks up
Calcium and magnesium are the main minerals minerals, which increase its alkaline level. However,
found in drinking water which contribute up to 20% many people who drink alkaline water buy alkaline
of the recommended total daily intake other than water that's been through a chemical process called
food. Meanwhile, only less than 5% of the total electrolysis. Alkaline water is available in many
intake of other elements is provided by drinking grocery or health food stores as well as made at
water (Olivares & Uauy, 2005). Many studies show home., If water is properly filtered to remove
that drinking water that contains very low mineral contaminants, ionized and re-mineralised or
content, such in RO, might affect health status purchased from a quality source, there's no evidence
(Kozisek, 2005). Antioxidant properties were found to suggest a limitation on how much water alkaline
in fruit infused water (detox water) due to its high water can be consumed daily.
phytochemical content, based on a study conducted
by Ariyawansa & Ramanathan, 2021. When sourced and stored safely, spring water is
typically the healthiest option. When spring water is
In Malaysia, water supply for domestic use derives tested and minimally processed, it offers the rich
99% from surface water such as rivers whereas the mineral profile that our bodies desperately crave.
remaining 1% originates from groundwater. The Therefore, access to safe drinking water is
most common source of drinking water in Malaysia fundamental to health. In Malaysia, all commercial
331
drinking water should comply with the Food mechanism in hot climates and in periods of
Regulations 1985, read together with the Food Act physical activity. Maintaining adequate fluid intake
1983. According to Zurahanim et al. (2020), generally and optimal hydration is important for children for
all of the water samples studied contain metal physiological reasons and for the adoption of
elements and their concentrations recommended by healthy sustainable drinking habits (Bottin et al.,
the WHO Guidelines for Drinking-Water Quality 2019). Under conditions of severe dehydration,
2006 and the Malaysian Food Regulation 1985. decreased sympathetic nervous activity, impaired
Therefore, commercial drinking water (reverse thermoregulation and impaired cognitive and
osmosis and mineral water) and tap water in physical performance can be observed (Stookey et
Malaysia are safe for human consumption. al., 2011).
Another type of water that is becoming trendy is Alcohol should be prohibited in children and
infused water. Infused water is water that has been adolescents. Meanwhile sports drinks and energy
added with a few slices of fruits or herbs. This drinks should be avoided. It is widely known that
mixture will be left to stand for a few hours (4-12 alcohol-containing drinks have diuretic effects
hours) before consumption. In this way, the water whereas the purpose of sports drinks is to rehydrate
consumed becomes more flavourful and fresh the body and replace the electrolytes after intense
(Haitami et al., 2017). By infusing tasty flavours, sweating during exercise while energy drinks are
many people tend to drink more water. Infusion can normally used to stimulate the body. Children and
thus be a way to make water more appealing. adolescents experience adverse effects from energy
drinks in greater numbers than adults because of
Dehydration occurs when the drop in body water is the higher total body concentrations of caffeine
KM13 great enough for blood volume to decrease, thereby relative to body mass, and their relative caffeine
reducing the ability to deliver oxygen and nutrients naivety (Higgins & Babu, 2013). Generally, children
to cells and remove waste products. Children and and adolescents do not need supplemental
adolescents are susceptible to voluntary electrolyte replacement, water is the better choice
dehydration, especially during exercise, and may not for rehydration purposes (American Academy of
recognize the need to replace lost fluids. Body water Pediatrics, 2018).
loss through sweat is an important cooling
13.3.1 Dietary
Total water requirements to meet hydration needs Caffeine belongs to the methylxanthines group and
can be met by plain drinking-water, by water from it is the most consumed psychostimulant (alkaloid)
caloric and non-caloric beverages, and by moisture worldwide because it is present in coffee, which is
from foods. In general, plain water and beverages the second most consumed liquid in the world, after
supply much more of total daily water than does water. Half of the caffeine intake in children comes
food moisture. Plain water and beverages supply 65– from cola drinks, and the energy drink consumption
75% of total water, while the foods supply another in this group has increased by 6% in the past decade
25–35 %, depending on age (Vieux et al., 2016). Plain (Yeyetzi et al., 2020). The literature has shown
water is an excellent source of fluid for children and evidence of alterations in children’s growth and
young people. Water is the best fluid for meeting development, such as iron absorption deficiencies
hydration needs (ie, quenching thirst). Water also and weight loss. The effects of caffeine in children
contains no energy (kilojoules) or sugars that can include changes in the sleep cycle, which could
damage teeth (MOHNZ, 2012). Many studies have indirectly alter the weight and growth of children,
shown that a high proportion of children and and greater sensitivity to the alkaloid at an
adolescents do not drink enough to meet water emotional level (anxiety and depression). This may
intake recommendations (Iglesia et al., 2015; Vieux lose more water through extra urination (Scharf &
et al., 2016; Chouraqui, 2022) A number of studies DeBoer et al., 2016; Yeyetzi et al., 2020). Coffee, tea
have demonstrated that having a low fluid or water and drinking chocolate contribute very few
intake can compromise several body functions, nutrients to the diet unless made with milk. They
cardiovascular and increased risk of developing also contain caffeine, which is a psychoactive
hyperglycemia and recurrent kidney stones (Arwa stimulant drug that acts on the central nervous
et al., 2017; Laksmi et al., 2018). system. Coffee and tea are not recommended for
children younger than 13 years. If young people
332
aged 13 years or older drink tea or coffee, it is need to drink more water if their diet is high in salty,
recommended that they limit their intake to one to spicy or sugary foods. Or more water is necessary if
two cups per day. They should avoid drinking tea at they don’t eat a lot of hydrating foods that are high
mealtimes, as this drink contains tannins and in water like fresh or cooked fruits and vegetables
polyphenols, which can inhibit the absorption of (Ozen et al.,2014). Children and young people should
nutrients, such as iron (MOHNZ, 2012). be encouraged to get their fluid from water and milk,
and to eat fresh fruit because it provides dietary
Sugar-sweetened beverages (SSBs) are a leading fiber, vitamins and minerals. When choosing juice,
source of empty calories and can be considered as limit intake to no more than one diluted glass per
one of the key elements of child obesity prevention day, equating to a maximum of 250 ml after the juice
initiatives. Poor diet quality in children was linked has been diluted (at least half water, dilute more for
with beverage consumption patterns high in sugars younger children). To protect teeth, juice should be
and low in dairy beverages. Individuals consumed consumed with meals rather than between meals
at least one serving of SSB per day, a level of (MOHNZ, 2012).
consumption that has been associated in different
studies with a 25% increased future risk of type 2 Alcohol consumption can increase individual
diabetes and obesity (Arwa et al., 2017). Indeed, a pleasure and stimulate social interaction. Drinking
high water intake has been associated with CKD fluids other than water can contribute to an intake
risk reduction, while several meta-analyses of caloric nutrients in excess of requirements, or in
associated a high daily intake of sugared beverages alcohol consumption that in some people may
with a CKD risk increase. Compared with infrequent insidiously bring about dependence. Evidence
sugared beverage consumers (<1 serving/week or ≤ indicates those who drink, higher average alcohol
1 serving/month), individuals consuming on average consumption is associated with an increased risk of KM13
≥ 1 servings of 250 ml/day of sugared beverages had death from all causes compared with lower average
a higher risk of developing kidney stones, metabolic alcohol consumption. Alcohol misuse or consuming

syndrome, type 2 diabetes, obesity and hypertension alcohol in excess of recommendations increases the
(Ozen et al., 2014; Iglesia et al., 2015). A report on the risk of several other conditions such as liver disease,
Emirati diet, which was based on data from the cardiovascular disease, injuries, and alcohol use
current study, showed that sugar-added soft and disorders (Yeyetzi et al., 2020). The Alcohol Advisory
fruit drinks accounted for 60%–71% of calories from Council advises that for children and young people
beverages among individuals aged 6–18 years under the age of 18 years, not to drink alcohol as the
(Habiba et al., 2019). Studies have shown that by safest option. However, if 15–17 year olds do drink
replacing SSB with plain water is associated with alcohol, they should do so only once a week; they
less energy intake (Scharf & DeBoer et al., 2016; should never exceed recommended adult daily
Arwa et al., 2017). limits and consumption should usually be below
such levels; and the drinking should take place in a
The World Health Organization (WHO) has raised supervised environment. Those under 15 years of
concerns regarding an excessive intake of SSB for age are at greatest risk of harm from drinking and
children. This concern is based on a meta-analysis not drinking in this age group is especially
of long-term prospective cohort studies conclude important (MOHNZ, 2012).
that children consuming the largest intakes of SSB
had a greater likelihood of being overweight or 13.3.2 Psychosocial factors
obese than children with the lowest intakes.
Consequently, the WHO has set recommendations Maintaining adequate fluid intake and optimal
for intake of free sugars to <10 % of total energy hydration is important for children for physiological
intake and suggests a further reduction to <5 % of reasons and for the adoption of healthy, sustainable
total energy intake (WHO, 2015). Evidence has drinking habits. Introducing water to children early
suggested that a reduction in energy intake and encouraging healthy drinking habits from the
facilitating weight management can be achieved youngest age is therefore essential to support
among regular SSB consumers if they replace their adequate fluid intake and optimal hydration in
SSB with drinking water (WHO, 2015; Guelinckx et childhood and in later life. Parenting practices such
al., 2015). as role modelling and controlling home beverage
availability are considered part of the social and
It is also important to consider the contributions of physical environment which can be manipulated to
water from food to total water intake, as this can change beverage intake behaviours of children
vary through diet. Children can get an average of (Arwa et al., 2017).
20% of their water from the foods they eat. They
333
Parental influence on child beverage intake may be thermoregulatory and cardiovascular strain (Watso
related to knowledge about diet and health. Parental & Farquhar, 2019). It causes performance
influence on beverage decision making and impairment and an increased risk of exertional heat
behaviours need to be addressed during the critical sickness (muscle heat cramps, fainting, heat
developmental period of early adolescence as exhaustion, and life-threatening heatstroke),
dietary behaviours tend to track into adulthood. especially during prolonged physical activity and
Study indicated that controlling home beverage under hot/ warm temperatures (Council on Sports
availability and role modelling by parents may Medicine and Fitness and Council on School Health,
influence child beverage intake, whereas only parent 2011). There is little doubt that dehydration of more
knowledge about sugar in beverages was than 2% of body mass disrupts physiological
associated with child beverage intake (Iglesia et al., systems and reduces physical performance in adult
2015; Arwa et al., 2017). athletes (Murray, 2007). Kavouras et al. (2012)
demonstrated that improvement in hydration status
Indeed, several recent studies have examined the through an educational intervention led to
utility of providing water to school children on significant enhancement in endurance performance
attentiveness and cognitive functioning in children. in exercising children. Thus, promoting fluid intake
Within the family and school context, some actions in exercising children is certainly important.
may be put into place by adults to support healthy
drinking habits in children. For example such as Water demands can rapidly increase during physical
offering water to children regularly throughout the activity, thus drinking more water during and after
day without relying on one’s own thirst, associating exercise is recommended to replace the water lost
water intake with ”moments” such as wake up, through sweat (American Academy of Pediatrics
KM13 breakfast, morning and afternoon breaks to establish Committee on Nutrition and Council on Sports
a routine, making water accessible to children, at all Medicine and Fitness, (AAP, 2011). "With children
times by using age-appropriate cups or bottles that and adolescents, careful attention is important when
children can access and drink from independently, selecting a beverage to hydrate before, during, or
providing a positive parental drinking model for after exercise," according to the clinical report of the
children at home and at school and making water American Academy of Pediatrics (AAP, 2018) and
fun by various means such as drinking straws, fresh Committee on Nutrition and Council on Sports
herbs or sliced fruits, sparkling water, personalized Medicine and Fitness (AAP, 2011). In most cases,
glass, or bottle (Arwa et al., 2017; Habiba et al., 2019). drinking water is enough to replace the water lost
through sweating during exercise for children who
13.3.3 Physical performance engage in frequent physical activity. In addition,
water has no effect on calorie intake or solute
From a mechanistic standpoint, pre-pubertal burden in the kidneys. As a result, it is good to
adolescents may better retain body fluids during consume it as part of a healthy lifestyle that includes
exercise due to lower perspiration rates than adults. a balanced diet and moderate physical activity.
In comparison to adults, larger insensible water
losses per unit of body weight imply a higher water 13.3.4 Cognitive performance
need per unit of body weight. The data available on
children's physiological responses and physical It's difficult and complicated to define cognitive
performance in hot weather is insufficient to function. Cognitive functioning refers to multiple
establish firm conclusions. Furthermore, contrary to mental abilities, including learning, thinking,
previous beliefs, new research suggests that, reasoning, remembering, problem-solving, decision
despite distinct primary thermoregulatory making, and attention (Fisher et al., 2019). Adults'
pathways, children and adults may have similar cognitive performance, including memory, attention,
thermoregulation in the heat. There is no indication motor abilities, and mood, has been shown to be
that children are at a higher risk of dehydration or affected by dehydration (Armstrong et al., 2012;
hyperthermia during physical exertion in hot Stachenfeld et al., 2018; Benton & Young, 2015; Pross
weather than adults (Rowland 2008; Falk & Dotan, et al., 2013). Although there is limited evidence in
2008). When compared to adults, there is no children, minor dehydration (1-2 percent body
increased risk of exertional heat sickness in weight) has been linked to memory impairment
sufficiently hydrated children (Arlegui et al., 2021; (Drozdowska et al., 2020; Fadda et al., 2012; Masento
Rivera-Brown et al., 2006; Rowland et al., 2008). et al., 2014). Similarly, a recent study revealed that
dehydration could have an immediate impact on the
Dehydration inhibits a variety of physiologic structure and function of the brain in adolescents
activities during physical exertion, increasing (Kempton et al., 2011).
334
Edmonds et al., (2017) assessed the dose-response Council (US) Subcommittee on the Tenth Edition of
effect of water on thirst, mood and cognitive the Recommended Dietary Allowances Food and
performance in both adults and children. Nutrition Board, 1989). For children age 7 – 9 years
Participants were offered either no water, 25 ml or old with PAL 1.6 for boys (1800 kcal) and girls (1600
300 ml water to drink. 96 adults and 60 children (7- kcal), multiplying the energy requirement (NCCFN,
9 years old) were assessed at baseline and 20 min 2017) by these factors gives an average fluid intake
after drinking (or no drink); on thirst and mood requirement of 2.7 L and 2.4 L for 7 to 9 year old boys
scales, letter cancellation and a digit span test. In and girls respectively. Assuming that approximately
both adults and children, a small drink (25 ml) was one third (1 L) is derived from food, a conservative
enough to boost visual attention such as (letter estimate is that 7- to 9-year-old children require
cancellation). A large drink boosted digit span in around 1.5 L per day. These requirements will rise
adults, but it had little effect on children. A tiny drink in warm weather and when exercising.
increased thirst ratings in children but not in adults.
Drinking has a dose-response effect on visual Other estimates of daily water requirements for
attention in both children and adults. Small amounts children include those based on findings from the
of fluid appear to improve visual focus without German DONALD study of 479 healthy boys and
relying on thirst reduction. Memory performance girls aged 4 to 10.9 years. Estimated adequate intake
may be linked to thirst, but this relationship differs values of total water for German children in this age
across children and adults. group ranged from 1.01 to 1.05 ml per kcal energy
expenditure (Manz, Wentz & Sichert- Hellert, 2002).
In another study, it was mentioned that the benefit The World Health Organization recommend for
of drinking water on working memory and attention children weighing 10 kg should consume 1 L per
depends upon children's hydration status and renal day and 0.75 L water per day is needed by a 5kg KM13
response to water intake (Perry et al., 2015). Their infant, under average conditions, but this should be
study tested on children of 9-12 years of age over a increased depending on conditions, up to 4.5 L, for

period of 2 hours on a series of cognitive tests example, if the child is undertaking manual labour
consisting of digit span, pair cancellation, and in high temperatures (WHO, 2017).
delayed match to sample tasks. They found that
children who had a lower decrease in urine Using the available data on energy requirement in
osmolality following water intake performed the current Malaysian RNI (NCCFN, 2017) and the
considerably better on the water given day than on U.S. National Research Council water requirement
the control day on a digit-span test and a pair- for children (1.5 ml per kcal energy expenditure per
cancellation task. Children who exhibited larger day), the recommendation for water is shown in
decreases in urine osmolality following water intake Table 13.1 and 13.2. This recommendation takes into
performed better on the control day compared to the account the water derived from solid food as well as
water given day on the digit-span task and pair- drinking water and beverages. As mentioned above,
cancellation task. These findings showed that the estimated water from solid food is one third and
maintaining appropriate hydration throughout time the rest from drinking water and beverages.
could be crucial for cognitive improvement. Preferably, the intake of drinking water and
beverages is from plain water. The source of
13.3.5 Basis for recommendation beverages from milk also can be considered to meet
water and milk intake requirements. Looking at the
Sources of water consumed in order to meet body usual intake of plain water by adults in Malaysia
needs include beverages, food, and drinking water. based on NHMS 2015 (IPH, 2015), it is suggested
Although water is thought of as the primary fluid to that a 2 to 6 year old child should consume 4 to 5
sustain hydration, fluids in different types of glasses, a 7 to 12 year old should consume 6 to 8
beverages and foods contribute significantly to a glasses and a 13 to 18 year old should consume 7 to
person’s daily fluid needs. Foods such as soup and 9 glasses of plain water daily. In order to standardize
ice cream were included in the food category (IOM, the age group 13 to 18 years old, we recommend the
2005). range between 7 to 8 glasses as the recommended
intake. Intake of plain water as suggested, can be
In 1989, the U.S. National Research Council achieved through adequate intake of plain water
estimated that for children aged one year and above, while at school (750 ml - 1000 ml; 3 – 4 glasses),
the average water requirement was 1.5 ml per kcal home (750 ml - 1000 ml; 3- 4 glasses) and outdoor
energy expenditure per day (National Research activities 250 ml - 500 ml 1- 2 glasses).
335
Table 13.1: Calculation of water requirement for boys according to Malaysian RNI
Water
One third The rest from
Age Energy (boy) requirement
coming from water and Glasses
(years) Kcal per day (1.5 ml per
solid food beverages
kcal)
2 to 3 1000 1500 500 1000 4
4 to 6 1300 1950 650 1300 5

7 to 9 1800 2700 900 1800 7
10 to 12 1900 2850 950 1900 8
13 to 15 2200 3300 1100 2200 9
16 to 18 2300 3450 1150 2300 9
Adapted from: NCCFN (2017), values are rounded up to the nearest tens.
For children aged 4 – 6 years, PAL 1.4 is recommended to be used for the general population. For children above 7 years,
adolescents and adults, PAL of 1.6 (i.e., moderately active) is recommended to be used for the general population.
Table 13.2: Calculation of water requirement for girls according to Malaysian RNI
KM13 Water
One third The rest from
Age Energy (girl) requirement
coming from water and Glasses
(years) Kcal per day (1.5 ml per
solid food beverages

kcal)
2 to 3 900 1350 450 900 4
4 to 6 1200 1800 600 1200 5
7 to 9 1600 2400 800 1600 6
10 to 12 1700 2550 850 1700 7
13 to 15 1800 2700 900 1800 7
16 to 18 1900 2850 950 1900 8
Adapted from: NCCFN (2017), values are rounded up to the nearest tens.
For children aged 4 – 6 years, PAL 1.4 is recommended to be used for the general population. For children above 7 years,
adolescents and adults, PAL of 1.6 (i.e., moderately active) is recommended to be used for the general population.
336
13.4 Current Status
National Health and Morbidity Survey conducted in A study among 2,086 Malaysian overweight and
2017 among 27,497 students aged 10 to 17 years old obese school children reported that primary school
in 212 selected schools in Malaysia found that 88.1% children brought plain water frequently in a week
of students preferred to bring plain water to school than secondary school children. Both overweight
compared to sweetened beverages. Almost half of and obese school children mostly bought and drank
the adolescents (46.1%) reported that they brought plain water at the school canteen compared to other
drinks to school every day (IPH, 2017b). This survey beverages (Rusidah et al., 2019).
also found out that 60.4% students drank plain water
five times or more per day for the past 30 days. Meanwhile, there was a negative correlation
Female students drank plain water more frequently between intakes of soft drinks, sweetened tea and
compared to male students (IPH, 2017a). This survey total SSB compared to cognitive function among
also reported that almost all Malaysian adolescents adolescents (10 to 14 years old) in Selangor. Only
(99.7%) drank plain water on an average of 1.5 litres 33.0% of adolescents who participated in the study
daily (6 servings) (IPH, 2017b). were well hydrated. The score for cognitive function
was significantly higher among hydrated
adolescents compared to dehydrated counterparts
(Serene et al., 2020).

KM13
Key Recommendation (KR) 1: Drink an adequate amount of plain water daily.


KR1: HTA1:
Give children and adolescents the recommended plain water intake as shown in Table 13.3.
KR1: HTA2:
Choose plain water instead of sugar-sweetened beverages.

Bring plain water to Ensure the child to bring plain water to school Educate parents/
school and when away and when away from school. caregiver to ensure
from home. children/ adolescent
drink plain water
according to the
recommendation and
plain water is available
all the time.

Drink plain water Ensure the child drinks plain water frequently Educate parents/
frequently even when even when not thirsty. caregiver to give the
not thirsty. children/ adolescent
plain water frequently
when engaging in
outdoor activities and
the child is sick.
337
Key Recommendation (KR) 1: Drink an adequate amount of plain water daily. (cont.)

KR1: HTA5: KR1: HTA5: KR1: HTA5: -

Drink plain water Encourage the child to Encourage the child to
frequently when drink plain water drink plain water
engaging in outdoor frequently when frequently when
activities. engaging in outdoor engaging in outdoor
activities. activities.

Drink more water above Give more water above
the recommended the recommended
amount when you are amount when your child
sick to prevent is sick to prevent
dehydration. dehydration.
KR1: HTA7: - -
KM13
Add lemon or lime to enhance the flavour of
plain water consumption.
Table 13.3: Recommended plain water intake of children and adolescents by age (6 months to 18 years)
Age groups Plain water intake/ day
6 - 11 month ½ glass
1 - 3 year 1 - 2 glasses
Note: 1 glass = 250 ml

Source: American Academy of Pediatric Dentistry (2021); NCCFN (2021); NCCFN (2017)
338
Key Recommendation (KR) 2: Vary fluid intake from other food sources.


Consume fluid from Guide parents/ Encourage your children Teach children/
other sources such as caregiver to avoid intake to consume other fluid adolescents to choose
soups, beverages and of caffeinated beverages sources such as soups, other fluid sources
juices, preferably low in in children and limit beverages and juices, such as soups,
fat, sugar and salt. intake in adolescents. preferably low in fat, beverages and juices,
sugar and salt. preferably low in fat,
sugar and salt.

Avoid intake of Guide parents/ Prohibit your children Teach children to
caffeinated beverages caregiver to choose from taking caffeinated avoid intake of
for children and limit other fluid sources such beverage and teach caffeinated beverages
intake of caffeinated as soups, beverages adolescents to limit and limit intake in
beverages (coffee, tea, and juices, low in fat, intake of caffeinated adolescence.
KM13
cola drink) to one cup sugar and salt for beverages (coffee, tea,
per day for adolescent. children/ adolescents. cola drink) to one cup
per day.

Prohibit intake of Guide parents/ Prohibit children/ Guide teacher to
alcoholic drinks. caregiver to prohibit adolescents from taking prohibit intake of
intake of alcoholic alcoholic drinks. alcoholic drinks among
drinks among children children and
and adolescents. adolescents.
339
13.6 References
AAP (2011). American Academy of Pediatrics Committee on Nutrition and the Council on Sports Medicine
and Fitness (2011). Clinical report - Sports drinks and energy drinks for children and adolescents: are
they appropriate? American Academy of Pediatrics Committee on Nutrition and the Council on Sports
Medicine and Fitness. Pediatrics 127: 1182-1189.
AAP (American Academy of Pediatrics) (2018). Adolescent Consumption of Sports Drink. American
Academy of Pediatrics Committee on Nutrition and the Council on Sports Medicine and Fitness.
American Academy of Pediatric Dentistry (2021). Healthy beverage consumption in early childhood:
Recommendations from key national health and nutrition organizations: Summary of oral health
considerations. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of
Pediatric Dentistry; 565-8.
American Academy of Pediatrics Committee on Nutrition and the Council on Sports Medicine and Fitness
(2011). Clinical report - Sports drinks and energy drinks for children and adolescents: are they
appropriate? Pediatrics 127: 1182-1189.
Ariyawansa, G.P., & Ramanathan, R. (2021). Antioxidative Potential and Phytochemical Content of Detox
Water. Advanced Journal of Graduate Research. 31;10(1):41-50.
KM13 Arlegui, L., Smallcombe, J.W., Fournet, D., Tolfrey, K., & Havenith, G. (2021). Body mapping of sweating
patterns of pre-pubertal children during intermittent exercise in a warm environment. Eur J Appl
Physiol 121(12), 3561–3576. doi: 10.1007/s00421-021-04811-4.
Armstrong, L.E. & Johnson, E. C. (2018). Water intake, water balance, and the elusive daily water
requirement. Nutrients 10(12),1928. doi: 10.3390/nu10121928.
Armstrong, L.E., Ganio, M.S., Casa, D.J., Lee, E.C., McDermott, B.P., Klau, J.F., Jimenez, L., Le Bellego, L.,
Chevillotte, E., & Lieberman, H.R. (2012). Mild dehydration affects mood in healthy young women. J
Nutr 142: 382-8.
Arwa, Z., Cynthia, D., & Marla, R. (2017). Beverage Intake among Children: Associations with Parent and
Home-Related Factors. Int. J. Environ. Res. Public Health. 14, 929-.; doi:10.3390/ijerph14080929.
Benton, D., & Young, H.A. (2015). Do small differences in hydration status affect mood and mental
performance? Nutr Rev. 73 Suppl 2:83-96. doi: 10.1093/nutrit/nuv045.
Bottin, J.H., Morin, C., Guelinckx, I. & Perrier, E.T. (2019). Hydration in Children: What Do We Know and Why
Does it Matter? Ann Nutr Metab. Suppl 3:11-18. doi: 10.1159/000500340.
Chouraqui J. P. (2023). Children's water intake and hydration: a public health issue. Nutrition reviews, 81(5),
610–624. doi: 10.1093/nutrit/nuac073
Council on Sports Medicine and Fitness and Council on School Health (2011). Policy Statement - Climatic
Heat Stress and Exercising Children and Adolescents. Pediatrics, 128(3), e741–e747. doi:
10.1542/peds.2011-1664.
Drozdowska, A., Falkenstein, M., Jendrusch, G., Platen, P., Luecke, T., Kersting, M., & Jansen, K. (2020). Water
Consumption during a School Day and Children's Short-Term Cognitive Performance: The
CogniDROP Randomized Intervention Trial. Title of paper missing! Nutrients. 2020 May 2;12(5):1297.
doi: 10.3390/nu12051297.
Edmonds, C.J., Crosbie, L., Fatima, F., Hussain, M., Jacob, N., & Gardner, M. (2017). Dose-response effects of
water supplementation on cognitive performance and mood in children and adults. Appetite. 108:464-
470. doi: 10.1016/j.appet.2016.11.011
340
Fadda, R., Rapinett, G., Grathwohl, D., Parisi, M., Fanari, R., Calò, C.M., & Schmitt, J. (2012). Effects of drinking
supplementary water at school on cognitive performance in children. Appetite. 59(3):730-7. doi:
10.1016/j.appet.2012.07.005.
Falk, B. and & Dotan, R. (2008). Children's thermoregulation during exercise in the heat. Appl Physiol Nutr
Metab 33(2):420-7. doi: 10.1139/H07-185.
Fisher, G.G., Chacon, M., & Chaffee, D.S. (2019). Theories of Cognitive Aging and Work. In: Work Across the
Lifespan. Baltes, B. B., Rudolph, C. W., & Zacher, H. (Eds.). Elsevier pg 17-45.
Food and Nutrition Board (1989). 10th edition.
Guelinckx, I., Iglesia, I., J. H. Bottin., P. De Miguel-Etayo, E. M., Gonzalez-Gil, J. Salas-Salvado, S. A. Kavouras
J. Gandy, H. Martinez, S. Bardosono, M. Abdollahi, E. Nasseri, A. Jarosz, Ma, E. Carmuega, I. Thiebaut.,
& Luis A. Moreno (2015)., Intake of water and beverages of children and adolescents in 13 countries.
Eur J Nutr 54 Suppl (2):S69–S79. doi:10.1007/s00394-015-0955-5.
Habiba, I. Ali., Ayesha, S., Al Dhaheri, 1, Fadima Elmi, Shu Wen Ng, Sahar, Z., Eric, O., & Husain, S. (2019).
Water and Beverage Consumption among a Nationally Representative Sample of Children and
Adolescents in the United Arab Emirates. Nutrients. 11, 2110; doi:10.3390/nu11092110.
Haitami Haitami, Annisa Ulfa, & Akhmad Muntaha. (2017). Kadar Vitamin C Jeruk Sunkist Peras Dan Infused
Water. Medical Laboratory Technology Journal, 3(1), 98 –102. KM13
Higgins, J.P., & Babu, K.M. (2013). Caffeine reduces myocardial blood flow during exercise. Am. J. Med.

126:730–e731 8.
Iglesia, I., Guelinckx, I., De Miguel-Etayo, P.M., Gonzalez-Gil, E.M., Salas-Salvado, J., Kavouras, S.A., Gandy,
J., Martinez, H., Bardosono, S., Abdollahi, M., Nasseri, E., Jarosz, A., Ma, G., Carmuega, E., Thiebaut, I.,
& Moreno, L.A. (2015). Total fluid intake of children and adolescents: cross-sectional surveys in 13
countries worldwide. Eur J Nutr. 54 (Suppl 2):57–67. doi: 10.1007/s00394-015-0946-6.
Institute of Medicine (IOM). (2005). Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and
Sulfate. Institute of Medicine, Washington, DC: The National Academies Washington, DC.
Press.https://doi:org/10.17226/10925.
Institute for Public Health (IPH) (2015). National Health and Morbidity Survey 2015 (NHMS2015). Vol. II:
Non-Communicable Diseases, Risk Factors & Other Health Problems.; 2015 Institute for Public Health,
Ministry of Health Malaysia.
Institute for Public Health (IPH) i IPH (2017a). National Health and Morbidity Survey (NHMS) 2017:
Adolescent Health Survey 2017, Institute for Public Health, Ministry of Health Malaysia.
Institute for Public Health (IPH) ii IPH (2017b). National Health and Morbidity Survey (NHMS) 2017:
Adolescent Nutrition Survey 2017, Institute for Public Health, Ministry of Health Malaysia.
Kavouras, S.A., Arnaoutis, G., Makrillos, M., Garagouni, C., Nikolaou, E., Chira, O., Ellinikaki, E., & Sidossis,
L.S. (2012). Educational intervention on water intake improves hydration status and enhances
exercise performance in athletic youth. Scand J Med Sci Sports 22(5):684-9. doi: 10.1111/j.1600-
0838.2011.01296.x.
Kempton, M.J., Ettinger, U., Foster, R., Williams, S.C., Calvert, G.A., Hampshire, A., Zelaya, F.O., O’Gorman,
R.L., McMorris, T., Owen, A.M., & Smith, M.S. (2011). Dehydration affects brain structure and function
in healthy adolescents. Hum Brain Mapp 32: 71-79.
341
Kozisek, F. (2005). Health risks from drinking demineralised water. Health Risks from drinking demineralised
Water. In: nutrients in drinking Water. World Health Organization, Geneva. pp. 148-163. Nutrients in
drinking water. 1(1); 148-163.
Laksmi, P.W., Morin, C., Gandy, J., Moreno, L.A., Kavouras, S.A., Martinez, H., Salas Salvado, J., & Guelinckx,
I (2018). Fluid intake of children, adolescents and adults in Indonesia: results of the 2016 Liq.In7
national cross-sectional survey. European Journal of Nutrition (2018) 57 (Suppl 3):S89–S100:
https://doi:org/10.1007/s00394-018-1740-z.
Manz, F., Wentz, A. & Sichert-Hellert, W. (2002). The most essential nutrient: defining the adequate intake
of water. J Pediatr 141(4):587-92. doi: 10.1067/mpd.2002.128031.
Masento, N.A., Golightly, M., Field, D.T., Butler, L.T., van Reekum. C.M. (2014). Effects of hydration status
on cognitive performance and mood. Br J Nutr. 111(10):1841-52. doi: 10.1017/S0007114513004455.
MOH (1985). Malaysian Food Act 1983 and Food Regulation 1985. Ministry of Health Malaysia, Putrajaya.
Ministry of Health. MOHNZ (2012). Food and Nutrition Guidelines for Healthy Children and Young People
(Aged 2–18 years): A background paper. Partial revision February 2015. Wellington: Ministry of Health,
Wellington, New Zealand..
Murray, B. (2007). Hydration and physical performance. J Am Coll Nutr 26: 542S-548S. doi:
KM13 10.1080/07315724.2007.10719656.
National Research Council (US) Subcommittee on the Tenth Edition of the Recommended Dietary
Allowances. (1989). Recommended Dietary Allowances: 10th Edition. National Academies Press (US).
NCCFN (2017). Recommended Nutrient Intakes. A report of the Technical Working Group on Nutritional
Guidelines. National Coordinating Committee on Food and Nutrition (NCCFN),. 2017. Ministry of
Health Malaysia, Putrajaya.
NCCFN (2021). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and Nutrition,
Ministry of Health Malaysia, Putrajaya.
Olivares, M & Uauy, R. (2005). Essential nutrients in drinking water. In: nutrients in drinking Water. World
Health Organization, Geneva. pp. 41-60.Nutrients in drinking water. p.41.
Ozen, A.E., Bibiloni, M.D., Pons, A., & Tur, J.A. (2014) Fluid intake from beverages across age groups: a
systematic review. J Hum Nutr Diet. 28(5):417-42. doi:10.1111/jhn.12250 (*10).
Perry, C.S 3rd, Rapinett, G., Glaser, N.S., & Ghetti, S. (2015). Hydration status moderates the effects of drinking
water on children's cognitive performance. Appetite. 95:520-7. doi: 10.1016/j.appet.08.006.
Pross, N., Demazières, A., Girard, N., Barnouin, R., Santoro,1 F., Chevillotte, E., Klein, A., and & Le Bellego, L.
(2013). Influence of progressive fluid restriction on mood and physiological markers of dehydration
in women. Br J Nutr; 109(2):313-21. doi: 10.1017/S0007114512001080.
Rivera-Brown, A.M., Rowland, T.W., Ramirez-Marrero, F.A., Santacana, G., & Vann, A (2006). Exercise
tolerance in a hot and humid climate in heat-acclimatized girls and women. Int J Sports Med 27: 943-
950.doi: 10.1055/s-2006-923863.
Rowland, T. (2008). Thermoregulation during exercise in the heat in children: old concepts revisited. J Appl
Physiol. 105: 718-724. doi: 10.1152/japplphysiol.01196.2007.
342
Rusidah, Selamat., Junidah Raib., Nur Azlina, Abdul Aziz., Norlida, Zulkafly., Ainan Nasrina, Ismail., W Nurul
Ashikin, W Mohamad., Nur Izzatun Nasriah, Nasruddin., Muhammad Yazid, Jalaludin., Fuziah, Md
Zain., Zahari, Ishak., Abqariyah, Yahya., & Abdul Halim, Mokhtar. (2019). Dietary Practices and Meal
Patterns among Overweight and Obese School Children in Malaysia: Baseline Data from a School-
Based Intervention Study. Ecology of Food and Nutrition. 59 (3); 263-278. doi:
10.1080/03670244.2019.1694922.
Scharf, R.J. &; DeBoer, M.D. (2016). Sugar-Sweetened Beverages and Children’s Health. Annu. Rev. Public
Health; 2016, 37, 273–293. doi: 10.1146/annurev-publhealth-032315-021528.
Serene, En Hui Tung., Yi, Zhang Ch'ng., Thaneswary, V Karnan., Pei Nee, Chong., Jamil Osman Zubaidah &
Yit Siew, Chin. (2020). Fluid intake, hydration status and its association with cognitive function among
adolescents in Petaling Perdana, Selangor, Malaysia. Nutrition Research and Practice. 14:490-500.
doi: 10.4162/nrp.2020.14.5.490.
Stachenfeld, N.S., Leone, C.A., Mitchell, E.S., Freese, E., & Harkness, L. (2018). Water intake reverses
dehydration associated impaired executive function in healthy young women. Physiol Behav.
185:103-111. doi: 10.1016/j.physbeh.2017.12.028.
Stookey, J.D., Brass, B., Holliday, A., & Arieff, A. (2011). What is the cell hydration status of healthy children
in the USA? Preliminary data on urine osmolality and water intake. Public Health Nutr 15:2148–2156
doi: 10.1017/S1368980011003648.
KM13
Vieux, F., Maillot, M., Constant, F., & Drewnowski, A. (2016). Water and beverage consumption among
children aged 4–13years in France: analyses of INCA 2 (Etude Individuelle Nationale des

Consommations Alimentaires 2006–2007) data. Public Health Nutr;.19(13):2305–2314. doi:
10.1017/S1368980015003614.
Watso, J.C., & Farquhar, W.B. (2019). Hydration Status and Cardiovascular Function. Nutrients. 11(8):1866.
doi: 10.3390/nu11081866.
World Health Organisation WHO (2015) Guideline: sugar intake for adults and children, World Health
Organisation, Geneva.
World Health Organisation WHO (2017) Guidelines for drinking-water quality (GDWQ) (fourth edition). World
Health Organisation, Geneva.
Yeyetzi, C., Torres-Ugalde., Angélica, Romero-Palencia 2, Alma D. Román-Gutiérrez., Deyanira Ojeda-

Ramírez., and & Rebeca, M. E. Guzmán-Saldaña. (2020). Caffeine Consumption in Children: Innocuous
or Deleterious? A Systematic Review. 2020. Int. J. Environ. Res. Public Health; 17, 2489;
doi:10.3390/ijerph17072489.
Zurahanim, F.A., Wan NF WA., Nurul I A, Norasihah, MS., Wan R WM., Yuvaneswary, V., & Nor Aini, A. (2020).
Drinking Water Quality in Malaysia: A Review in Its Current Status. Int. J. Environ Sci Nat Res.
24(2),556132; 10.19080/IJESNR.2020.24.556132.
343
KM13
344
Key Message 14
Consume safe foods and beverages

KM14
Key Message 14
Assoc. Prof. Dr. Hasnah Haron, Dr. Fadhilah Jailani, Dr. Nurul Huda Razalli, Ms. Shazlina Mohd Zaini,
Ms. Siti Fatimah Mohd Tarmizi and Ms. Nor Nabihah Ab Rahman
14.1 Terminology
Bisphenol A by keeping food separated and by keeping hands,

Bisphenol A (BPA) is an industrial chemical used in utensils and food handling surfaces clean.
the manufacture of polycarbonate baby feedings Preventing cross-contamination is a key factor in
bottles and plastic containers. BPA based plastic is preventing foodborne illness
clear and tough and is also used in a material called
epoxy resin, which lines the inside of some metal Date of minimum durability
food and drink cans. BPA is known to cause Date of minimum durability means the date until
interruption to the human hormonal system, which the food, when kept in accordance with any
disrupting the body’s function. The United States storage conditions set out in the label of such food,
Food and Drug Administration warned of possible will retain any specific qualities for which tacit or
hazards to fetuses, infants, and young children in express claim has been made. The date of minimum
2010 (Dan Brennan, 2021). durability in respect of any food shall be shown in
the following form: "BEST BEFORE’’ or ‘’BEST BEF’’
Cross contamination (MOH, 1985). It also means the date which signifies
Cross-contamination is the transfer of harmful the end of the period, under any stated storage
microorganisms to a food from other foods, cutting conditions, during which the unopened product will
boards, utensils, surfaces, or hands. It is prevented remain fully marketable and will retain any specific
346
qualities for which implied or express claims have Food and water borne disease
been made. However, beyond the date the food may A food-or water-borne disease is any illness
still be acceptable for consumption. Types of food resulting from the consumption of contaminated
usually with date of minimum durability are bread, food and drinking water. Most cases are actually
frozen foods and canned products. infections caused by a variety of food-borne
pathogenic bacteria, viruses, parasites or chemical
Expiry date substances entering the body through
Expiry date means the date after which the food, contaminated food or water. The contamination of
when kept in accordance with any storage food occurs at any stage of the food production,
conditions set out in the label of such food, may not delivery and consumption chain. It can result from
retain the quality attributes normally expected by a several forms of environmental contamination
consumer. It also means the date which signifies the including pollution in water, soil or air, as well as
end of the period under any stated storage unsafe food storage and processing.
conditions, after which the product should not be
sold or consumed due to safety and quality reasons. Food poisoning
These dates are required on certain foods that have Food poisoning is a type of food borne disease
specific nutritional compositions that could falter which is due to the infection or irritation of the
after the determined expiration date. In other words, digestive tract that spreads through food or
after the expiration date has passed, the food may beverages. It mostly presents with acute onset of
not have the nutrient content as described on the vomiting and/or diarrhoea and/or symptoms from
label. The expiry date in respect of any food shall be other systems as a result of ingesting contaminated
shown in one of the following forms; ‘’EXPIRE foods or water, which contains infectious, toxigenic
DATE’’ or ‘’EXP DATE’’, ‘’USE BY’’ or ‘’CONSUME microorganisms or noxious elements. KM14
BY’’ or ‘’CONS BY’’ (MOH, 1985). Types of food
usually with expiry date are milk, yoghurt, cream Personal hygiene

and eggs. Personal hygiene is generally defined as cleanliness
of the body and proper maintenance of personal
Fresh food appearance. This generally includes all body areas
Fresh foods are raw foods that have not changed and clothing.
colour, do not have unpleasant odour, are not
withered and their texture remains unchanged. It is Safe water
usually considered as highly perishable and Water that is clean and free from contamination and
minimally preserved food which is perceived to be does not have objectionable taste or odour.
nutritionally superior.
14.2 Introduction
Food safety is described as the area of public health to consumption. It can also result from
that aims to protect consumers from the risks of food environmental contamination including pollution of
poisoning and foodborne diseases resulting from the water, soil and air. These diseases are cholera,
contamination of food be it from pathogens or typhoid fever, hepatitis A, dysentery and food
chemicals (WHO, 2015). It has been recognized as a poisoning and mainly related to poor sanitation. It
critical component in public health and addresses may lead to permanent health problems and
the handling, preparing and storing of food in order disability (Shafiza Ezat, Neety & Sangaran, 2013;
to reduce the risk of contamination and infection. NCCFN, 2020).
Food borne diseases are defined as diseases, usually
either infectious or toxic in nature, caused by Food-borne diarrhoea diseases are among the most
hazards that enter the body through the ingestion common diseases worldwide. Each year, diarrhoea
of food. These include biological hazards such as diseases cause an estimated 1,300 million episodes
infectious bacteria, toxin producing organism, worldwide and result in some four to five million
moulds, parasites and viruses, chemical hazard such deaths among children below the age of 5. The
as natural toxins, food additives, pesticide residues, World Health Organization (WHO, 2015) reported
veterinary drug residues, environmental that 3% of two million deaths each year, including
contaminants and allergens as well as physical among children, were attributed to diarrhoeal
hazard such as metal, glass, stone and bone chips diseases. In Malaysia, the incidence of food borne
(WHO, 2020). The contamination of food may occur diseases like cholera, typhoid, hepatitis A and
at any stage in the process from the food production dysentery have significantly decreased over the
347
years with no remarkable changes shown since food was significantly improved after the food safety
2017 until 2018 (MOH, 2018). However, food intervention was carried out in the school canteens
poisoning still remains increasing throughout the (Nik Rosmawati et al., 2016).
years. Food poisoning incidence in Malaysia has
increased from 44.18 (2010) to 58.68 (2014) per Food safety is the responsibility of several agencies
100,000 populations (MOH, 2010 & 2015). Data in Malaysia, principally the Food Safety and Quality
between the year 2008 until 2018 did not show any Division (FSQD), Ministry of Health (MOH).
significant reduction in incidence rates and number Recognising that educating the young on the
of episodes of food poisoning (MOH, 2018). importance of good hygienic practices as a way to
reduce food-borne diseases is a strategy that would
Food poisoning incidents at schools have increased have lasting impact, MOH has launched the Food
to more than 50% from 2015 to 2016 (MOH, 2016). Safety Campaign with the theme “SEE, SMELL,
Incremental episodes of food poisoning were TASTE” in 2010. This campaign is the follow-up to
reported in 2018 compared to 2017. The majority of the Food Safety Promotion Programme in schools
food poisoning episodes occurred in Ministry of that was implemented from 2007 to 2009 and still
Education (MOE) schools, followed by non-MOE being used till present. This programme is one of the
schools, institutions other than schools, homes and initiatives taken by the government to reduce food
other localities (MOH, 2018). Food poisoning among poisoning cases that often occur in schools,
students usually stems from consuming food involving primary and secondary school children.
prepared in school canteens, hostel kitchens or The Food Hygiene Regulations gazetted in 2009 was
under supplementary food programmes. Food to provide an infrastructure to control the hygiene
poisoning outbreaks in schools are attributed to and safety of food, including the preparation,
KM14 several factors in which food handlers are the most handling, distribution, sale and consumption of food
common source of contamination. Improper food to protect public health (NCCFN, 2013).
handling, such as the use of leftover chicken,
improper food storage, and unhygienic practices It is recommended that in order to prevent and
among food handlers in small food businesses, control food-borne diseases, inter-agency
canteens, residential homes, and other places, involvement, in particular between agencies that are
according to analyses of reported outbreaks around responsible for the provision of basic environmental
the world, including in Malaysia (Campos et al., facilities and local authorities, plays an important
2009; FAO, 2013; Hejar et al., 2011; Ryu et al., 2011). role in enforcing laws related to the establishment
and operation of food outlets. Data from the National
The main reasons for school food poisoning Disease and Pathogen Surveillance System, which
outbreaks in Malaysia are: the overly extended links to systems from various related agencies, will
period between the preparation and serving of food, provide useful information that is important for a
the storage of cooked food under an ambient better understanding of food-borne diseases in
temperature before serving, and cross- Malaysia. In addition to regulations, it is important
contamination (Salleh et al., 2017; Soon et al., 2011). to educate consumers to choose safe and clean food
Additionally, higher temperatures in kitchens and beverages. Health education is one of the most
compared with those in dining areas create an ideal effective means of reducing the problem of food-
condition for bacterial proliferation. It has also been borne illnesses but this will only be effective if it
established that the surfaces of common kitchen convinces everyone involved along the food chain,
items provide favourable breeding grounds for from food handlers to the consumers, to improve
foodborne bacteria. These include the surfaces of their food safety habits. If both food handlers and
cutting boards, wiping cloths, sinks, cleaning consumers play their respective roles, the problem
sponges, and knives (Abdul Mutalib et al., 2015). of food poisoning can be reduced (NCCFN, 2013).
Knowledge related to rules when preparing safe
348
Childhood health behavioural patterns, particularly and objects that could carry germs. National Health
eating behaviours often persist into adulthood, and and Morbidity Survey 2017 reported that more than
some of the unhealthy ones are eventually linked to 80% of adolescents had always washed their hands
adult morbidity and mortality (Lioret et al., 2020). after using the toilet (86.6%; 95% CI = 85.85-87.36)
The same goes for food safety practice. Children (Salleh et al., 2019). A recent study among pre-
who have the opportunity to learn about safe food schoolers in Klang Valley reported that while the
handling and consumption from their parents or majority of preschoolers gained knowledge of
other adults will develop a habit that will protect handwashing from their parents, only 63%
them against foodborne diseases as suggested by demonstrated good handwashing technique
researchers conducting recent studies in this field (Tengku Jamaluddin, 2020). This highlights the
(Zyoud et al., 2019; Syeda et al., 2021). Youths in importance to further instil the habit of doing correct
secondary schools are at a point where they are handwashing to minimise contraction of food-borne
starting to handle food for themselves. Syahira et al. diseases especially diarrhoea. In a systematic
(2019) reported that form four students in Hulu review on 22 randomised controlled trials reported
Langat district, Selangor have good level of cooking by Ejemot-Nwadiaro et al. (2008), it was concluded
ability and majority (58.8%) of them cooked at least that hand washing promotion may reduce the
a few times a week. With the high confidence in incidence of diarrhoea in children and adults by
their ability to cook, it indicates active involvement about 30%.
in food preparation and handling. Thus, instilling
good and adequate food safety knowledge and Compared to adults, infants and young children
practice is important in ensuring a good lifelong specifically tend to have a weaker immune system. KM14
food handling habits thus reducing risks associated Hence, it is important to ensure that safe water and
with foodborne diseases. safe food products are being used. Among all

methods to make water safe to drink, boiling is the
Available data suggests that nearly all cases of food- assured method that can kill disease-causing
borne diseases are caused by microbiological organisms including viruses, bacteria and parasites.
contaminants and that mishandling at some stage However, in an emergency situation where water is
of the food chain is often responsible for the contaminated with fuel or toxic chemicals, water
resulting illness highlighting the importance of good will not be made safe to consume by boiling. In this
food hygiene practices (WHO, 2020). For this situation, bottled water is the safest choice for
chapter, the Five Keys to Safer Food by WHO (2006) drinking and cooking and washing (CDC, 2020).
and published articles and guidelines have been
used as the basis or rationale for the proposed key All the food products must be well protected and be
recommendations namely; practise good personal free from insects, rodents, and pests to avoid the
hygiene, use safe water and safe food, prepare food spread of food-borne pathogens. All cooked foods
hygienically, cook food thoroughly, keep food should be cooked thoroughly in order to prevent
appropriately, read the product label, choose clean, food contamination, especially Potentially Hazardous
safe foods and drinks, use safe food containers and Food such as meat and poultry, dairy products, and
choose clean and safe premises when eating out or fish and seafood. Raw meats should be avoided for
buying food from outside. The Malaysian food children’s consumption. These perishable products
industry is governed by the Food Act 1983 and the need to be properly cooked to a temperature of 70°C
Food Regulation 1985, which protect consumer to kill almost all dangerous microorganisms (WHO,
rights, particularly in terms of food safety, hygiene, 2008). Bacteria grow best with a temperature range
and quality. A recent study reported that Malaysian between 40°C and 60°C. Maintaining food in the
consumers are becoming more aware of these temperature danger zone can cause microorganisms
standards and are making better food choices (Nasir to multiply very quickly (FAO, 2008). Improper
et al., 2018). holding temperature of food is the number one
contributing factor that leads to food borne disease
Handwashing is one of the most critical personal because spore forming bacteria like Clostridium
hygiene habits to observe when handling foods, as botulinum, Clostridium perfringens and Bacillus
it can protect consumers from being sick from cereus can still survive cooking temperatures. Food
illness-causing microorganisms. Particularly in that has been cooked should be held at a safe
children, frequent hand washing should be temperature (less than 5°C or more than 60°C).
encouraged before and after eating, including after Temperature abuse commonly occurred during storage,
each possible encounter with dirty materials, things food preparation and serving time (Lee et al., 2017).
349
Based on an intervention study conducted by Nik among parents on the use of BPA based plastics in
Husain et al. (2016), food safety training failed to consumer products such as milk bottles and food
increase knowledge of temperature control such as containers. Even though prospective studies
awareness of the temperature danger zone and the regarding the association of BPA exposure with
correct temperatures for food storage and heating long-term health outcomes are sparse, there is
among food handlers. New et al. (2017a) reported concern that BPA may act on hormonally mediated
that most of their respondents used a microwave pathways to disrupt normal growth and
oven for reheating purposes. More than 70% of the development due to its endocrinologic activity. A
respondents did not reheat food periodically nor stir recent review on BPA exposure through food
their food midway through the reheating process. highlighted that BPA has also been linked to altered
This could potentially lead to non-uniform heating neurodevelopment, obesity, and precocious puberty
leading to presence of cold spots which will allow (Almeida et al., 2018).
bacteria (if present) to survive and grow when
conditions are optimal. Any food that needs A careful selection of container material is required
reheating, particularly ready-to-eat foods, must be to avoid negative effects on the quality and safety
reheated sufficiently to reach an internal of food and beverages because the interaction
temperature of 74°C within two hours to prevent the between materials and food is influenced by many
number of organisms reaching levels that can cause factors. Most plastic products are reported to release
food borne illness (McSwane, Rue & Linton, 2005). or let different chemicals migrate into food and
Holding food at these safe temperature ranges will beverages in different amounts, depending on the
slow or stop the growth of microorganisms (WHO, storage time, temperatures and chemistry of the
2008). By practising the appropriate serving time, packaging and the food items (Muncke et al., 2020).
KM14 the risk of food poisoning can be avoided. It is important to examine any food-handling
symbols imprinted on the plastic container. A
According to Singh et al. (2019) foodborne disease standardised system of symbols is used on plastics
was likely to occur three times more frequently to indicate their appropriate uses around food. A
through cross-contamination. The occurrence of symbol depicting a cup and fork means that the
contaminated food is when foodborne pathogens plastic is safe for storing food. Other symbols
were transmitted to humans via foods as a result of include radiating waves meaning “microwave-safe,”
direct or indirect contamination while handling a snowflake meaning “freezer-safe,” and dishes in
foods. Inappropriate food handling practices such water meaning “dishwasher-safe.” (Appendix 14.3).
as the use of unwashed cooking utensils, the
sharing of chopping boards to cut wet and dry Governments, producers, industry, and consumers
ingredients, the contact between raw and cooked all have responsibilities for food safety. Food
foods are potential vehicles for cross-contamination labelling is one approach for consumers to learn
causing food poisoning (Nur Baizura & Ahmad, more about the foods they are considering
2021). purchasing. Parents especially as adult consumers
can protect their children from food-borne diseases
Furthermore, the health impact of environmental and allergic responses by properly following the
toxicants from plastic food packaging and information provided on food labels such as
containers is also a major concern among expiration dates, handling directions including
consumers. Due to the possibility of harmful preparation particularly infant formulas, and allergy
chemicals and toxins being released by certain warnings. Current food safety development not only
types of plastic, it is important to educate consumers considers microbiological, physical, and chemical
on plastic containers that are safer to be used to food hazards, but also addresses the problem of food
store food and water. Recycle symbols on food allergy, which has become a health problem due to
containers can be referred to in order to identify the the increasing prevalence and complexity of modern
code numbers that are safe for food storage. Avoid food and its globalisation (Ravishankar & Jamuna,
using plastic containers with code number 3: 2018). School-age children and older should be
Polyvinyl Chloride (PVC), number 6: Polystyrene (PS) taught on how to read expiry dates and evaluate
and number 7: Other (can contain various plastics, food quality in terms of the look, smell and taste to
such as Bisphenol A (BPA) (Appendix 14.2). promote safe food consumption practice.
Particularly on children’s health, it is a concern
350
14.4 Current Status
Food poisoning incidents have increased in recent Children and adolescence are always more likely to
years, according to statistics published by the be affected than the general population. Children
Ministry of Health Malaysia's Food Safety and under 5 carry 40% of the foodborne disease burden
Quality Division, with 5,017 cases recorded in 2013, (WHO, 2020), with these young children likely to
5,208 cases in 2014, 5,678 cases in 2015, and a total experience more severe impacts of foodborne
of 6,012 cases in 2016 (MOH 2016). The number of illness. In Malaysia, a higher percentage of food
registered cases increased 9.21 percent, which were poisoning outbreaks occur in educational
14732 cases in 2018 compared to 13490 cases in the institutions, mainly in primary and secondary
same period of 2017. The food poisoning episodes in schools followed by universities, colleges, and
Ministry of Education schools involving canteens training centres. Out of the 33 food poisoning
declined 8 percent; while food poisoning in the outbreak episodes in Terengganu occurred in 2016,
hostel kitchen increased by 7.46 percent (MOH, 23 (63.6%) involved schools (Nurbaizura & Ahmad,
2018). 2021). During the same year, Perak recorded 887
students out of the 1263 victims (New et al., 2017b).
Depending on the etiological factors, symptoms of According to the National Health Morbidity Survey
food poisoning include abdominal pain, vomiting, III (2006), the highest incidence of acute diarrheal
diarrhoea, and headache (Abd et al., 2017). A total of illness is registered by teenagers aged 15-19 years
23 medical records of patients, admitted from (7.7%), followed by children aged 0-4 years (4.5%)
January 2009 to December 2019 were reviewed. The and 5-9 years (3.4%). Food poisoning among
greatest proportion of food poisoning occurred students usually stems from consuming food
between the ages of 0 and 9 years, with a prepared in school canteens, hostel kitchens or KM14
predominance of the male gender. Malay patients under supplementary food programmes.
accounted for most food poisoning cases. All cases

of poisoning, including a mushroom poisoning case, Typhoid, cholera, hepatitis A, and dysentry
were accidental. To conclude, this study revealed Incidence rate trend for typhoid, cholera, hepatitis A
that the most common cause involved in the poisoning and dysentery showed a downward trend between
was unspecified food poisoning, followed by the year 2000 until 2006 (Figure 1). However, there
ingestion of poisonous mushrooms (Fong et al., 2021). were no remarkable changes shown from 2017 until
2019. Since 2016, the annual incidence rate for
typhoid, cholera, hepatitis A and dysentery has been
less than one per 100,000 populations (MOH, 2019).
Incidence Rate for Typhoid, Cholera, Hepatitis A and Dysentery in Malaysia, 2000 - 2019
4.5
4.0
3.5
(per 100,000 population)
3.0
Incidence Rate
2.5
2.0
1.5
1.0
0.5
0.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Typhoid 3.45 2.89 3.48 3.13 1.89 4.1 0.77 1.2 0.72 1.07 0.73 0.95 0.75 0.73 0.7 1.39 0.51 0.58 0.53 0.56
Cholera 0.53 2.32 1.49 0.54 0.35 1.48 0.89 0.49 0.34 0.98 1.53 1.91 0.96 0.58 0.45 0.79 0.52 0.01 0.5 0.25
Dysentery 1.92 1.45 1.19 1.24 1.39 0.54 0.39 0.54 0.33 0.54 0.38 0.22 0.29 0.28 0.27 0.39 0.38 0.37 0.5 0.68
Hepatitis A 2.14 1.89 1.2 0.89 0.42 0.17 0.24 0.35 0.13 0.14 0.13 1.42 1.58 0.48 0.21 0.34 0.23 0.47 0.3 0.29
Figure 14.1: Incidence rate for typhoid, cholera, hepatitis A and dysentery in Malaysia (2009 - 2019)
Source: MOH (2019)
351
Typhoid Hepatitis A
The incidence rate for Typhoid has declined for the Data for the past 10 years had shown an increase in
last 10 years. In the year 2018, the incidence rate for incidence of Hepatitis A in the year 2011 and 2012.
Typhoid was 0.53 per 100,000 populations, declined The increase in the year 2010 was due to an
as compared to the year 2017. Two states recorded outbreak among the Orang Asli community in
high incidence rates. They were Kelantan, 2.33 per Terengganu while in the year 2012 there was an
100,000 population and Sabah, 1.48 per 100,000 outbreak in Perak caused by contaminated alcoholic
population. The main risk factors linked to the beverage toddy which was produced illegally. Since
Typhoid infection were the transmission from the year 2013, the incidence rate of Hepatitis A was
carriers among food handlers, unsafe food handling stable with a rate of below one per 100,000
and unsatisfactory hygiene. In certain areas, the use populations. The Orang Asli were often linked to
of unsafe water and poor sanitation were the major Hepatitis A outbreaks due to unsafe water supply.
risk factors to Typhoid infection. However, since 2015, there have been no Hepatitis
A cases reported among the Orang Asli community.
Cholera In the year 2018, the incidence rate of Hepatitis A
Since the last 10 years, the incidence rate for Cholera was 0.3 per 100,000 populations, a slight decline as
showed a consistent trend with Sabah recording the compared to the year 2017 (0.47 per 100,000
highest incidence rate every year. In the year 2018, population). Most Hepatitis A cases reported in the
the incidence rate for Cholera was 0.50 per 100,000 year 2018 occurred sporadically and did not involve
populations, which was an increase compared to an outbreak.
the year 2017 (0.01 per 100,000 population). Out of
the total number of cases reported, 98.8% was from Food poisoning
KM14 the state of Sabah. The high incidence rate in Sabah Data for the past 10 years did not show any
was contributed by non-Malaysian comprising significant changes in incidence rates and number
65.7% of the total cases, especially among residents of episodes of food poisoning between the year 2008
who did not have any valid identification document. until 2018 (Figure 14.2). In the year 2018. A total of
The main risk factors included unsafe water supply, 500 episodes of food poisoning were reported, an
poor hygiene and sanitation. There was an imported increase compared to 404 episodes in the year 2017.
Cholera case reported in Selangor in the year 2018, The number of food poisoning episodes which
a Bangladeshi worker who had just arrived in occurred in schools in 2018 had increased slightly
Malaysia. to 143 episodes from 140 episodes in the year 2017.
Food poisoning in schools contributed to 44.8% in
Dysentery the year 2017 compared to 39% in the year 2018. In
Dysentery is a syndrome of acute infective 2018 out of 500 episodes of food poisoning, 143
diarrhoeal disease with the presence of blood in (28.6%) episodes occurred in Ministry of Education
stools caused by specific infectious agents such as (MOE) schools, 51 episodes (10.2%) occurred in
Shigella dysenteriae, E. Coli 0157, Entamoeba Non-MOE schools, 70 episodes (14%) in institutions
histolytica etc. Since the last 10 years, there has other than schools, 124 episodes (24.8%) occurred at
been no significant change in the incidence rate of homes and 112 episodes (22.4 percent) occurred in
Dysentery with an annual rate of less than one case other localities.
per 100,000 populations. In the year 2018, the
incidence rate of Dysentery increased to 0.50 per
100,000 populations from that of the year 2017. Most
of the cases occurred sporadically and did not
involve an outbreak.
352
Incidence and episodes of food poisoning in Malaysia (2008 - 2018)

600 70
500 60
(per 100,000 population)

50
400
Incidence Rate
No. of Case
40
300
30
200
20
100 10
0 0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Bilangan kes 420 303 311 434 454 494 501 409 522 404 500
Kadar insidens 62.47 36.17 43.28 57.06 44.93 49.79 58.65 47.34 55.21 42.25 45.71
Figure 14.2 : Incidence and episodes of food poisoning in Malaysia (2008 - 2018)
KM14
Source: MOH (2018)

Key Recommendation (KR) 1: Practise good personal hygiene.


Keep fingernails short and clean. Ensure the fingernails of Educate the public on the
children are short and clean. importance of practising good
personal hygiene.

Wash hands with clean water Ensure children wash hands with
and soap before and after eating clean water and soap before and
as well as after going to the after eating as well as after going
toilet, playing outside, blowing to the toilet, playing outside,
nose, coughing or sneezing and blowing nose, coughing or
handling pets or dirty materials sneezing and handling pets or
(Appendix 14.1). dirty materials. (Appendix 14.1).
- KR1: HTA3: -
Provide children with their own
set of safe cutlery.
353
Key Recommendation (KR) 2: Use and consume safe water and food
General Parents/ Caregiver Health Professional Teacher


Use clean, safe and Ensure clean, safe and Educate the public Educate children and
treated water. treated water. consuming safe water adolescents in using
and food. and consuming safe
water and food.

Boil tap water for Ensure boil tap water for
drinking. drinking.

Choose fresh, clean Ensure to select fresh,
and wholesome foods. clean and wholesome
foods.
KM14
Choose foods that are Ensure to choose foods
properly sealed and that appropriately
abelled. sealed and labelled.
Key Recommendation (KR) 3: Prepare food hygienically
General Parents/ Caregiver


Wash thoroughly fruits and vegetables that are to Ensure fruits and vegetables that are to be
be eaten raw with safe and clean water. eaten raw with safe and clean water to be
washed thoroughly.

Clean all surfaces and equipment used for Ensure to clean all surfaces and equipment
food preparation. used for food preparation.

Use clean cooking utensils during food preparation Ensure to use clean cooking utensils during food
to avoid food poisoning. preparation to avoid food poisoning.

Use separate chopping boards for cooked and raw Ensure to use separate chopping boards for
food (example: meat, vegetables and fruits). If the cooked and raw food (example: meat,
same chopping board and utensils are used, wash vegetables and fruits). If the same chopping
thoroughly between uses. board and utensils are used, wash thoroughly
between uses.
354
Key Recommendation (KR) 3: Prepare food hygienically. (cont.)


Use clean utensils when handling food rather than Ensure to handle food with clean utensils rather
bare hands as much as possible. than bare hands as much as possible.

Avoid handling foods if you have cuts, burns or Ensure to avoid handling foods if having cuts,
wounds on your hand unless properly bandaged. burns or wounds on hand unless properly
bandaged.
Key Recommendation (KR) 4: Cook food thoroughly

KM14
(to adolescents)

Cook food thoroughly, especially meat and meat Ensure to cook food thoroughly, especially meat
products, poultry, eggs and seafood. Bring foods and meat products, poultry, eggs and seafood.
like soups and stews to boil. Do not take raw meat, Bring foods like soups and stews to boil. Do not
fish and eggs. feed children with raw meat, fish and eggs.

Reheat cooked food thoroughly. Do not reheat Ensure to reheat cooked food thoroughly. Do not
foods more than once. reheat foods more than once.

Cook frozen food thoroughly before eating. Ensure to cook frozen food thoroughly before
eating.

When cooking, stir the food so that it cooks evenly. Ensure when cooking, stir the food so that it
cooks evenly.
355
Key Recommendation (KR) 5: Keep food appropriately

(to adolescents)

Do not prepare food too early. Ensure food is not prepared too Educate the public on the
Do not leave cooked food at early and do not leave cooked importance of labelling the
room temperature for more than food at room temperature for food packages/ containers with
two hours. more than two hours. dates of storage.

Serve hot foods at temperature Ensure to serve hot food at Educate the public the
above 60°C while cold foods at temperature above 60°C while importance of the “First In First
temperature below 5°C. cold foods at temperature Out (FIFO)” concept by
below 5°C. consuming the food kept
earlier.

Promptly refrigerate all cooked Ensure to promptly refrigerate all
KM14
and perishable food (preferably cooked and perishable food
below 5°C) as soon as possible, (preferably below 5⁰C) as soon as
always within two hours after possible, always within two hours
purchase. after purchase.

Do not keep hot food Ensure to keep hot food
immediately into the refrigerator, immediately into the refrigerator,
as this will cause the as this will cause the temperature
temperature of the refrigerator to of the refrigerator to rise. Wait for
rise. Wait for food to cool down food to cool down a bit before
a bit before you put it in the you put it in the fridge.
fridge.

Cooked food should not be kept Ensure that cooked food should
longer than two days in the not be kept longer than two days
refrigerator. in the refrigerator.
- KR5: HTA6: -
Ensure packed food for school or
day care centres can safely be
prepared earlier, provided they
are kept in the fridge.
- KR5: HTA7: -
Ensuring the raw and cooked food
are stored separately to avoid raw
food contaminating cooked foods
(cross contamination).
- KR5: HTA8: -
Ensure meat, poultry and seafood
are kept in the freezer
compartment.
356
Key Recommendation (KR) 5: Keep food appropriately. (cont.)

(to adolescents)
- KR5: HTA9:
Ensure that food should be
covered in a closed container,
kept at a cool and dry place,
away from chemicals and at a
suitable storage temperature.
- KR5: HTA10:
Ensure to protect kitchen areas
from insects, pests and other
animals.
Key Recommendation (KR) 6: Read the product label.

KM14

General Parents/ Caregiver Health Professional Teacher
(to adolescents)

Read the list of Ensure to read the list Encourage the public Educate children and
ingredients to get of ingredients to get on reading the product adolescents to read
information on information on allergens. label. the product label
allergens.

Read the date marking Teach children to read
on food packaging: the date marking on
food packaging:
a. EXPIRY DATE/ USED BY/ CONSUMED BY -

The final date in which product should not be
sold or consumed due to food safety and
quality reasons (such as milk, yoghurt, cream
and eggs).
b. BEST BEFORE - The date of minimum

durability of food under any stated storage
condition due to food safety and quality reasons
(such as bread, frozen foods and canned
products).

Follow the food storage Ensure children follow
and food preparation the food storage and
instructions on the label. food preparation
instructions on the label.
357
Key Recommendation (KR) 7: Choose clean, safe foods and drinks.
General
Parents/ Caregiver Teacher

Choose food that is still hot, Choose food that is still hot, fresh Teach children to use their
fresh and kept in a clean and kept in a clean container. senses (see, smell, taste) to
container. recognise contaminated or
spoiled food.

Teach children to use their senses Remind children against
(see, smell, taste) to recognise sharing drinking bottles
contaminated or spoiled food. because of the risk of infection.

Discard all leftover foods and Remind children to avoid
drinks brought back from school. sharing cutleries.
KM14
- KR7: HTA4: -
Discard unfinished pasteurised or
packed milk which is not
consumed within two hours

storage at room temperature.
- KR7: HTA5: -
Children should be warned
against sharing drinking bottles
because of the risk of infection.
- KR7: HTA6: -
Avoid sharing spoons when
feeding children.
358
Key Recommendation (KR) 8: Use safe food containers.

(to adolescents)

Refer to the number of the recycle symbol stamp Avoid placing/ pouring hot food or beverage
under plastic containers. Choose plastics that directly into a plastic container or bottles.
are safe to use as food storage containers
including (Appendix 14.2):
A. Plastic #1: PET or PETE (Polyethylene
Terephthalate)
B. Plastic #2: HDPE (High Density Polyethylene)
C. Plastic #4: LDPE (Low Density Polyethylene)
D. Plastic #5: PP (Polypropylene)

Avoid using as food storage containers including: Ensure to refer to the number of the recycle
Plastic #3: PVC (Polyvinyl Chloride) symbol stamp under plastic containers. Choose
Plastic #6: PS (Polystyrene) plastics that are safe to use as food storage
KM14
Plastic #7: Other (can contain various plastics, containers including (Appendix 14.2):
such as Bisphenol A (BPA) Plastic #1: PET or PETE (Polyethylene
Alternatively, choose ‘BPA free’ bottles. Terephthalate)

Plastic #2: HDPE (High Density Polyethylene)
Plastic #4: LDPE (Low Density Polyethylene)
Plastic #5: PP (Polypropylene)

Examine any food-handling symbols imprinted on Ensure to avoid using as food storage containers
the plastic container (Appendix 14.3). including:
Plastic #3: PVC (Polyvinyl Chloride)
means that the plastic is safe for Plastic #6: PS (Polystyrene)
storing food. Plastic #7: Other (can contain various plastics,
such as Bisphenol A (BPA)
meaning “microwave-safe,” Alternatively, choose ‘BPA free’ bottles.
meaning “freezer-safe,”
meaning “dishwasher-safe.”
- KR8: HTA4:
Examine any food-handling symbols imprinted
on the plastic container (Appendix 14.3).
means that the plastic is safe for storing food.
meaning “microwave-safe,”
meaning “freezer-safe,”
meaning “dishwasher-safe.”
359
Key Recommendation (KR) 9: Choose clean and safe premises when eating out or buying food
from outside.


Choose food premises that are clean and tidy: Ensure to choose food premises that are clean
a. located far away from street, rubbish dumps, and tidy:
clogged drains, septic tanks or waste a. located far away from street, rubbish
disposals. dumps, clogged drains, septic tanks or waste
b. with running pipe water, proper drainage disposals.
system, and covered rubbish bin. b. with running pipe water, proper drainage
c. free from signs or presence of pets, rodents, system, and covered rubbish bin.
pests and insects. c. free from signs or presence of pets, rodents,
pests and insects.

Choose food premises where the food handlers Ensure to choose food premises where the food
practise good personal hygiene and habits at handlers practise good personal hygiene and
work such as wearing a hair restraint (hat or hair habits at work such as wearing a hair restraint
KM14
net). (hat or hair net).

Choose premises that serve properly-covered Ensure to choose premises that serve properly-
food and beverages. covered food and beverages.

Choose premises that use crockery, cutlery and Ensure to choose premises that use crockery,
utensils that are clean and in good condition and cutlery and utensils that are clean and in good
use them in the correct way. condition and use them in the correct way.
360
14.6 References
Abdul Mutalib, N.A., Syafinaz, A.N., Sakai, K., & Shirai, Y. (2015). An overview of food borne illness and food
safety in Malaysia. International Food Research Journal, 22(3): 896- 901.
Abd W, Lani, M., Zin, W., Abdullah, W.Z.W., Chilek, T.Z.T., & Hassan, Z. (2017) A review on incidences of
foodborne diseases and interventions for a better national food safety system in Malaysia. Malays
Appl Biol 46: 1–7.
Almeida, S., Raposo, A., Almeida González, M., & Carrascosa, C. (2018). Bisphenol A: Food exposure and
impact on human health. Comprehensive Reviews in Food Science and Food Safety, 17(6), 1503-1517.
CDC (2020). Making water safe in an emergency. Centers for Disease Control and Prevention. Retrieved on
20 October 2021.https://www.cdc.gov/ healthywater/emergency/drinking/making-water-safe.html
Colton Blairin (2022). Which Plastics are Safe for Food Storage and How to Use Them.
https://ezprepping.com/which-plastics-are-safe-for-food-storage-and-how-to-use-them/
Campos, A.K.C., Cardonha, A.M.S., Pinheiro, L.B.G., Ferreira, N.R., Azevedo, P.R.M. & Stamford, T.L.M. (2009).
Assessment of personal hygiene and practices of food handlers in municipal public schools of Natal,
Brazil. Food Control 9 (20): 807-810.
Dan Brennan (2021, Dec 17). The Facts About Bisphenol A. https://www.webmd.com/children/bpa KM14
Ejemot-Nwadiaro, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M., & Critchley, J. A. (2008). Hand washing

promotion for preventing diarrhoea. Cochrane database of systematic reviews, (1).
FAO (2008). Risk–based food inspection manual. Food and Nutrition Paper 89. Food and Agriculture
Organization, Rome.
FAO (2013, May). Foodborne disease monitoring and surveillance systems.

www.fao.org/docrep/meeting/006/j2381e.htm (accessed 20 May 2015).
Fong, X.K., Phan, C.W., Shamsuddin, N., Zulkifli, L.M., Tan, Y.S. & Sabaratnam, V. (2021). Poisoning Cases of
Noxious Substances Eaten as Food: A Retrospective Study at a Teaching Hospital In Malaysia.
Malaysian Journal of Public Health Medicine 21 (2): 178-189.
Hejar, A., NorAfiah, M., Hayati, K., Salmiah, S., Yusma, M. & Titi, R. (2011). Cleanliness of food premises in
Bahau. Malaysian Journal of Public Health Medicine, 11(Supp 3):31
Lee, H.K., Abdul Halim, H., Thong, K.L. & Chai, L.C. (2017). Assessment of food safety knowledge, attitude,
self-reported practices, and microbiological hand hygiene of food handlers. International Journal of
Environmental Research and Public Health, 14(1), 55.
Lioret, S., Campbell, K. J., McNaughton, S. A., Cameron, A. J., Salmon, J., Abbott, G., & Hesketh, K. D. (2020).
Lifestyle patterns begin in early childhood, persist and are socioeconomically patterned, confirming
the importance of early life interventions. Nutrients, 12(3), 724.
Lupilon (2021, June 23). What Do the Symbols on Plastic Food Containers Mean? https://iupilon.com/what-
do-the-symbols-on-plastic-food-containers-mean/
McSwane, D. Z., Rue, N. R., & Linton, R. (2005). Essentials of food safety and sanitation. 4th edition. Pearson
College Division.
MOH (1985). Food Regulations 1985. Ministry of Health Malaysia, Kuala Lumpur.
MOH (2008). Health Education Division, Ministry of Health Malaysia, Putrajaya
361
MOH (2010). Malaysia Health Facts 2010. Planning Division Health Informatics Centre, Ministry of Health
Malaysia, Putrajaya. 11(August), 1–4.
Malaysia, Putrajaya.
Malaysia, Putrajaya. 1–19.
MOH (2016). Annual Report 2016. Disease Control Division, Ministry of Health Malaysia. Putrajaya.
MOH (2018). Annual Report 2018. Disease Control Division, Ministry of Health Malaysia. Putrajaya.
MOH (2019). Annual Report 2019. Disease Control Division., Ministry of Health Malaysia. Putrajaya.
Muncke, J., Andersson, A.M., Backhaus, T., Boucher, J.M., Almroth, B.C., Castillo, A.C., Chevrier, J., Demeneix,
B.A., Emmanuel, J.A., & Fini, J.B. (2020) Impacts of food contact chemicals on human health: A
consensus statement. Environ. Health 2020, 19, 1–12.
Nasir, Noreina, K., Jusoh, Nur Aniza, Q.M., & Ying, T.S. (2018). The Use of Information on Food Labels: The
Consumers’ Perspective in Malaysia. Advanced Science Letter 5(24): 3274-3278(5).
https://doi.org/10.1166/asl.2018.11357.
KM14
NCCFN (2013) – Malaysian Dietary Guidelines for Children and Adolescents 2013. National Coordinating
NCCFN (2020). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and Nutrition,
Ministry of Health Malaysia, Putrajaya.
New, C.Y., Thung, T.Y., Premarathne, J.M.K.J.K., Russly, A.R., Abdul Karim, S.M. & Son, R. (2017a) Microwave
oven safety: A food safety consumer survey in Malaysia. Food Control. 80:420–427.
New, C.Y., Ubong, A., Premarathne, J.M.K.J.K., Thung, T.Y., Lee, E., Chang, W.S., Loo, Y.Y., Kwan, S.Y., Tan,
C.W., Kuan, C.H. & Son, R. (2017b) Microbiological food safety in Malaysia from the academician’s
perspective Food Research 1(6): 183-202
NHMS (2006). Laporan Tinjauan Kesihatan dan Morbiditi Kebangsaan (National Health Morbidity Survey
III). Kementerian Kesihatan Malaysia, Putrajaya.
Nik Husain, N.R., Wan Muda, W.M., Noor Jamil, N.I., Nik Hanafi, N.N. & Abdul Rahman, R. (2016). Effect of
food safety training on food handlers’ knowledge and practices. A randomized controlled trial. British
Food Journal. 2016; 118(4): 795–808.
Nik Rosmawati, N.H., Wan Manan, W.M., Noor Izani, N.J., Nik Nurain, N.H. & Razlina, A.R. (2016). Effect of
food safety training on food handlers’ knowledge and practices. British Food Journal 4 (118): 795 –
808. http://dx.doi.org/10.1108/BFJ-08-2015-0294
Nur Baizura, A.A. & Ahmad Filza, I. (2021). Food poisoning outbreaks among schoolchildren in Terengganu
and their associated factors Sains Malaysian 50(4): 1027-1036.
Ravishankar, V.R. & Jamuna, A.B. (2018). Food Safety and Protection. CRC Press. Taylor & Francis Group.
Ryu, J.H., Ko, J., Park, H., Yang, S. & Kim, H. (2011). Microbial examination of non-heated foods served in
feeding programs of elementary schools, Iksan City, Jeonbuk Province, Korea. Journal of Food
Protection 9 (74): 1564-1568.
362
Salleh, W., Lani, M.N., Abdullah, W.Z.W., Chilek, T.Z.T. & Hassan, Z. (2017). A review on incidences of
foodborne diseases and interventions for a better national food safety system in Malaysia. Malaysian
Applied Biology 46(3): 1-7.
Salleh, N.C., Anuar, M.F.M, Abdullah, N.A., Yaw, S.L., Wong, N. I., Pei, T.T., Awaluddin, S.M. & Aris, T. (2019)
Prevalence and Factors Associated With Oral and Hand Hygiene Practices Among Adolescents in
Malaysia: Findings From the National Health and Morbidity Survey 2017. Asia Pacific Journal of Public
Health 31(8_suppl):97S-104S.
Soon, J., Singh, H. & Baines, R. 2011. Foodborne diseases in Malaysia: A review. Food Control 22(6): 823-
830.
Shafiza Ezat, W.P., Neety, D. & Sangaran, G. (2013). Paper Reviews of factors, surveillance and burden of
food borne disease outbreak in Malaysia. Malaysian Journal of Public Health Medicine 13: 98-105.
Singh, M., Walia, K., & Farber, J. M. (2019). The household kitchen as the ‘last line of defense’ in the
prevention of foodborne illness: A review and analysis of meat and seafood recipes in 30 popular
Canadian cookbooks. Food Control, 100, 122-129
Syahira, S., Huda, B.Z. & Mohd Rafee, B.B. (2019). Factors associated with level of food safety knowledge
among form four students in Hulu Langat District, Selangor. International Journal of Public Health
and Clinical Sciences 6(2):252-265
KM14
Syeda, R., Touboul Lundgren, P., Kasza, G., Truninger, M., Brown, C., Lacroix Hugues, V.,... & McNulty, C. A.
M. (2021). Young People’s Views on Food Hygiene and Food Safety: A Multicentre Qualitative Study.

Education Sciences, 11(6), 261.
Tengku Jamaluddin, T.Z.M., Mohamed, N.A., Mohd Rani, M.D., Ismail, Z., Ramli, S., Faroque, H., Abd Samad,
F.N., Ariffien, A.R., Che Amir Farid, A.A.R. & Isahak, I., 2020. Assessment on Hand Hygiene Knowledge
and Practices Among Pre-school Children in Klang Valley. Global Pediatric Health, 7,
p.2333794X20976369.
WHO (2006). Guidelines: A guide to healthy food markets. World Health Organization, Geneva.
WHO (2008). Food and Agriculture Regional Asia Pacific. Preventing Food-borne Illness from Farm to Plate
Highlights of Best Practice. The World Health Organization : Geneva.
WHO (2015). Estimates of the global burden of foodborne diseases. World Health Organization, 1–255.
WHO (2020). Food Safety. Retrieved on 20 October 2021. https://www.who.int/en/news-room/fact-

sheets/detail/food-safety
Zyoud, S. E., Shalabi, J., Imran, K., Ayaseh, L., Radwany, N., Salameh, R. & Al-Jabi, S. (2019). Knowledge,
attitude and practices among parents regarding food poisoning: a cross-sectional study from
Palestine. BMC Public Health, 19(1), 1-10.
363
Appendix 14.1
Keep your
hands clean
!"#$%&'()%
$"*+#%,)',-).&
KM14 #;186
Lather hand Rub your palms Rub each finger and Scrub nails on
with soap between fingers palms
!"#$%&$'()#*+&,-(
+#,.*/
• After using the toilet
• Before eating
• Before and while
preparing food
• When you touch raw
food materials,
contaminated surfaces;
your face, nose,
ears or other parts of
Rub back of hands Wash hands with Dry hands with clean the body
and between fingers sufficient clean water cloth or tissue • Whenever your hands
are dirty
/0123%42356%723%891:13;%5<61261=
>41%74?<71%<6%<3%@?A9%42356
!"#"$%&'()*(+,-.%+(!-.-'$"-
Published by: Health Education Division, Ministry of Health Malaysia
www.infosihat.gov.my, www.myhealth.gov.my
(MOH, 2008)
364
Appendix 14.2
Recycle symbols usually on the bottom of the container are as below:
1 2 3 4 5 6 7
PETE HDPE PVC LDPE PP PS OTHER
*Numbers 1 – 7 are used to refer to the different types of plastics inside the recycling triangle
diagram.
Safe Avoid Description
Plastic #1 PET or PETE – (Polyethylene Terephthalate) – clear, strong and

lightweight plastic that makes it a good option for storing water and food
even for the long term.
Plastic #2 HDPE (High-Density Polyethylene) – impact-resistant, long-lasting, and KM14

weather resistant. Work well as water containers for things like washing
your dishes or cleaning your clothes, not for drinking unless you can

clean them thoroughly. There are several durable food-grade buckets
that are made from HDPE that work great for storing food for the long-
term.
Plastic #3 PVC – (Polyvinyl Chloride) – rigid or flexible, in items like bibs, teething
rings, and sandwich bags. It contains numerous toxic chemicals
including lead and phthalates.
Plastic #4 LDPE (Low-Density Polyethylene) – considered less toxic than other

plastics and safe for use.
Plastic #5 Plastic #5: PP – (Polypropylene) – tough, lightweight, and has a high

heat resistance so it is unlikely to leach chemicals as many other
plastics do.
Plastic #6 Plastic #6: PS — (Polystyrene) – rigid, in items like egg cartons,

Styrofoam cups, and plasticware. Can leach styrene, a known
neurotoxin along with other harmful health effects.
Plastic #7 Plastic #7 Plastic #7: – Plastic #7 is the recycling code for plastics that can contain
BPA and although some #7 plastics don’t, it is a good idea to avoid
using it to store food if possible.
(Colton Blairin, 2022)
365
Appendix 14.3
Plastic container safety symbols
KM14
Food safe Microwave-safe
Freezer-safe Dishwasher-safe
(Lupilon, 2021)
366
Key Message 15
Educate children and adolescents on the use of

nutrition information on food labels
KM15
Educate children and adolescents on the use of nutrition information on food labels
Key Message 15
Educate children and adolescents on the use of

nutrition information on food labels
Dr. Emmy Hainida Khairul Ikram, Dr. Ng See Hoe, Ms. Siti Dinie Syazwani Azlam, Ms. Noryanti Rahmat,
Ms. Rabia’atuladabiah Hashim and Ms. Norlaily Md Nasir
15.1 Terminology
Food label brand equity characters, toy, price discount, and

A food label includes any tag, brand, mark, pictorial premium) (WHO, 2012).
or other descriptive matter, written, printed,
stencilled, marked, painted, embossed or impressed Front-of-Pack Nutrition Labelling (FOP-NL)
on or attached to or included in, belonging to or Front-of-pack nutrition labelling (FOP-NL) is any
accompanying any food (MOH, 1983). system that presents simplified nutrition information
on the front-of-pack of pre-packaged foods. This
Food marketing includes but is not limited to symbols/graphics, text
All forms of commercial communications or or a combination thereof, that provide information
messages with the effects to increase recognition, on the overall nutritional value of the food and/or on
appeal and/or consumption of particular food the nutrients (FAO/WHO, 2019).
products. These include direct and indirect
advertising or promotion of a product or brand Ingredient list
through a variety of media channels (e.g. television, A statement on food labels to show all the used
radio, print, billboards, the Internet, or personal ingredients to produce the particular product. The
contact at point-of-sale) and related marketing ingredients are listed in descending order of proportion
techniques (e.g. sponsorship, product placement, by weight, from the most to the least (MOH, 1985).
368
Nutrition claims Pre-packaged food

Nutrition claim is any claim made on a label of a Pre-packaged food is food packaged or made up in
food product pertaining to its nutritional quality advance in a container, ready for offer to the
(FSQD, 2023). consumer, or for catering purposes. A package
includes anything in which or any means by which
Nutrition information or labelling food is wholly or partly cased, covered, enclosed,
Nutrition information on food labels is often taken contained, placed or otherwise packed in any way
to include nutrition labelling, nutrition claims, whatsoever and includes any basket, pail, tray or
authorised front-of-pack nutrition labelling system receptacle of any kind whether opened or closed
as well as ingredient list. (MOH, 1983).
Nutrient declarations Quantitative ingredient declaration (QUID)

Nutrient declarations are a standardised listing of Quantitative Ingredient Declaration (QUID) is
the nutrient content of a food (WHO, 2022). required when one or more ingredients used in the
manufacturing of a food are being emphasized on
Nutrition information panel (NIP) the label either through word, pictures or graphics.
The nutrition information panel (NIP) or a nutrition QUID is also required if the ingredient is not within
label is a table found in one section of a food label the product name but that ingredient is essential to
declaring the amount of energy, carbohydrate, total characterize the food.
sugars, protein and fat, as well as vitamins and
minerals contained in the food (FSQD, 2023).
KM15
15.2 Introduction
Nutrition labelling on food products has emerged as achieve optimal nutritional well-being. Several
a major policy tool for healthy eating promotion. combat strategies and intervention programmes
Children and adolescents are the future for the that include nutrition labelling have been identified
nation, therefore promoting and inculcating healthy to address the food and nutrition challenges such as
eating and active living lifestyle from childhood is the nutritional deficiencies, diet-related diseases as
significantly crucial to improve the nutritional well- well as over-nutrition that currently encountered by
being of the population and achieve total fitness and the people in the country (NCCFN, 2016). Nutrition
wellness. Hence, educating and empowering information on food label is a cost-effective
children and adolescents to make appropriate food population-level intervention and should be widely
choices have been identified as an effective long- accessible, such as at food outlets and on pre-
term strategy towards promoting healthier food packaged foods (Campos et al., 2011; Waddell et al.,
consumption pattern. One of the ways of doing this 2018; Roberto et al., 2021).
would be to familiarise the children with nutrition
information on food labels and provide sufficient Establishing a conducive environment to support
guidance to make effective use of those nutrition comprehensive advocacy of the use of nutrition
information to make appropriate choices in every information on food labels is critical, enabling a
possible occasions. better exposure and awareness among children and
adolescents towards reading food labels. This
There is no doubt that the habit of reading nutrition requires whole-of-government and whole-of-society
information on food labels should be inculcated from approaches, with collaborations including
childhood. When they are able to read the food corresponding government agencies, parents and
labels by themselves, this will facilitate the caregivers, civil society, the private sector, academia
identification of nutrition information and nutritional and media. The collaboration principles should
quality judgement of the food products, guiding centre on public health nutrition interests, helping
them in making better food choices. After all, the children and adolescents to recognise the benefits
habit of reading nutrition information on food labels of reading food labels and enabling them to make
becomes the tool for them to make healthful choices effective use of nutrition information on food labels
throughout their lives (USFDA, 2022; Roberto et al., to choose products that caters for their nutritional
2021; Wang et al., 2022). needs. Only with the support from all parties, the
use of nutrition information on food labels could be
The National Plan of Action for Nutrition of Malaysia more accessible and transformed into a social norm,
III (NPANM) 2016-2025 has been developed and contributing as part of the nutrition interventions to
served as the national blueprint for Malaysians to build a healthy and well-being nation.
369
The Malaysian government developed Food Act information and convince consumers to purchase.
1983 and Food Regulations 1985 to safeguard Noteworthy, factual information on food labels often
consumers, and consistently revising these based intertwines with persuasive food marketing
on the emerging scientific evidence to ensure only techniques, posing risks for consumer confusion,
safe and quality foods could be prepared and offered particularly in children and adolescents and
in the local market (MOH, 1983 & MOH, 1985). In challenging them to make healthy food choices
addition, the government introduced several (WHO, 2022; Lei et al., 2022). Therefore, children and
nutrition policies and programmes to make nutrition adolescents need to be educated and empowered
information accessible to the public, facilitating to use the nutrition information on food labels,
informed food choices for healthy diets. Food labels making this lifelong skill to be part of the healthy
serve as a communication medium by the food dietary practises from a young age.
industries to convey general and nutrition
15.3.1 Nutrition information on food labels 15.3.1.1 Nutrition information panel (NIP)
Nutrition information on food labels is a trending Nutrition labelling is a useful educational tool that
issue on the global stage, urging Member States to describes the ingredient lists, nutrient declarations,
implement as a policy tool, as cited in some of the supplementary nutrition information (which
official WHO documents that adopted by the World includes front-of-pack nutrition labelling), and
KM15 Health Assembly (WHO, 2021). The current food nutrition and health claims. The nutrients might be
environment exposes consumers to powerful food declared as a table format in one section of a food
marketing, predominantly on foods that undermine label, commonly known as a nutrition information
healthy diets and often with misleading nutrition panel (NIP). In Malaysia, NIP is compulsory to be
labelling. Therefore, the call of empowering declared for selected foods under Food Regulations
consumers would be timely, creating a healthy food 1985 - Clause 18B (2) as follows:
environment that integral with nutrition labelling.
This will have an intergenerational impact on • A total of 163 food types, including: pasta,
children and adolescence, particularly those who are breakfast cereals, bread; milk and milk
adolescent girls, ensuring these young populations products; sweetening creamer; flour confection;
have an optimal nutritional status (WHO, 2020; meat products and canned meat; fish products
WHO, 2021). and canned fish; preserved egg; edible fats and
oil; vegetable products and juices; soup and
Nutrition information on a food label would include soup stock; fruit products and juices; jam, fruit
nutrition information panel (NIP), nutrition claims, jelly marmalade and seri kaya; nuts and nut
front-of-pack nutrition labelling (FOP-NL) and products; premix coffee; chocolate, milk
ingredient list. Such information is particularly chocolate, milk shake; sauces, salad dressing,
important to assist consumers in making informed mayonnaise, chutney and pickle; soft drinks;
food choices when planning their daily diets. Figure and isotonic electrolyte drink as listed in the
15.1 shows a food label example with all the Appendix 1 (MOH, 1985).
common nutrition information. Nutrition labelling,
nutrition claims and ingredient list are regulated Foods making nutrition claims.
under the context of Food Regulations 1985 (MOH
1985). Meanwhile, energy icon and Healthier Choice • Foods that “contain” or “added” (or words of
Logo Malaysia are authorised FOP-NL that similar meaning) or “enriched” or “fortified” (or
implementing in Malaysia to complement nutrition words of similar meaning) with specific
information on food labels and facilitate consumer vitamins, minerals, amino acids, fatty acids,
understanding of the nutritional quality of food nucleotides or other food components (with
products. permitted other function claims).
• Special purpose foods: infant formula, follow-up

formula, canned food for infants and young
children and cereal-based food for infants and
young children.
370
N V I TA
GA M
IN
N
E
D
P E NUH
TA M I N
V I
3b
E
N
N A
UH G
D E N
2 KALSIUM
Inilah yang kita perlukan

Perbandingan produk dalam
kategori susu berperisa sahaja
untuk membantu
pertumbuhan tulang dan
gigi yang kuat.
PROTEIN
Ia membantu dalam
membina dan membaiki KM15
tisu-tisu badan anda.
4 Bahan Ramuan:
Pepejal Susu, Serbuk Koko,
Gula, Mineral (Kalsium), Bahan Perisa,
Penstabil (INS407), Bahan Pewarna (INS150C),
SUSU
Bahan Pemanis (INS 995)
1
BERPERISA
MAKLUMAT PEMAKANAN
Size hidangan : 200ml
COKLAT
Jumlah hidangan : 5
Setiap Setiap Hidangan

100ml (200ml)
Tenaga 48 kcal 96 kcal
Karbohidrat 4.2 g 8.4 g
3a
Jumlah gula 6.8 g 13.6 g
Dihomogenkan
kan
Laktosa 5.8 g 11.6 g
dan
Protein 2.6 g 5.2 g
Setiap hidangan Lemak 2.3 g 4.6 g
(200ml) mengandungi
Dipasteurkan
kan Vitamin D 1.0 2.0
tenaga
Vitamin B6 0.5 mg 1.0 mg
96kcal
Vitamin B12 0.4 0.8
5% Kalsium 130 mg 260 mg
Berdasarkan
2000 kcal
1 Nutrition
2 3a 3b Healthier
4
Nutrition Energy Choice Logo Ingredient
Information Panel
Claims Icon (HCL) List
(NIP)
3
Front-of-Pack Nutrition Labelling
(FOP-NL)
Figure 15.1: Example of food label with all the common nutrition information.
Source: MOH (2019)
371
Meanwhile, there are foods exempted from the When NIP is factually and informatively provided,
nutrition labelling requirements. For instance, fresh this can assist consumers to make better food
fruits and vegetables, raw meat and poultry (except choices and plan for their daily meals. This nutrition
when grounded), raw fish and seafood, foods information on food labels enables consumers to
prepared or processed at the store (e.g., bakery judge the nutritional quality of a food based on the
items, salads), foods that contain very few nutrients containing energy and nutrients of concern such as
(e.g., coffee, tea, herbs and spices) and alcoholic carbohydrate, total sugars, protein, fat and sodium,
beverages. as well as other vitamin and mineral contents, along
with other general information such as ingredient
The regulations require the information of energy list, storage conditions, instructions for use and
content and all the mandatory nutrients must be expiry date. In addition, consumers could optimise
declared in each serving of a food. For a product that ‘per 100g or per 100ml’ information to compare
contains more than one serving, the nutrition nutrition information on food labels across different
information should also be expressed in ‘per 100g’ brands, selecting food products with the highest
or ‘per 100ml’. Also, the serving size should be stated nutritional quality and value for money. The
on the label. Regarding the unit declaration, energy standardised NIP in the market could further
(calorie) can be labelled in kilocalories (kcal), simplify the whole concept of healthy eating,
kilojoules (kJ) or both formats. For mandatory providing consistent, understandable, and usable
nutrients like carbohydrate, total sugars, protein and cues of nutritional composition of the product for
fat, these must be declared in gram (g), while consumers to make informed and healthier food
sodium to be labelled in milligram (mg). A sample of choices.
NIP, declaring only the mandatory or core nutrients,
KM15 is given in Table 15.1. Food labelling had some positive effects on
consumer choices, including reductions of calorie
Asides from the mandatory nutrients, optional and total fat intakes, as well as less selection of
nutrients may also be included in the NIP. For unhealthy food choices (Benajiba et al., 2020). Miller
instance, dietary fibre and cholesterol contents may et al. (2015) conducted a review and found that most
be declared without a minimum threshold criterion, studies reported nutrition knowledge to be
while vitamin and mineral declarations are limited significantly associated with consumer use and
to products containing at least 5% of the comprehension of nutrition labelling. Notably,
corresponding Nutrient Reference Value. Similarly, studies examined in this review included findings
these optional nutrients should be labelled in ‘per from both subjective and objective measures, as
100g or per 100ml’ and ‘per serving’ formats as well as a small representation of the young age
shown in Appendix 2. population between 17 and 18 years old. Campos et
al. (2011) highlighted variations in the use of
Table 15.1: A sample of NIP with only mandatory nutrients
Nutrition Information
Serving size: 200 ml
Serving per package: 5
Per 100 ml Per serving (200 ml)
Energy (kcal) 100 200
(kJ) 420 840
Carbohydrate (g) 23.8 47.6
Total sugars* (g) 11.5 23.0
Protein (g) 1.1 2.2
Fat (g) 0 0
Sodium (mg) 0 0
*Total sugars refer to all monosaccharides and disaccharides contained in the food
Source: MOH (1985)
372
nutrition labelling across socio demographic groups, prohibited health claims (verbal or written
with relatively lower use found in children and messages) that are often marketed on the need to
adolescents, as well as individuals with lower consume excessive amounts of such products and
income and older adults who are obese. Evidence omit specific food groups that are critical in
also shows a consistent link between the use of maintaining a healthy diet.
nutrition labels and healthier diets. A systematic
review reported that educational interventions, even The following subsections elaborate on the
in a one-off briefing would significantly improve permitted nutrition claims in the Malaysian market
consumer understanding and usage of the nutrition and the impact of nutrition claims on children and
information on food labels (Moore et al., 2018). Such adolescents.
improvements were reported among children and
adolescents, as evidenced by studies conducted in a. Nutrient content claims
the United States (Sanders et al., 2015; Wolfe et al.,
2018) and India (Gavaravarapu et al., 2016). Nutrient content claims feature the level of a
nutrient contained in a food product. Such claims
15.3.1.2 Nutrition claims can be made for protein, dietary fibre, alpha-linolenic
acid, ganglioside and 13 vitamins, as well as 11
Nutrition claims are permitted on food labels, minerals. Examples of permitted nutrient content
governing under the Food Regulations 1985 - claims are “source of vitamin C” or “high in
Clauses 18A to 18E (MOH, 1985). In Malaysia, there calcium”. Such featured nutrients might be
are five permitted types of nutrition claims that characterised as ‘good nutrients’ that bear health
include: benefits and encourage consumption. In contrast,
another type of nutrient content claim features ‘bad KM15
a. Nutrient content claim nutrients’, including energy and nutrients of
b. Nutrient comparative claim concern such as fat, saturated fat, cholesterol, trans-
c. Nutrient function claim fatty acids, sugars and sodium. Despite all energy
d. Other function claim and nutrients (except trans-fat) being essential to
e. Nutrient enrichment or fortification support normal body functions, ‘bad nutrients’ are
claim often perceived to pose unhealthy dietary risks thus
discouraging excessive intakes. For instance, “low
These claims are in line with the guidelines of the in cholesterol” or “trans-fat free”. Nutrient
Codex Alimentarius, a set of international standards thresholds for the permitted nutrient content claims
and guidelines established by the Joint Food in Malaysia can be refer in FSQD (2023).
Programme of the Food and Agriculture
Organization (FAO) and the World Health b. Nutrient comparative claims
Organization (WHO). If a food label declares any
nutrition claims mentioned above, mandatory Nutrient comparative claims compare energy and/or
nutrition labelling must be complied by labelling the nutrient levels of two or more foods. The difference
amount of all the mandatory core energy and in energy or nutrient levels must achieve at least
nutrients (i.e., carbohydrate, total sugars, protein, fat 25%, while micronutrient sets as at least 10%
and sodium), as well as the nutrient and/or other variations (FSQD, 2023). “Less fat”, “reduced salt”,
food components that being claimed. “extra vitamin A”, and “more protein” are examples
of the nutrient comparative claims permitted in
Disease risk reduction claims link consumption of a Malaysia.
food or food component to reducing the risk of
developing a disease. For instance, “Nutrient A helps c. Nutrient function claims
reduce risk of coronary heart disease”. Noteworthy,
such claims are not permitted in Malaysia. The third type of nutrition claims is the nutrient
Consumers should realise that chronic diseases are function claim, describing the physiological role of
multifactorial and taking a particular nutrient or food the nutrient in growth, development and normal
component alone will not reduce the risk of diet- functions of the body. An example of such claims is:
related diseases like coronary heart diseases, calcium helps in the development of strong bones
diabetes and cancers. Practising healthy lifestyles and teeth. The Ministry of Health gazetted 23
with an emphasis on healthy eating patterns should permitted nutrient function claims for 15 vitamins
be the core principle centred on population health and minerals, with supporting scientific evidence
and nutrition. This will prevent consumers to be over a long time (FSQD, 2023).
deceived by products with misleading and
373
d. Other function claims In Uruguay, Arrúa et al. (2017a) evaluated the impact
of labelling designs on children aged 9 to 13 years.
Besides the classic nutrients like macronutrients, One of the tested labelling was nutrition claims, of
vitamins and minerals, specific food components which yoghurt was labelled as containing calcium
contained in foods could be declared as other plus vitamin D and sponge cake was enriched with
functions claims, emphasising its beneficial health iron and folic acid that both consist of high sugar
or improvement effects on the body functions. For content. Findings showed that children’s preference
instance, plant sterol helps to lower blood for these products was not significantly influenced
cholesterol; and oat soluble fibre (beta-glucan) helps by nutrition claims but by low-income families.
to lower blood cholesterol. In Malaysia, 43 permitted Although products with nutrition claims did not
other function claims for 22 food components have establish children’s preferences (Arrúa et al., 2017a),
been approved by the Ministry of Health, based on findings from the same research group found that
the recent scientific evidence (FSQD, 2023). Only such products significantly caused a positive impact
other function claims that listed in Food Regulations on children’s choices. For instance, Ares et al. (2016)
1985 are permitted to be declared on food labels, of noticed this impact on the same tested yoghurt and
which the majority are non-nutrients. sponge cake labels, whereas Arrúa et al. (2017b)
found a similar impact on high sugary orange juices
e. Nutrient enrichment and fortification that contained Vitamin C.
claims
15.3.1.3 Ingredient list
The fifth type of nutrition claims relates to the
enrichment or fortification of nutrients and other Ingredients that are used to formulate a product will
KM15 food components to foods. Such claims often determine its nutritional value. In Malaysia, all pre-
associate terminologies such as “contain”, “added”, packaged food products must declare the ingredient
“enriched”, “fortified”, or equivalent, with specific list on food labels. The ingredients are listed in the
vitamins, minerals, amino acids, fatty acids, order of weight, from the most to the least. For
nucleotides, or other food components for permitted example, if the first few ingredients are whole grains
other function claims. Foods with these claims must such as whole-grain wheat, oat, or barley, the
meet the specified minimum level of nutrients or product contains a high proportion of whole grains.
other food components as stipulated by Food Likewise, if sugars or equivalent terms form the first
Regulations 1985 (FSQD, 2023). Examples of nutrient few ingredients, the food is high in sugars (Tee et al.,
addition claims are “this beverage contains 2019). It should also be noted that an ingredient can
prebiotics” or “this milk powder has added DHA”; be labelled in different terms, such as sugars
whereas “this bread is enriched with vitamin B2” or equivalent terms in the ingredient list include
“this flour is fortified with iron” refer to nutrient sucrose, glucose, fructose or corn syrup. For health-
enrichment or fortification claims. conscious consumers, reading the ingredient list
would guide them to comprehend better about the
Impact of nutrition claims on children and food products. For instance, to avoid nutrients of
adolescents concern (e.g., added sugars, trans-fat, non-sugar
sweeteners), additives and allergens. For those who
Nutrition claims are often being utilised in nutrition wish to avoid intake of ultra-processed foods and
marketing campaigns. Some of these are directed to beverages, a practical method for identification is
children and caregivers, promoting nutrition claim recommended (Monteiro et al., 2019) to examine the
benefits to growth and development but fading the ingredient list. The rule of thumb is if the ingredient
containing negative nutrients (e.g., high sugar and list includes food substances that are rarely used in
sodium) in the products. A review by Ares et al. kitchens (e.g., high-fructose corn syrup,
(2022) indicated that children perceived foods with maltodextrin) and cosmetic additives that are used
a nutrition claim to be healthier, even though the to increase palatability (e.g., flavour enhancers,
tested products were nearly identical except the sweeteners), this would be a ultra-processed food or
labelling of claims. Comprehensive packaging beverage.
regulations are necessary to protect children's
health and encourage healthier eating habits from 15.3.1.4 Quantitative Ingredient
early years. Dixon et al. (2014) revealed that foods Declaration (QUID)
with nutrition claims (e.g., source of fibre, trans-fat
free) and celebrity endorsements influenced The Ministry of Health has gazetted a new labelling
Australian children more likely to select energy- requirement for Quantitative Ingredient Declaration
dense and nutrient-poor foods. (QUID). QUID is required when one or more
374
Figure 15.2: Example of QUID
ingredients used in the manufacturing of a food are 15.3.1.5 Front-of-Pack Nutrition Labelling
being emphasized on the label either through word, (FOPNL)
pictures or graphics. QUID is also required if the
ingredient is not within the product name but that In Malaysia, energy icon and Healthier Choices Logo KM15
ingredient is essential to characterize the food (HCL) are two authorised FOP-NL systems
which refers to the quality specification as stated in introduced by the Ministry of Health in 2012 and
commodity standard stipulated under Food 2017, respectively. Both systems present
Regulations 1985. convenient, relevant, and simple (symbols/ graphics)
information about the nutrient content or nutritional
For the purpose of QUID, the ingredient(s) shall be quality of a product on the front packaging (WHO,
declared in percentage unit, either by weight or 2019).
volume, next to the name(s) of the ingredient(s). This
declaration can be in the principal display panel, or a. Energy Icon
in the list of ingredients or stated in a statement on
the label. This labelling requirement can help Energy icon (Figure 15.3) is an informative system
consumers obtain more transparent information and that serves as a quick guide for consumers to obtain
provide more options to the consumer in choosing per serving calorie/ energy content at the front panel
a better product depending on their needs and of a food. The percentage of calorie/ energy
preferences. contributed by one serving of the product also being
stated in this icon. It is expressed in the percentage
Using a Milk Chocolate Nuts product as an example, of 2000 kcal, a fixed caloric value that is endorsed for
nuts are emphasized in the name of the food as well this local system based on the average daily energy
as pictorially; therefore the percentage of each nut requirement of a normal weight adult. Energy icon
must be declared. Note that the percentages are is useful in performing a rapid comparison of the
indicated next to the name of each nut. At the same calorie content over two or more products and
time, the ingredients that are essential to facilitating the selection of a smarter food choice
characterize the milk chocolate are milk fat and (MOH, 2021). As energy icon is a voluntary
cocoa paste as stipulated under commodity programme in Malaysia that forms part of the food
standard in the Food Regulations 1985. Therefore, and beverage industries’ commitments to address
the percentage of the milk fat and cocoa paste must obesity and diet-related non-communicable
also be declared (Figure 15.2). diseases, thus it is common that not all the pre-
packaged foods in the market will display or carry
the energy icon on their labels (MOH, 2021).
375
One serving
(200 ml) contains
Amount of energy (kcal) in one serving of

the product, which is 130 kcal in 200 ml
Energy (1 serving)
130 kcal
Energy contributed by one serving of the
product, expressed as % of average
7% daily adult energy requirement (2000
kcal), which is 7% out of 2000 kcal
Based on
2000 kcal
KM15
Figure 15.3: A sample of Energy Icon

Source: Adapted from Tee et al. (2019)
b. Healthier Choice Logo Malaysia category and this makes product selection to be
easier for consumers. Using the food category of
In 2017, the Ministry of Health launched Healthier breakfast cereals as an example, consumers can at
Choice Logo Malaysia (HCL), a voluntary FOP-NL a glance spot product on the food shelves that
programme that provides instant point-of-sale display the HCL on their front packaging.
information to consumers in making smarter food Theoretically, breakfast cereals without HCL may be
choices. To display the HCL on food labels, a less favoured option if there is an intention to
industries must apply and obtain HCL select a product with lower fat, sugar and salt or
authentication from the Ministry of Health, higher dietary fibre levels. Despite that, consumers
Malaysia. This endorsement logo, either in red or are reminded not to choose products solely based
black colour, is located on the front panel of a food on the HCL endorsement but also to optimise other
label (Figure 15.4). HCL is only allowed to be available nutrition information on food labels (e.g.,
displayed if the products comply with energy and/or NIP, nutrition and health claims, ingredient list etc.)
nutrient (e.g., fat, sodium, total sugars, dietary fibre, to obtain an overview of the product’s nutritional
whole grains, vitamins or minerals) thresholds set quality (Tee et al., 2019) and guide decision-making.
for the corresponding food categories. Such As HCL certificate upon approval will only be valid
thresholds will be periodically reviewed and for 24 months, this requires to be re-evaluated after
strengthened by the HCL Expert Committee based expiry (MOH, 2020). To avoid being exploited,
on the emerging scientific evidence and the consumers are encouraged to check on the products
directions of national health and nutrition policy. with HCL that have been authenticated and
remained valid on the HCL website portal
Products with the endorsement of HCL can be (http://myhcl.moh.gov.my/index.php/site/productlis
regarded as healthier options within the same food t).
376
HEALTHIER HEALTHIER
CHOICE CHOICE
AT
AT
PIL
PIL
IA
IA
KE
KE
YS
YS
ME
ME
LA
LA
TE TE
N
N
IH
IH
A A
RI M RI M
AN AN
IH
IH
AN AN AN N
S S
K E S I H AT K E S I H ATA
LEBIH LEBIH
Figure 15.4: HCL logo

Note: Both red and black colours are allowed for HCL, but should only display either one on the single product label.
Source: MOH (2020)
Impact of front-of-pack nutrition labelling on adolescents KM15
Literature indicates that FOP-NL has a positive hand, drawing from the Norway experience,
impact on adolescents’ beliefs. In the United States, adolescents had significantly higher health
VanEpps et al. (2016) conducted a randomised perceptions (p<0.01) and were more likely to choose
control trial on the effect of different FOP-NL (p<0.001) snacks with a Keyhole symbol, which is an
systems on adolescents. In comparison with no endorsement FOP-NL system that represents
FOP-NL, adolescents who were exposed to calorie healthier options (Wang et al., 2016). In addition, the
labelling on front packaging significantly increased study found a gender difference in preference over
the estimations of caloric content and added sugars nutrients to be listed on the front packaging, of
contained in the sugar-sweetened beverages, as which boys favoured energy to be labelled than
well as reduced their perceptions that such girls.
beverages could promote a healthy life. On the other
15.3.2 Commitments from all stakeholders to inculcate the habit of reading food labels
from childhood
a. Government agencies
Everyone in society plays a very important role to Malaysia, the Ministry of Health has developed and
educate children and adolescents about nutrition introduced several nutrition policies and
information on the food labels. To materialise this programmes to increase public awareness towards
role, a conducive environment that supports the calorie content and/ or nutrients of concern,
comprehensive advocacy of reading food labels enabling the population to make informed food
must be established in the very first place. In choices.
377
These include: about health, especially in the selection of healthy

• MyNutriDiari, a smart phone application which foods becomes essential for developing a lifelong
aims to help the Malaysians to monitor their skill. The term ‘empowerment’ relates to ‘power’ and
daily calorie intake and sharing the calorie also being known as a concept, a process, and a
content for Malaysian’s favourite food/ dishes result (Tengland, 2008). This can be seen as a
as well as the nutrient content of certain food complex health-related goal for health promotion,
products (MOH, 2015). consisting aspects of three central concepts on
welfare, health, and quality of life. Regarding the
• Healthy Cafeteria and Bersih, Selamat dan Sihat process or approach, this fundamentally involves
(BeSS) programmes provide accreditation and participants in problem formulation, decision
certification to cafeterias/ restaurants which making and action, which means that the experts
prepare healthier and safe foods for consumers. have to relinquish some of their control and power
One of the requirements for these programmes (Tengland, 2007). Pendergast et al. (2011) stated that
is to display calorie labelling on the menu poor food choices and lower dietary quality related
(MOH, 2019a; MOH, 2019c). to the lack of knowledge on “What foods are made
of?”; “Why and how does food labelling information
• MyChoice, a new initiative implemented in need to be read?”; and “How and why are healthy
2021 which helps consumers to identify foods being prepared and safely cooked to avoid
healthier foods and beverages on the menu food poisoning?”.
when dining out or ordering take-away foods.
Food items on the menus that carry MyChoice Over the years, the Ministry of Health Malaysia
logo must comply with the energy and nutrient through the Health Education Division has taken the
KM15 (e.g., sodium for foods, while total sugars for initiative to implement the Health Promotion in
beverages) thresholds established for Learning Institutions (HePiLI) initiative. Under the
accreditation (MOH, 2021a). One of the purview of HePiLI, there are several programmes
recommended actions includes to label the such as:

calorie and nutrient content of all provided
foods. • Tunas Doktor Muda at pre-schools,
• “Kembara Pemakanan Sihat di Pasaraya”, an • Program ImFree, Kelab Doktor Muda, Program
activity under “Program Pemakanan Sihat di Ekspresi Anak Remaja Lestari (PEARL) at
Pasar Raya” that uses supermarket as a place primary and secondary schools, and
to educate consumers about healthy eating and
food safety. Supermarkets are the focus of • Program Siswa Sihat (PROSIS) at university.
people to get food supplies for the whole family.
Therefore, the selection of food ingredients at These programmes aim to empower and educate
the supermarket can determine the type of food children, adolescents, and young adults/youths on
eaten at home. One of the main aspects focused basic health knowledge, as well as to encourage
in this activity is on how to read and them to practise healthy lifestyles. In addition, these
understand food labelling and nutrition programmes adopt peer influence strategies in
information panel. Adolescents are one of the disseminating health information, empowering
target groups for this activity, which will be peers to be role models in practising healthy
conducted by nutritionist and food lifestyles. The mode of implementation of HePiLI’s
technologist. programmes is through the school co-curriculum
and by insertion into the school curriculum. Henry
All the above initiatives are deemed to inculcate a & Rickman (2007) indicated that peer effects were
calorie and nutrient-conscious society, helping theoretically important and empirically significant
Malaysians to realise the importance of looking out in school settings. Young children may conform to
energy and nutrient content of a particular food food-related behaviours of remote peers and offer
product/ food item on the menu when making food the potential promise of interventions involving
choices. remote peers in promoting their healthier dietary
choices (Kim et al., 2019). Reading food labels forms
Empowerment forms part of the health promotion one of the focused elements under the healthy
strategies. Children and adolescents are the future eating topic of the HePiLI’s programme modules,
of the country. Therefore, emphasising the concept thus exposing children and adolescents to practical
of empowerment to ensure that they are literate activities on how to read food labels in the training.
378
b. Food industry d. Parents and caregivers
Apart from that, it is also very crucial for the food Learning nutrition information on food labels from
supply system to get involve in supporting the childhood and adolescence offers them a better
government’s policies and maximise the children understanding and acceptance to make effective
and adolescents’ opportunities on the exposure of use of this information in their daily routine. If the
nutrition information on food labels. The exposure growing environments fill with facilitating
and acceptance of children and adolescents opportunities, this will likely foster this skill to be
towards reading food labels can be further picked up easier as a lifelong habit. Parents, as the
enhanced when: closest persons to children and adolescents, play a
critical role in shaping their eating habits and
• Food and beverage industries label food dietary patterns. Scaglioni et al. (2018) indicated that
products or menus with accurate and a family system that surrounded a child’s domestic
comprehensive nutrition information. life would have an active role in establishing and
promoting behaviours that persist throughout their
• Educational materials to be highly accessible lives. Therefore, no matter how busy parents are in
(e.g., at the entrance of hypermarkets) to alert day-to-day work and chores, it is vital to be involved
consumers to practise reading food labels in their children’s lives.
during grocery shopping.
Parents or caregivers could set up a positive eating
• Shelf talkers/ tagging to be displayed at the environment at home and become good role models
hypermarkets to introduce and emphasise to guide their children develop healthy eating
healthier food options that are available. habits. One of the approaches is to educate their KM15
children about the importance of having a nutritious
diet and encourage them to read nutrition
• Labelling of calories and/or nutrients to be
information since childhood. Helping the children
available on the food menu at the school
understand how to read nutrition information is
canteens, retailers and food kiosks, cafeteria
important, as this is a ‘tool’ for making healthy food
and other dining restaurants, as well as food
choices throughout their lives (USFDA, 2018). Many
delivery service platforms.
opportunities can be optimised by parents or
caregivers to provide informal teaching sessions
c. Civil society
about reading food labels, including at home, at
supermarket and during restaurant visits. In this
Elements of nutrition information on food labels can
way, the whole family can participate in decision-
be integrated into community educational
making for health, distinguish foods that posing
campaigns, as well as educational materials
unhealthy dietary risks, and become more conscious
prepared by professional bodies and non-profit
of what to eat.
organisations. Over the years, great efforts have
been observed in activities carried out by the
One of the best ways to create children’s interest is
Nutrition Society of Malaysia, the Malaysian
to let them participate in the decision-making
Dietitians’ Association and the Malaysian
process, particularly during grocery shopping. This
Association for the Study of Obesity to promote the
is a great time for parents or caregivers to teach
use of nutrition labelling. This was evidenced by
their children to compare products using quantity
frequent advocacy of the message - “Making
‘per 100g or per 100ml’ and explain the declared
effective use of nutrition information on food labels”
nutrition information. This activity can guide their
in the health promotion materials: Guide to Healthy
children to differentiate food products in the market,
Eating and Active Living Volume 1 – 3 (Tee et al.,
identifying healthier food options. In addition,
2019, 2020, 2021). Also, creative and interactive
parents or caregivers can use teachable moments in
activities such as the healthy shopping tour
everyday activities to foster the habit of reading
conducted by governmental nutritionists and food
nutrition information in their children. Every time
technologists or the guided supermarket tour during
the children read the nutrition labelling, parents or
Nutrition Month Malaysia Food-Fit-Fun Fair offered
caregivers should compliment them and encourage
opportunities to engage the community and
the action. Positive reinforcement, praise, and
empower them to practise healthy shopping
encouragement will foster the young population to
through reading and understanding the food labels
repeat the praised behaviour, particularly when they
(NMM, 2019).
are learning new skills.
379
15.3.3 Impacts of food marketing to children and adolescents
Children and adolescents are exposed to ubiquitous Notably, these tactics such as the use of sports
food marketing. For instance, product design and celebrities as the promotional character have shown
packaging at point-of-sale, product placement, a negative impact of influencing children to choose
advertising at broadcast and non-board media and unhealthy foods (Dixon et al., 2014).
company sponsorship (WHO, 2012) (Figure 15.5).
Diverse and repetitive food marketing seeks to At the point of sale, attractive food packaging serves
exploit their mental developmental vulnerability as a form of marketing tactics to trigger the
(Boyland et al., 2016) and bring dual profits for the attention of children and parents (Ares et al., 2022).
food industry. These include boosting household Elliott & Truman (2020) found that promotional
spending on the advertised food products to exert character usage such as cartoons, brand mascots,
short-term corporate growth and establishing and licensed characters on food packages is the
children’s life course brand loyalty as the long-term most prominent child-targeted marketing
target (Clark et al., 2020). Such exposures raise technique. The authors also pointed out that
dietary concerns as many of the advertised foods are packaging imagery and thematic colour with the
high in fat, sugar and salt contents with ultra- presence of claims (e.g., healthier, low-fat) as other
processed characteristics of added flavouring and common techniques that would influence children’s
additives to increase food palatability and addiction. food perceptions and preferences. Young children
The rapid market growth of ultra-processed foods is tend to pay more attention to the marketing tactics
prevalent in Asia including Malaysia, with one of the used on the food packaging and interfere with their
attributing factors linked to pervasive food ability to evaluate product healthiness, particularly
KM15 marketing (Baker & Friel, 2016). In tandem with those with licensed cartoons (Elliott & Brierley, 2012;
emerging evidence from Malaysia, high exposure of Elliott & Truman, 2020; Ogle et al., 2017). When such
unhealthy food marketing to children has been techniques tag along with fun themes, these
reported, either in the form of broadcast or non- increase product preferences with greater affection
broadcast media (Belinda & Zolkepli 2019; Ng et al., observed from low-income and young children’s
2014; Tan et al., 2018). groups (Arrúa et al., 2017). In addition, some
evidence showed that the placement technique of
Media and marketing advancement offers various unhealthy foods at the prominent in-store areas
opportunities for the industry to promote their such as the ends of aisles, checkouts and islands
products. Unfortunately, persuasive unhealthy food would increase their sales, thus the reverse might
marketing tactics have been employed to optimise bring better dietary-related behaviours to the
the coverage and effectiveness of the population (Shaw et al., 2020).
communications. The most cited techniques
observed in the literature that target children and Digital food marketing is an emerging trend for food
adolescents include attractive label packaging, promotion. Food brand child-oriented websites,
product placement, movie tie-ins, health/ nutrition advergames, creative engagement, and behavioural
claims, promotional characters and personalities advertising through digital analytics on social media
(e.g. licensed characters, sportspersons, celebrities, (e.g., Facebook brand pages, product posts) are the
health professionals), emotional appeals (e.g. common nature of this marketing (WHO, 2016).
triggering hunger, thirsty, happiness, fun, fantasy, Real-time monitoring of the Australian adolescents’
rhythmic music, family bonding and/or festive mobiles revealed a high exposure to unhealthy foods
celebrations), brand-rich advergames and premium (median of 99-100 promotions per week), such as
offers (e.g. free toys, competitions, rebates, vouchers) fast foods, chocolate and confectionery, and sugar-
(Jenkin et al., 2014; Smith et al., 2019; Omidvar et al., sweetened beverages (Kelly et al., 2021). In Malaysia,
2021). A meta-analysis showed that online food- Tan et al., (2018) highlighted a high proportion of
related advergames had small to moderate impacts unhealthy food advertising (56.3%) such as fast food
(Effect size, g=0.30, 95%CI: 0.22-0.37, I2=89%) to and sweet confectionery in children’s flavoured
promote unhealthy foods targeting children and YouTube channels. In the digital world, the food
adolescents, as well as influenced their eating industry could earn media impressions from the
behaviours (Folkvord F & van ‘t Riet, 2018). In target groups by deploying online influencers and
Malaysia, the use of persuasive marketing celebrities to promote their products (Kelly et al.,
techniques such as promotional characters, taste, 2021). Despite the age registration limit applied for
and emotional appeals (e.g., fun and playful social media platforms (e.g., at least 13 years old for
elements) has been frequently cited (Belinda & Facebook, YouTube, TikTok, and Twitter), these
Zolkepli, 2019; Ng et al., 2014; Tan et al., 2018). unregulated media and universal access to online
380
Exposure: In-store
supermarket and product
packaging.
Exposure: Sport Tactic: Product placement
club sponsorship (e.g. end-of-side, checkout),
Tactic: Banner and cartoons and mascots in
branding on sports the store or on the
items (e.g. sportwear), packaging, packaging
sports celebrity design (e.g. colour,
endorsement. in-pack gifts)
Exposure: Print
Exposure: Outside school branding. KM15
marketing Tactic: Shop or stall
Tactic: Food truck or vehicle signboard sponsorship,
with catchy songs. free samples and
tastings.
Food
Exposure: Exposure: Media TV.
Examples of
Billboard marketing Tactic: Product placement,
Marketing
Tactic: Premium movie tie-in, celebrity
offers (e.g. free endorsement, theme
toys, buy 1 free 1, promotion (e.g. family
bundle sales) bonding, festive celebration)
Techniques Exposure: in-school branding.

Tactic: Sponsorship of school
items (e.g. pencil box,
school bag) and CSR
linked with products or
Exposure: Public transits brands.
Tactic: Theme promotion
(e.g. tasty, fantasy,
trendy)
Exposure: Digital Exposure: Radio
food marketing. broadcasting.
Tactic: Advergames, Exposure: Tactic: Premium offers
influencers, digital Print media. (e.g. lucky draws, price
engagement. Tactic: Premium reduction), use child
offers (e.g. voices.
! 2/8
giveaways, vouchers)
Figure 15.5: Examples of food marketing techniques
381
gadgets attribute loopholes. Children and unhealthy food and drink consumption, by a score
adolescents could still be exposed to paid social of 0.067 units. A meta-analysis also revealed that
media marketing campaigns and enable them to children who were exposed to unhealthy food
directly or indirectly (via the family member’s marketing had a significant moderate effect on
account) like, comment and share the advertised higher food intake (standardised mean difference:
food content. Even more worrying, kid influencers 0.56, 95%CI 0.18-0.94, I2=98%) (Boyland et al., 2016).
have been used as a peer engagement tactic to Sadeghirad et al. (2016) concurred with this finding,
promote unhealthy foods, by placing these products revealing children would have 30 kcal (95%CI: 2.9-
or brands in their YouTube video channels and 57.9, I2=72%) or 4.8g (95%CI: 0.8-8.8, I2=31.6%)
generating millions of media impressions (Alruwaily higher mean difference of dietary intakes when they
et al., 2020). were exposed to these marketing. Nutrition and
media literacies would facilitate children and
Over the years, unhealthy food marketing receives adolescents to make better food choices in the
wide attention as its harmful impacts on children complex food marketing environment (Elliott &
and adolescents, thus warranting urgent Brierkey, 2012). In Malaysia, young children’s
interventions. Food promotion triggers children’s television screen time was significantly associated
purchase requests and enhances parent-child with unhealthy food advertisement fondness,
conflicts about product purchases (Buijzen & related purchase requests, and product preferences
Valkenburg 2003; Cairns et al., 2013). Systematic (Ng et al., 2015). Notably, this impact would likely be
reviews indicated that unhealthy food marketing magnified, when considering the cumulative effects
and related techniques influenced nutrition of other media exposures and related persuasive
knowledge, food attitudes, preferences, and techniques that target children and adolescents in
KM15 consumption of children and adolescents (Cairns et their daily lives. A longitudinal study suggested that
al., 2013; Smith et al., 2019). For instance, Kelly et al. the most effective measure to prevent the negative
(2016) found a dose-response relationship for every impacts of food marketing would be to reduce their
hour of weekly television viewing to increase media consumption (Binder et al., 2020).
15.4 Current Status
In recent years, despite a growing interest on the Several studies have been conducted to determine
knowledge, awareness, and practices of reading the knowledge, attitude, and practice of reading food
food labels as recommended in Malaysian Dietary labels amongst adolescents in Malaysia. For
Guidelines 2020 (NCCFN, 2020), there has been no instance, a population representative local finding
local study among children reporting on the use and on food and nutrition labelling was conducted
practices of reading nutrition information on food through the adolescent nutrition surveys, under the
labels. Drawing from the Turkey experience, National Health and Morbidity Survey in 2017 (IPH,
Sahingoz (2012) found that among 356 children in 2017). This nationwide survey recruited adolescents
Ankara province, 77.5% of the children read aged 13 to 17 years old, exploring the prevalence of
manufacturing and expiry date, followed by 65.2% reading food and nutrition labels and identifying the
read ingredients, 43.8% read the name of nutrition reasons for not reading food labels. A total of 27,410
material, and 34.8% read the food labels. Less than respondents responded to food/nutrition labelling
half of the interviewed children (43%) claimed that questions in this survey. The study reported more
information on food labels could impact purchasing than half (51%) of adolescents in Malaysia would
decisions (Sahingoz, 2012). In Greece, Gialitakis & occasionally or once in a while read food labels
Chryssochoidis (2006) assessed food labelling when buying or receiving foods or drinks. While the
understanding among 1,294 schoolchildren. remaining respondents were either always read
Children mostly paid attention to the expiry date, (33%) or never read food labels at all (16%). The most
followed by brand name, country of origin, vitamins, favoured information on food labels checked by
calories, additives, sugar, and fat contents. They also adolescents was the expiry date (78.6%), followed
found out that 28.7% of the children had hard times by food ingredients (28.7%), nutrition facts (24.8%),
understanding the information on food labels, with storage instruction (18.2%), and nutrition claims
merely 1.5% obtaining full accuracy in interpretation (17.3%). The cited main reasons for those who
tests and the majority (81.3%) correctly answered responded never read the food labels included not
three out of seven questions. interesting (38.0%), did not understand the
information (19.2%), and time constraints (17.7%).
382
The findings also revealed that adolescents did not participants aged 13 to 14 years old have
know the importance of food labels (14.4%); agreed participated in this study. The educational message
that the printing size of food labels was too small utilised in this study was Info-Nutriteen which
(12.3%), and stated that they were already aware of included the introduction information related to
information on food labels (11.8%). nutrition labelling, serving size and macronutrients,
NIP, nutrition claims, energy labelling, the HCL, and
Norsakira et al. (2019) investigated the personal usage of nutrition labelling while making food
factors that hindered adolescents from practising choices. The study found that 92.7% of the
reading nutrition labels. Findings showed that only participants positively accepted the information
24.2% of adolescents aged 13 to 16 years old in uploaded on the Instagram page. Besides, 95.6%
selected areas of Negeri Sembilan always read the agreed on the use of video as being interesting and
food labels before purchasing, while the other 30.3% easy to understand. Furthermore, 94.4% of the
and 45.5% of adolescents either ‘sometimes’ or participants were satisfied with infographics to
‘never’ read the food labels, respectively. The study deliver the message on Instagram. In addition, some
showed a very low prevalence of reading food labels of the participants agreed that Info-Nutriteen
among adolescents in Negeri Sembilan, highlighting increased their knowledge, understanding, and
the lack of interest, former experience of a regular ability to interpret the nutrient content of packaged
purchase over the same product, hunger and food food and motivated the adolescents in the study to
cravings, time constraints, and taste of the foods choose a healthier food product. Additionally, a
being the main barriers for such a practice. school-based intervention (including reading the
food label) in reducing overweight and obesity
A quasi-experimental study has been conducted to among adolescent in Malaysia have been developed
examined the feasibility of Instagram-based (Lai et al., 2022). This intervention module would be KM15
nutrition education media, using compelling implemented and assessed for its effectiveness in
infographics and short videos to facilitate the Malaysia. If proven effective, the intervention
understanding of nutrition labelling in adolescents module would be useful for improvement in the
in Malaysia (Norsakira et al., 2020). A total of 125 school health programme.
383
Key Recommendation (KR) 1: Build together a conducive environment to support the

accessibility of nutrition labelling.
Government/ NGOs / Others
KR1: HTA1:
Strengthen education of nutrition labelling usage in school syllabus and curriculum.
KR1: HTA2:
Strengthen nutrition labelling components into community educational campaigns to advocate public
awareness.
KR1: HTA3:
Comply with nutrition labelling regulations and relevant guidelines on pre-packaged foods and
encourage more comprehensive nutrition labelling available in the market.
KR1: HTA4:
KM15 Strengthen educational materials and healthier choice options to facilitate consumers to practise
reading food labels during grocery shopping.
Key Recommendation (KR) 2: Create opportunities to cultivate interests among children and
adolescents on the use of nutrition labelling.
General Teachers / Health

Parents/ Caregiver
(to children and adolescents) Professionals

Be aware and recognise the Talk about nutrition and explain Introduce creative and fun
benefits of reading nutrition how to look out for healthier food activities to attract interest of
labelling and make this as a options through reading nutrition children and adolescents
habit in life. information during daily activities. towards reading nutrition
labelling by encouraging
involvement of NGOs, Parents
Teacher Association (PTA),
other relevant agencies and
health professionals, e.g.:
healthy shopping tour,
interactive games.

Instil an interest to learn about Compliment children and Use attractive mediums to
nutrition labelling from all the adolescents when reading create interests and expose
available and reliable resources. nutrition labelling and encourage children and adolescents with
this habit. nutrition information knowledge
e.g.: Youtube, Facebook,
Instagram, TikTok &
MyNutriDiari.
384
Key Recommendation (KR) 3: Practise using all information available on nutrition labelling and
make healthier food choices
General Teachers / Health

Parents/ Caregiver

Use “LABEL” approach to Prepare the grocery shopping list Intensify the educational
make informed food choices: together with children and module of nutrition labelling
adolescents and guide them to through co-curricular activities,
a. Look thoroughly the differentiate healthier food e.g.: training module for Kelab
Nutrition Information Panel products. Doktor Muda.
(NIP) to understand the
nutritional quality of a
particular product.
b. Assess nutrients of concern

by comparing ‘per 100g or
per 100ml’ in NIP from
different brands within the
same food category.
KM15
c. Be aware that the ingredient
list of a product is in
descending order by weight
and make good use of the
quantitative ingredient
declaration..
d. Evaluate overall nutritional

values of a product and not
solely rely on the declared
nutrition claims, e.g.: “High
in Calcium”, “Low Fat” or
“Lower in Sugar”.
e. Locate Front of Pack

Labelling such as Energy
Icon to obtain energy
content per serving at a
glance and Healthier
Choice Logo to identify
healthier products within
the same food category.

Teach children and adolescents Educate children and
to choose a healthier choice adolescents on the importance
option during snacking time, e.g.: of reading nutrition labelling
plain milk contains and stay alert to the influences
≥ 150mg/100ml calcium and no of food marketing (e.g.:
added sugar. product packaging, TV and
social media) and related
tactics (e.g.: use of influencer,
cartoons, mascots, celebrities
and premium offers).
385
Key Recommendation (KR) 3: Practise using all information available on nutrition labelling and
make healthier food choices (cont.)
General Teachers/ Health

Parents/ Caregiver

Challenge children and Guide children and
adolescents to swap out one adolescents to recognise
unhealthy food item and replace prohibited and misleading food
with a healthier option. marketing based on nutrition
labelling in Food Regulations
1985 such as:
a. Health claims that state any

food or nutrient that could
help, reduce, prevent or
cure diseases are
prohibited.
b. Promotion using tactics of

KM15
high grading, quality or
superiority violates the
Food Regulations 1985.
- KR3: HTA4: -
Explain why some advertised
foods are of concern (e.g.: high in
sugar causes dental caries and
obesity by using all information
from nutrition labelling.
386
15.6 References
Alruwaily A, Mangold C, Greene T, Arshonsky J, Cassidy O, Pomeranz JL, Bragg M (2020). Child social media
influencers and unhealthy food product placement. Pediatrics, 146(5):1-10.
Ares G, Arrúa A, Antúnez L, Vidal L, Machín L, Martínez J, Curutchet MR, Giménez A (2016). Influence of
label design on children's perception of two snack foods: Comparison of rating and choice-based
conjoint analysis. Food Quality and Preference, 53:1-8.
Ares G, Velázquez AM, Vidal L, Curutchet MR, Varela P (2022). The role of food packaging on children’s
diet: Insights for the design of comprehensive regulations to encourage healthier eating habits in
childhood and beyond. Food Quality and Preference 95 (104366): 1-10.
Arrúa A, Vidal L, Antúnez L, Machín L, Martínez J, Curutchet MR, Giménez A, Ares G (2017a). Influence of
Label Design on Children's Perception of 2 Snack Foods. J Nutr Educ Behav., 49(3): 211-217.
Arrúa A, Curutchet MR, Rey N, Barreto P, Golovchenko N, Sellanes A, Velazco G, Winokur M, Giménez A,
Ares G (2017b). Impact of front-of-pack nutrition information and label design on children's choice
of two snack foods: Comparison of warnings and the traffic-light system. Appetite, 116:139-146.
Baker P, Friel S (2016). Food systems transformations, ultra-processed food markets and the nutrition
transition in Asia. Globalization and Health 12:80.
KM15
Belinda, FCL & Asnira Zolkepli I (2019). A content analysis of appeals in food advertisements for children
on online tv streaming. SEARCH J. Media Commun. Res. 11:113–136.
Benajiba, N., Mahrous, L., Bernstein, J., Aboul-Enein, B. H. (2020). Food labeling use by consumers in Arab
countries: a scoping review. Journal of Community Health, 45(3), 661-674.
Binder A, Naderer B, Matthes J, Spielvogel I (2020). Fiction is sweet. The impact of media consumption on
the development of children’s nutritional knowledge and the moderating role of parental food-related
mediation. A longitudinal study. Nutrients 12:1478.
Boyland EJ, Nolan S, Kelly B, Tudur-Smith C, Jones A, Halford JCG, Robinson E (2016). Advertising as a cue
to consume: A systematic review and meta-analysis of the effects of acute exposure to unhealthy
food and nonalcoholic beverage advertising on intake in children and adults. Am J Clin Nutr
103(2):519-533.
Buijzen M & Valkenburg PM (2003). The effects of television advertising on materialism, parent-child conflict
and unhappiness: A review of research. Applied Development Psychology 24(4):437-456.
Cairns G, Angus K, Hastings G, Caraher M (2013). Systematic reviews of the evidence on the nature, extent
and effects of food marketing to children. A retrospective summary. Appetite 62: 209-215.
Campos S, Doxey J & Hammond D (2011). Nutrition labels on pre-packaged foods: a systematic review.
Public Health Nutrition 14(8):1496-1506.
Clark H, Coll-Seck AM, Banerjee A, et al. (2020). A future for the world’s children? A WHO-UNICEF-Lancet
Commission. Lancet 395: 605-658.
Dixon H, Scully M, Niven P, Kelly B, Chapman K, Donovan R, Martin J, Baur LA, Crawford D, Wakefield M
(2014). Effects of nutrient content claims, sports celebrity endorsements and premium offers on pre-
adolescent children's food preferences: experimental research. Pediatric Obesity 9: e47-e57.
Elliott C & Truman E (2020). The power of packaging: A scoping review and assessment of child-targeted
food packaging. Nutrients 12:958.
387
Elliott C, Brierkey M (2012). Healthy choice?: Exploring how children evaluate the healthfulness of packaged
foods. Can J Public Health 103(6):e453-e458.
FAO/WHO (2014). Conference Outcome Document: Framework for Action – ICN2 2014/3 Corr.1. Second
International Conference on Nutrition, Rome.
FAO/WHO (2019). Proposed Draft Guidelines on Front-of-Pack Nutrition Labelling – CX/FL 19/45/6. Codex
Committee on Food Labelling. Joint FAO/WHO Food Standards Programme, Rome.
Folkvord F & van ‘t Riet (2018). The persuasive effect of advergames promoting unhealthy foods among
children: A meta-analysis. Appetite 129: 245-251.
Food Safety and Quality Division (2023). Guide to Nutrition Labelling and Claims. Putrajaya: Food Safety
and Quality Division, Ministry of Health.
Gavaravarapu SM, Snehasree S, Vemula SR, Mendu VVR (2016). Read-B4-U-Eat: A Multicomponent
Communication Module to Promote Food Label Reading Skills Among Adolescents in India. Journal
of Nutrition Education and Behavior, 48(8): 586-589.
Gialitakis, G., & Chryssochoidis, G. (2006). Schoolchildren’s understanding of food labels. Young Consumers.
Henry, G. T., & Rickman, D. K. (2007). Do peers influence children's skill development in preschool?.
KM15 Economics of education review, 26(1), 100-112.
Institute for Public Health (IPH) (2017). National Health and Morbidity Survey (NHMS) 2017: Adolescent
Nutrition Survey 2017. Kuala Lumpur: IPH, Malaysia.
Jenkin G, Madhvani N, Signal L, Bowers S (2014). A systematic review of persuasive marketing techniques
to promote food to children on television. Obesity Reviews 15:281-293.
Kelly B, Bosward R, Freeman B (2021). Social online marketing engagement (SoMe) study of food and drink
brands: Real time measurement of Australian children. Journal of Medical Internet Research 23(7):
e28144.
Kelly B, Freeman B, King L, Chapman, K, Baur LA, Gill T (2016). Television advertising, not viewing, is
associated with negative dietary patterns in children. Pediatric Obesity 11: 158-180.
Kim, E. B., Chen, C., & Cheon, B. K. (2019). Using remote peers’ influence to promote healthy food choices
among preschoolers. Developmental psychology, 55(4), 703.
Miller LMS, Cassady DL, Applegate EA, Beckett LA, Wilson MD, Gibson TN, Ellwood K (2015). Relationships
among Food Label Use, Motivation, and Dietary Quality. Nutrients, 7:1068-1080.
Norsakira J, Norazmir Md Nor, Ruzita Abd Talib (2019). Nutrition labelling: an exploratory study on personal
factors that influence the practice of reading nutrition labels among adolescents. Malaysian Journal
of Nutrition 25.1
Norsakira J, Farha Shazira Mohd Sedik, Nurul Anisah Kamaruzaman, Norazmir Md Nor, Azrulhizam Shapi’i,
Ruzita Abd Talib. (2020). Use of instagram® to educate adolescents on nutrition labelling: a feasibility
study in Selangor, Malaysia. Jurnal Gizi dan Pangan 15, no. 3 (2020): 149-158.
Lai, W. K., Sherina, M. S., Rampal, L., & Gan, W. Y. (2022). Development Of A School-Based Intervention
Module In Reducing Overweight And Obesity Among Adolescents In Malaysia. International Journal
of Public Health and Clinical Sciences, 9(1), 24-36.
Lei, N., Liu, Z., Xiang, L., Ye, L., & Zhang, J. (2022). The extent and nature of television food and non-alcoholic
beverage advertising to children during Chinese New Year in Beijing, China.
388
Monteiro, C. A., Cannon, G., Lawrence, M., Costa Louzada, MD, Pereira Machado, P. (2019). Ultra-processed
foods, diet quality, and health using the NOVA classification system. Rome: FAO, 49.
MOH (1983). Food Act 1983. Ministry of Health Malaysia.
MOH (1985). Food Regulations 1985. Ministry of Health Malaysia.
MOH (2011). Promosi Pemakanan Sihat di Pasar Raya. https://nutrition.moh.gov.my/promosi-pemakanan-

sihat-di-pasar-raya/. (accessed December 2021).
MOH (2015). Risalah MyNutriApps II: MyNutriDiari. Nutrition Division, Ministry of Health Malaysia.
MOH (2019a). Garis Panduan Pengiktirafan “Bersih, Selamat dan Sihat” (BeSS). Food Safety & Quality
Division, Ministry of Health Malaysia.
MOH (2019b). Infographic Kit Healthier Choice Logo Malaysia. Nutrition Division, Ministry of Health
Malaysia.
MOH (2019c). Panduan Pengiktirafan Kafeteria Sihat Kepada Pengusaha Makanan. Nutrition Division,
MOH (2020). Guidelines on Healthier Choice Logo Malaysia. Nutrition Division, Ministry of Health Malaysia.
KM15
MOH (2021a). Guidelines on MyChoice Logo Malaysia. Nutrition Division, Ministry of Health Malaysia.
MOH (2021b). Malaysian Dietary Guidelines 2020. National Coordinating Committee on Food and Nutrition,
Ministry of Health Malaysia.
Miller, L. M. S., & Cassady, D. L. (2015). The effects of nutrition knowledge on food label use. A review of the
literature. Appetite, 92, 207-216.
Moore SG, Donnelly JK, Jones S, Cade JE (2018). Effect of Educational Interventions on Understanding and
Use of Nutrition Labels: A Systematic Review. Nutrients, 10,1432: 1-14.
NCCFN (2016). National Plan of Action for Nutrition of Malaysia III, 2016 – 2025. Nutrition Division, Ministry
of Health Malaysia.
Ng SH, Kelly B, Se CH, Chinna K, Sameeha MJ, Krishnasamy S, Ismail MN & Karupaiah T (2014). Obesogenic
television food advertising to children in Malaysia: sociocultural variations. Global Health Action
7(1):25169, 1-11.
NMM (2019). Nutrition Month Malaysia 2019: Make Time for Healthy Eating & Active Living (HE-AL).
https://www.nutritionmonthmalaysia.org.my/nmm-2019/. (accessed December 2021).
Ogle AD, Graham DJ, Lucas-Thompson, RG, Roberto CA (2017). Influence of cartoon media characters on
children’s attention to and preference for food and beverage products. Journal of the Academy of
Nutrition and Dietetics 117(2):265-270.
Omidvar N, Al-Jawaldeh A, Amini M, Babashahi M, Abdollahi Z, Ranjbar M (2021). Food marketing to

children in Iran: Regulation that needs further regulation. Curr Res Nutr Food Sci 9(3): 158-180.
Pendergast D, Garvis S, Kanasa H (2011). Insight from the public on home economics and formal food
literacy. Fam Consumer Sci Res J 39: 415-430.
389
Roberto, C. A., Ng, S. W., Ganderats-Fuentes, M., Hammond, D., Barquera, S., Jauregui, A., & Taillie, L. S.
(2021). The influence of front-of-package nutrition labeling on consumer behavior and product
reformulation. Annual Review of Nutrition, 41, 529-550.
Sadeghirad B, Duhaney T, Motaghispisheh S, Campbell NRC & Johnston BC (2016). Influence of unhealthy
food and beverage marketing on children’s dietary intake and preference: A systematic review and
meta-analysis of randomized trials. Obesity Reviews 17(10): 945-959.
Sahingoz, S. A. (2012) Food Label Reading Habits of Child Consumers.
Sanders, M. J., Reynolds, J., Bagatell, N., Treu, J. A., O’Connor, E., & Katz, D. L. (2015). Promoting Healthy
Lifestyles to Children at School. Journal of Public Health Management and Practice, 21(4), E27-E35.
Scaglioni S, De Cosmi V, Ciappolino V, Parazzini F, Brambilla P & Agostini C (2018). Factors Influencing
Children’s Eating Behaviours. Nutrients 2018, 10, 706.
Shaw SC, Ntani G, Baird J, Vogel CA (2020). A systematic review of the influences of food store product
placement on dietary-related outcomes. Nutrition Reviews, 78(12):1030-1045.
Smith R, Kelly B, Yeatman H & Boyland E (2019). Food marketing influences children’s attitudes, preferences
and consumption: A systematic critical review. Nutrients 11(4): 1-14.
KM15 Tan LA, Ng SH, Omar A & Karupaiah T (2018). What’s on YouTube? A case study on food and beverage
advertising in videos targeted at children on social media. Childhood Obesity 14(5):280-290.
Tee ES, Zaitun Y, Yap RWK, Ng KF, Lee ZY, Chin YS, Zawiah H (2019). HE-AL Guide to Healthy Eating &
Active Living Vol. 1. A Guide Book published by Nutrition Month Malaysia, Kuala Lumpur. pp. 21.
Tee ES, Yap RWK, Zawiah H, Ng KF, Lee ZY, Norimah AK, Chin YS (2020). HE-AL Guide to Healthy Eating
& Active Living Vol. 2. A Guide Book published by Nutrition Month Malaysia, Kuala Lumpur. pp. 24
– 25.
Tee ES, Yap RWK, Chin YS, Tan YT, Lee ZY, Denise K, Gan WY (2021). HE-AL Guide to Healthy Eating &
Active Living Vol. 3. A Guide Book published by Nutrition Month Malaysia, Kuala Lumpur. pp. 11.
Tengland PA. (2008). Empowerment: a conceptual discussion. Health Care Anal. 2008 Jun;16(2):77-96.
Tengland, PA. (2007). Empowerment: A goal or a means for health promotion?. Med Health Care Philos 10,
197.
USFDA (2022). Food Labelling and Nutrition. https://www.fda.gov/food/food-labeling-nutrition. (accessed

June 2022).
USFDA (2018). Read the Label Youth Outreach Materials. https://www.fda.gov/food/new-nutrition-facts-

label/read-label-youth-outreach-materials. (accessed December 2021).
Waddell, K., Wilson, M. G., Panchal, P., & Mattison, C. A. (2018). Rapid Synthesis: Identifying Effective and
Cost-effective Population-level Policies to Promote Healthy Eating.
Wang Q, Oostindjer M, Amdam GV, Egelandsdal B (2016). Snacks with nutrition labels: Tastiness Perception,
Healthiness Perception, and Willingness to Pay by Norwegian adolescents. Journal of Nutrition
Education and Behavior, 48(2): 104-111.
Wang, C. Y., Hsu, C. J., & Cai, D. (2022). Effects of food nutrition labels on the health awareness of school-
age children. BMC Public Health, 22(1), 1-13.
390
WHO (2012). A Framework for Implementing the Set of Recommendations on the Marketing of Foods and
Non-Alcoholic Beverages to Children. World Health Organization, Geneva.
WHO (2019). Guiding Principles and Framework Manual for Front-of-Pack Labelling for Promoting Healthy
Diets. World Health Organization, Geneva.
WHO (2016). Tackling food marketing to children in a digital world: trans-disciplinary perspectives. World
WHO (2020) United Nations Children’s Fund, World Health Organization, World Bank Group. Levels and
trends in child malnutrition: key findings of the 2020 edition of the Joint Child Malnutrition Estimates.
Geneva: World Health Organization, 2020.
WHO (2021) Implementing nutrition labelling policies: a review of contextual factors. Geneva: World Health
Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.
World Health Organization (WHO). 2022. Food marketing exposure and power and their associations with
food-related attitudes, beliefs and behaviours: a narrative review. Geneva: WHO.
World Health Organization. (2022). Nutrition labelling: policy brief.
Wolfe WS, Scott-Pierce M, Dollahite J (2018). Choose Health: Food, Fun, and Fitness Youth Curriculum
Promotes Positive Behaviors. Journal of Nutrition Education and Behavior, 50(9): 924-930. KM15
VanEpps EM, Roberto CA (2016). The Influence of Sugar-sweetened Beverage Warnings A Randomized
Trial of Adolescents' Choices and Beliefs. Am J Prev Med, 51(5): 664-672.
391
Appendices
Appendix 15.1: Foods requiring mandatory nutrition labelling
Regulation No Food category Types of food

(as extracted from Food Regulations 1985)
63 – 75 Prepared cereal Pasta, prepared cereal food (including breakfast cereals), bread
food and bread. (white bread, fruit bread, milk bread, meal bread, rye bread,
wheat-germ bread, wholemeal bread, enriched bread).
84 – 87, Milk & milk Skimmed milk or skim milk or non-fat milk or separated milk,
89 –113, 116 products. pasteurized milk, sterilized milk, ultra-high temperature milk or
U.H.T. milk, flavoured milk, full cream milk powder or dried full
cream milk, skimmed milk powder or skim milk powder or dried
non-fat milk solids or separated milk powder, malted milk
powder, recombined milk, reconstituted milk, evaporated milk or
unsweetened condensed milk, condensed milk, sweetened
condensed milk, lactose hydrolysed milk, filled milk, filled milk
powder, evaporated filled milk/unsweetened condensed filled
milk, condensed filled milk/sweetened condensed filled milk,
cream/raw cream, pasteurized cream, reduced cream/pouring
cream, butter, recombined butter, ghee, cheese, cottage
KM15 cheese, cream cheese, processed cheese, cheese paste,
cheese spread/cheese mixture, club cheese/luncheon cheese,
dried cheese/ powdered cheese, cultured milk/fermented milk,
ice cream.
134B Sweetening Sweetened creamer.

substance.
135 Flour confection. Any pastry, cake, biscuit/other product prepared from mixture of
flour/ meal and other food.
146 - 152 Meat products Meat paste, manufactured meat, smoked meat, canned meat,
and canned canned meat with other food, meat extract/ meat essence.
meat.
157 - 170 Fish products Fish product, cured, pickled/ salted fish, smoked fish, prepared
and canned fish. fish, canned fish, fish paste, belacan, fish sauce, cincalok,
oyster sauce, oyster flavoured sauce, fish ball or fish cake, fish
keropok, otak udang, petis/ heko, pekasam.
177 Egg product. Preserved egg
185 - 207 Edible fats and Margarine, fat spread, vanaspati, general standard for edible
edible oil. oil, cooking oil, refined coconut oil, unrefined coconut oil, corn
oil, cottonseed oil, groundnut oil, peanut oil/arachis oil, mustard
seed oil, refined, bleached, deodorized palm oil, neutralized,
bleached, deodorized palm oil, refined, bleached, deodorized
palm olein, neutralized, bleached, deodorized palm olein,
refined, bleached, deodorized palm kernel oil, olive oil, rice bran
oil, rapeseed oil or toria oil, safflower seed oil, sesame seed
oil/gingelly oil, soya bean oil, sunflower seed oil.
214 - 221 Vegetable Salted vegetable, dried salted vegetable, tomato paste, tomato
products and pulp, tomato puree, vegetable juice, canned vegetable,
juices fermented soya bean product.
392
Regulation No Food category Types of food

(as extracted from Food Regulations 1985)
223 - 224 Soup and soup Soup, soup stock.

stock.
226 - 242 Fruit products Dried fruit, mixed dried fruit, fruit product, candied fruit or glaced
and juices. fruit/ crystallized fruit, salted fruit, dried salted fruit, candied
peel, canned fruit, canned fruit cocktail, fruit juice, apple juice,
grapefruit juice, lemon juice, lime juice, orange juice, passion
fruit juice, pineapple juice.
246 - 249 Jam, fruit jelly, Jam, fruit jelly, marmalade, seri kaya.
marmalade and
seri kaya
252 - 259 Nuts and nut Nut, coconut milk, coconut cream, coconut cream concentrate,
products. coconut cream powder, dessicated coconut, coconut paste,
peanut butter.
KM15
269A Tea, coffee, Premix coffee.
chicory and
related products.
279 - 281 Cocoa products Chocolate, white chocolate, milk chocolate.
282 Milk shake Milk shake.
339 - 347 Sauce, chutney Sauce, soya sauce/ soya bean sauce/ kicap, hydrolysed
and pickle. vegetable protein sauce/hydrolysed plant protein sauce,
blended hydrolysed vegetable protein sauce/ blended
hydrolysed plant protein sauce, chilli sauce, tomato sauce/
tomato ketchup/ tomato catsup, salad dressing, mayonnaise,
chutney, pickle.
348 - 358 Soft drinks Syrup, fruit syrup/ fruit cordial/ fruit squash, flavoured syrup/
flavoured cordial, fruit juice drink, fruit drink, flavoured drink, soft
drink base/ soft drink premix, botanical beverage mix, soya
bean milk, soya bean drink.
360D – 360E Packaged Isotonic electrolyte drink, isotonic electrolyte drink base.
Drinking water
26 (7) Foods that “contain” or “added” (or words of similar meaning) or “enriched” or
“fortified” (or words of similar meaning) with specific vitamins, minerals, amino
acids, fatty acids, nucleotides or other food components (with permitted other
function claims).
18B (14) Foods that make any nutrition claim on a label of a food product pertaining to its
nutritional quality.
388-391 Special purpose foods: infant formula, follow-up formula, canned food for infants
and young children and cereal-based food for infants and young children.
Source: MOH (1985)
393
Appendix 15.2: Component of Nutrition Information Panel (NIP)
The NIP lists the amount of energy and several nutrients contained in the food. Example below explains the
different components of the NIP.
Nutrition Information
Serving size : 5 pieces (20 g)
Servings per package : 5
Nutrients Per 100 g Per serving (20 g)
Energy (kcal) 525 105
Carbohydrate (g) 56.2 11.2
Total sugars (g) 12.5 2.5
Protein (g) 8.0 1.8
Fat (g) 29.8 6.0
Sodium (mg) 25.0 5.0

KM15
Nutrient Listing The Amount of Nutrients Amounts of Nutrients per Serving
This column refers to nutrients

This is the amount of nutrients
contained in every 100 g (if
It is compulsory for many pre- and energy you receive in each
solid) or every 100 ml (if liquid)
packaged foods to list the serving of the food.
of a food or drink.
energy, carbohydrate, total In the example given, each
In the example given, every
sugars, protein, fat and sodium serving of food (20 g) gives you
100 g of the food provides 525
content. 105 kcal of energy.
kcal of energy, 56.2 g of
The amount of vitamins and If you consume 2 servings of
carbohydrate, 12.5 g of total
minerals may also be listed. the food, the energy and
sugars, 8.0 g of protein, 29.8 g
nutrients consumed will be
of fat and 25.0 mg of sodium.
doubled.
Source: Tee et al (2008)
394
Malaysian Dietary Guidelines
For Children & Adolescents
Focus Group Discussion on the

Key Messages,
Key Recommendations &
How To Achieve
(16th -17th March 2022)
Focus Group Discussion (FGD) on the Key Messages,
Key Recommendations and How to Achieve of the Malaysian Dietary
Guidelines for Children & Adolescents (16th & 17th March 2023)
Secretariat FGD
Ms. Rozalina Ismail Ms. Nur Irsalina Mohamed Zaki

Senior Assistant Director Research Officer MySTEP
Nutrition Division, MOH Nutrition DIvision, MOH
Putrajaya Putrajaya
Moderators
Dr. Ahmad Ali Zainuddin Mr. Saiful Adli Suhaimi

Nutrition Officer Health Education Officer
Institute for Public Health Institute of Health Behaviour Research
Shah Alam, Selangor Shah Alam, Selangor
Ms. Norrafizah Jaafar Dr. Norsyamlina Che Abdul Rahim

Health Education Officer Lecturer
Institute of Health Behaviour Research Universiti Malaysia Kelantan
Shah Alam, Selangor Kota Bharu, Kelantan
Mr. Azli Baharuddin Ms. Masitah Ahmad

Nutrition Officer Health Education Officer
Institute for Public Health Institute of Health Behaviour Research
Mr. Mohd Hairmanshah Mohd Shah Dr. Normawati Ahmad

Health Education Officer Health Education Officer
Institute of Health Behaviour Research Institute of Health Behaviour Research
Ms. Siti Suhaila Abdul Ghaffar

Nutrition Officer
Institute for Public Health
Shah Alam, Selangor
396
Participants
Dr. Salwani Omar Ms. Suguna Periasamy

Medical Officer Community Nurse
Klinik Kesihatan Kampung Gial Klinik Kesihatan Kuah
Kangar, Perlis Langkawi, Kedah
Ms. Nur Hazwani Roslan Dr. Chan Jin Mae

Nutrition Officer Medical Officer
Jabatan Kesihatan Negeri Perlis Pejabat Kesihatan Daerah Kampar
Kangar, Perlis Kampar, Perak
Mr. Rosdiizwan Roslan Ms. Intherani A/P Supramaniam

Dietitian Community Nurse
Klinik Kesihatan Kangar Klinik Kesihatan Malim Nawar
Kangar, Perlis Malim Nawar, Perak
Mr. Arief Haqimie Mohd Amir Ms. Nadirah Khairuddin

Assistant Medical Officer Dietitian
Klinik Kesihatan Beseri Klinik Kesihatan Tanjung Malim
Kangar, Perlis Tanjung Malin, Perak
Ms. Hazizah Hat Mr. Sujinder Singh A/L Dalbir Singh

Staff Nurse Assistant Medical Officer
Klinik Kesihatan Beseri Klinik Kesihatan Ayer Tawar
Kangar, Perlis Ayer Tawar, Perak
Dr. Sarmiza Saad Ms. Rohani Mustafa

Medical Officer Staff Nurse
Jabatan Kesihatan Negeri Kedah Klinik Kesihatan Kuala Kangsar
Alor Setar, Kedah Kuala Kangsar, Perak
Dr. Arfah Ahmad Ms. Hartini Ab A’ala

Medical Officer Dietitian
Klinik Kesihatan Changlun Hospital Pulau Pinang
Changlun, Kedah George Town, Pulau Pinang
Mr. Eng Zei Pei Ms. Nurliyana Saidin

Nutrition Officer Nutrition Officer
Klinik Kesihatan Taman Intan Klinik Kesihaan Bandar Tasek Mutiara
Sungai Petani, Kedah Simpang Ampat, Pulau Pinang
Ms. Nor Irafadzlyna Md Jalil Ms. Zaitun Mohamed Noor

Dietitian Community Nurse
Hospital Sultanah Bahiyah Klinik Kesihatan Ibu dan Anak Bukit Mertajam
Alor Setar, Kedah Bukit Mertajam, Pulau Pinang
Ms. Srisubasheni A/P Dorasamy Mr. Wan Azmi Wan Ya

Assistant Medical Officer Assistant Medical Officer
Klinik Kesihatan Laka Temin Jabatan Kesihatan Negeri Pulau Pinang
Bukit Kayu Hitam, Kedah George Town, Pulau Pinang
Ms. Rosmini Che Lah Ms. Ranjciita A/P Mohanaranjan

Matron Staff Nurse
Klinik Kesihatan Kuah Klinik Kesihatan Bayan Lepas
Langkawi, Kedah Bayan Lepas, Pulau Pinang
397
Ms. Ellin Kiung Dr. Izzah Ab Rahaman

Nutrition Officer Medical Officer
Klinik Kesihatan Seksyen 19 Klinik Kesihatan Pedas
Shah Alam, Selangor Pedas, Negeri Sembilan
Mr. Rozlinizam Kudori Ms. Ong Zi Yin

Dietitian Health Education Officer
Klinik Kesihatan Sungai Chua Jabatan Kesihatan Negeri Sembilan
Kajang, Selangor Seremban, Negeri Sembilan
Ms. Siti Hajar Suraji Mr. Muhammad Hafiz Saadon

Health Education Officer Assistant Medical Officer
Hospital Tengku Ampuan Rahimah Klinik Kesihatan Senawang
Klang, Selangor Seremban, Negeri Sembilan
Mr. Norizan Jimaan Ms. Norhasmira Abd Rani

Assistant Medical Officer Staff Nurse
Jabatan Kesihatan Negeri Selangor Klinik Kesihatan Senawang
Shah Alam, Selangor Seremban, Negeri Sembilan
Ms. Nurul ‘Atiqah Roslan Ms. Leelavathy A/P Seeralan Devan

Staff Nurse Community Nurse
Klinik Kesihatan Seksyen 7 Klinik Kesihatan Nilai
Shah Alam, Selangor Seremban, Negeri Sembilan
Ms. Jenny Anak Jok Mr. Norzain Musa

Community Nurse Nutrition Officer
Klinik Desa Sg Ramal Luar Klinik Kesihatan Merlimau
Kajang, Selangor Merlimau, Melaka
Dr. Noor Hafizah Ab Rahman Ms. Ti Xiao Xuan

Medical Officer Dietitian
Jabatan Kesihatan Wilayah Persektuan Kuala Klinik Kesihatan Rembia
Lumpur & Putrajaya Alor Gajah, Melaka
Kuala Lumpur
Ms. Rafinah Muhammad Rapi
Dr. Chong Ching Phang Health Education Officer
Dietitian Jabatan Kesihatan Negeri Melaka
Klinik Kesihatan Jinjang Ayer Keroh, Melaka
Kuala Lumpur
Ms. Narlily Mohd Nasir
Mr. Wan Muhammad Bishrulhaafi Wan Yaacob Assistant Medical Officer
Assistant Medical Officer Klinik Kesihatan Peringgit
Klinik Kesihatan Presint 18 Melaka Tengah, Melaka
Putrajaya
Ms. Hasmanini Mastura Hamzah
Ms. Kavitha A/P Sundram Staff Nurse
Staff Nurse Klinik Kesihatan Machap Baru
Klinik Kesihatan Komuniti Taman Tun Dr Ismail Alor Gajah, Melaka
Kuala Lumpur, Wilayah Persekutuan Kuala
Lumpur Ms. Siti Aisyah Hj. Yacob
Community Nurse
Ms. Siti Maharani Muhammad Salleh Klinik Kesihatan Machap Baru
Communtiy Nurse Alor Gajah, Melaka
Klinik Komuniti Hang Tuah
Kuala Lumpur, Wilayah Persekutuan Kuala
Lumpur
398
Ms. Siti Mariam Ali Ms. Siti Nasihah Baharuddin

Nutrition Officer Staff Nurse
Jabatan Kesihatan Negeri Johor Klinik Kesihatan Ibu dan Anak Kuala Lipis
Johor Bharu, Johor Kuala Lipis, Pahang
Ms. Noor Adzha Yusoof Dr. Nazirul Azam Ibrahim

Dietitian Medical Officer
Hospital Enche’ Besar Hajjah Khalsom Pejabat Kesihatan Daerah Kuala Nerus
Kluang, Johor Kuala Terengganu, Terengganu
Mr. Mohd Taufik Mohd Hassan Ms. Nurul Fatihah Hamin Ghani
Health Education Officer Nutrition Officer
Jabatan Kesihatan Negeri Johor Klinik Kesihatan Chendering
Johor Bharu, Johor Kuala Terengganu, Terengganu
Mr. Dinash A/L Ragawan Ms. Nurul Nadia Zamimi

Assistant Medical Officer Dietitian
Klinik Kesihatan Taman Universiti Klinik Kesihatan Batu 2 1/2
Johor Bharu, Johor Kemaman, Terengganu
Ms. Harinah Ebit Mr. Mohd Sabri Jusoh

Matron Assistant Medical Officer
Klinik Kesihatan Pasir Gudang Klinik Kesihatan Batu Rakit
Pasir Gudang, Johor Kuala Nerus, Terengganu
Ms. Haslinda Sedin Ms. Suhana Saad

Community Nurse Staff Nurse
Klinik Desa Sedenak Klinik Kesihatan Chendering
Kulai, Johor Kuala Terengganu, Terengganu
Dr. Sivanathan A/L Vijayakumar Ms Noor Farhanah Che Abu Bakar

Medical Officer Community Nurse
Klinik Kesihatan Bandar Kuantan Klinik Kesihatan Manir
Kuantan, Pahang Kuala Terengganu, Terengganu
Ms. Eunice Lai Wern Yean Ms. Nor Maihiza Akmal Mohd Salleh
Nutrition Officer Nutrition Officer
Klinik Kesihatan Cheroh Klinik Kesihatan Ketereh
Raub, Pahang Kota Bharu, Kelantan
Ms. Najwa Che Abdullah Mr. Mohd Hilmi Ya’kub

Dietitian Dietitian
Hospital Tengku Ampuan Afzan Klinik Kesihatan Tanah Merah
Kuantan, Pahang Tanah Merah, Kelantan
Mr. Azman Ahmad Mr. Mohd Riduan Ibrahim

Health Education Officer Assistant Medical Officer
Jabatan Kesihatan Negeri Pahang Jabatan Kesihatan Negeri Kelantan
Kuantan, Pahang Kota Bharu, Kelantan
Mr. Mohd Shafie Ali Ms. Noriza Bakar

Assistant Medical Officer Matron
Klinik Kesihatan Bandar Raub Klinik Kesihatan Beris Kubor Besar
Raub, Pahang Bachok, Kelantan
399
Ms. Aimi Nabila Yusoff

Nutrition Officer
Klinik Kesihatan Tatau
Bintulu, Sarawak
Ms. Wong Siew Rong

Dietitian
Klinik Kesihatan Batu Kawa
Kuching, Sarawak
Ms. Zaifa Haji Johari

Health Education Officer
Pejabat Kesihatan Bahagian Sri Aman
Sri Aman, Sarawak
Dr. Rexanna Malakun

Medical Officer
Jabatan Kesihatan Negeri Sabah
Mr. Shahrulnaz Norhazli Nazri

Nutrition Officer
Ms. Susilia Sinnar

Nutrition Officer
Ms. Chin Kim Ling

Nutrition Officer
Mr. Andy Ng Kwan Peng

Dietitian
Hospital Wanita dan Kanak-kanak
Mr. Melvin Ebin Bondi

Assistant Medical Officer
Pejabat Kesihatan Daerah Penampang
Penampang, Sabah
Ms. Desiree Alexandra Laban

Staff Nurse
Klinik Kesihatan Ibu dan Anak Pekan
Ms. Nanie Natasha Primos

Community Nurse
Klinik Kesihatan Menggatal
400
Malaysian Dietary Guidelines

For Children and Adolescents
Consensus Meeting
(13th - 15th July 2023)
401
Consensus Meeting on Malaysian Dietary Guidelines for Children and

Adolescents
(13th - 15th July 2023)
Ms. Zalma Abdul Razak Ms. Wan Fazlily Wan Mahmood

Nutrition Division, MOH Nutrition Division, MOH
Putrajaya Putrajaya
Ms. Rusidah Selamat Ms. Ain Hanani Budiono

Nutrition DIvision, MOH Nutrition DIvision, MOH
Putrajaya Putrajaya
Ms. Zaiton Daud Ms. Norfaiezah Ahmad

Putrajaya Putrajaya
Mr. Nazli Suhardi Ibrahim Ms. Siti Nur Hidayah Adznam

Putrajaya Putrajaya
Ms. Fatimah Sulong Ms. Irma Hanim Abdullah

Putrajaya Putrajaya
Ms. Siti Shuhailah Shaikh Abdul Rahim Ms. Nor Hanisah Zaini
Putrajaya Putrajaya
Ms. Noriza Zakaria Ms. Nur Azlina Abdul Aziz

Putrajaya Putrajaya
Ms. Junidah Raib Ms. Nuurdiana Mohd Rafien

Putrajaya Putrajaya
Ms. Khairul Zarina Mohd Yusop Ms. Munirah Nasir

Nutrition Division. MOH Nutrition Division, MOH
Putrajaya Putrajaya
Ms. Ainan Nasrina Ismail Dr. Nur Dayana Shaari

Nutrition DIvision, MOH Nutrition Division, MOH
Putrajaya Putrajaya
Ms. Rozalina Ismail Ms. Nur Hasyimah Khalid

Putrajaya Putrajaya
402
Ms. Siti Dinie Syazwani Azlam Ms. Nurliyana Mohamad Nizar

Nutrition DIvition, MOH Food Safety and Quality Division, MOH
Putrajaya Putrajaya
Ms. Noor Faezah Abdul Jalil Dr. Azliza Dato’ Zabha

Nutrition Division, MOH Oral Health Programme, MOH
Putrajaya Putrajaya
Ms. Nurul Syazwani Kamarulzaman Dr. Muhammad Adib Jamil

Nutrition DIvision, MOH Oral Health Programme, MOH
Putrajaya Putrajaya
Ms. Noor Ilya M. Hussin Dr. Siti Sarah Soraya Mohamad

Nutrition Division, MOH Oral Health Programme, MOH
Putrajaya Putrajaya
Ms. Julia Ba’on Ms. Nur Hidayatun Fadillah Mohd Nor

Nutrition DIvision, MOH Health Education Division, MOH
Putrajaya Putrajaya
Mr. Mohd Amar Farhan Abu Bakar Dr. Nik Rubiah Nik Abdul Rashid
Nutrition DIvision, MOH Family Health and Development Division, MOH
Putrajaya Putrajaya
Ms. Eriedawanis Bairuha Zainudin Ms. Lalitha Palaniveloo

Nutrition Division, MOH Institute of Public Health
Putrajaya Shah Alam, Selangor
Ms. Nur Irsalina Mohamed Zaki Mr. Mohd Faizal Ibrahim

Nutrition Division, MOH Jabatan Kesihatan Negeri Perlis
Putrajaya Kangar, Perlis
Dr. Feisul Idzwan Mustapha Mr. Haja Mohaideen Myden Kather

Disease Control Division, MOH Jabatan Kesihatan Negeri Perak
Putrajaya Ipoh, Perak
Dr. Nurhaliza Zakariah Ms. Zuhaida Harun

DIsease Control Division, MOH Jabatan Kesihatan Negeri Pulau Pinang
Putrajaya George town
Ms. Norlida Zulkafly Mr. Jaafar Mohamed Idris

Food Safety and Quality Division, MOH Jabatan Kesihatan Negeri Selangor
Putrajaya Shah Alam, Selangor
Ms. Nor Nabihah Ab Rahman Ms. Norlela Mohd Hussin

Food Safety and Quality Division, MOH Jabatan Kesihatan Negeri Sembilan
Putrajaya Seremban, Negeri Sembilan
Ms. Shazlina Mohd Zaini Dr. Wirdah Mohamed

Food Safety and Quality Division, MOH Jabatan Kesihatan Negeri Melaka
Putrajaya Ayer Keroh, Melaka
Ms. Rabia’atuladabiah Hashim Ms. Norhasliza Ariffin

Food Safety and Quality Division, MOH Jabatan Kesihatan Negeri Kelantan
Putrajaya Kota Bharu, Kelantan
403
Ms. Zahariah Mohd Nrdin Prof. Dr. Ruzita Abd Talib

Jabatan Kesihatan Negeri Terengganu Universiti Kebangsaan Malaysia
Kuala Terengganu, Terengganu Kuala Lumpur
Ms. Nurnadia Abdul Aziz Prof. Dr. Poh Bee Koon

Jabatan Kesihatan Negeri Terengganu Universiti Kebangsaan Malaysia
Kuala Terengganu, Terengganu Kuala Lumpur
Ms. Bong Mee Wan Assoc. Prof. Dr. Nik Shanita Safii
Jabatan Kesihatan Negeri Sarawak Universiti Kebangsaan Malaysia
Kuching, Sarawak Kuala Lumpur
Mr. Shahrulnaz Norhazli Nazri Assoc. Prof. Dr. Razif Shahril

Jabatan Kesihatan Negeri Sabah Universiti Kebangsaan Malaysia
Kota Kinabalu, Sabah Kuala Lumpur
Ms. Gui Shirly Assoc. Prof. Dr. Hasnah Haron

Jabatan Kesihatan Negeri Labuan Universiti Kebangsaan Malaysia
Wiayah Persekutuan Labuan Kuala Lumpur
Ms. Catherine Mering Dr. Norsyamlina Che Abdul Rahim

Pejabat Kesihatan Bahagian Miri Universiti Malaysia Kelantan
Miri, Sarawak Kota Bharu, Kelantan
Mr. Shahir Shamshuddin Assoc. Prof. Dr. Wong Jyh Eiin

Pejabat Kesihatan Daerah Batu Pahat Universiti Kebangsaan Malaysia
Batu Pahat, Johor Kuala Lumpur
Ms. Ratna Mustaffa Assoc. Prof. Dr. Zaharah Sulaiman

Pejabat Kesihatan Daerah Kuala Terengganu Universiti Sains Malaysia
Kuala Terengganu, Terengganu Kubang Kerian, Kelantan
Prof. Dr. Zalilah Mohd Shariff Assoc. Prof. Dr. Foo Leng Huat
Universiti Putra Malaysia Universiti Sains Malaysia
Serdang, Selangor Kubang Kerian, Kelantan
Prof. Dr. Loh Su Peng Assoc. Prof. Dr. Mahenderan Appukutty

Universiti Putra Malaysia Universiti Teknologi MARA
Serdang, Selangor Shah Alam, Selangor
Assoc. Prof. Dr. Hazizi Abu Saad Dr. Fadhilah Jailani

Universiti Putra Malaysia Universiti Teknologi MARA
Serdang, Selangor Shah Alam, Selangor
Assoc. Prof. Dr. Chin Yit Siew Dr. Yasmin Ooi Beng Houi
Universiti Putra Malaysia Universiti Malaysia Sabah
Serdang, Selangor Kota Kinabalu, Sabah
Dr. Siti Raihanah Shafie Dr. Law Leh Shii

Universiti Putra Malaysia Universiti Malaysia Sarawak
Serdang, Selangor Kota Samarahan, Sarawak
Emeritus Prof. Dr. Ismail Mohd Noor Dr. Hanapi Mat Jusoh
Universiti Kebangsaan Malaysia Universiti Islam Antarabangsa Malaysia
Kuala Lumpur Kuantan, Pahang
404
Dr. Norliyana Aris Ms. Nor Fatmahwati Yakup@Jhon

Universiti Malaysia Sabah Department of Fisheries Malaysia
Kota Kinabalu, Sabah Putrajaya
Dr. Nurfarhana diana Dr. Syahida Maarof

Universiti Pendidikan Sultan Idris Malaysian Agricultural Research and
Tanjung Malim, Perak Development Institute
Serdang, Selangor
Assoc. Prof. Dr. Sharifah Wajihah Wafa Syed
Saadun Tarek Wafa Ms. Norsaila Mohamad
Universiti Sultan Zainal Abidin National Unity and Integration Department
Kuala Terengganu, Terengganu Putrajaya
Assoc. Prof. Dr. Wee Bee Suan Ms. Azmaini Isa

Universiti Sultan Zainal Abidin Ministry of Women,
Kuala Terengganu, Terengganu Family and Community Development
Putrajaya
Emerita Prof. Dr. Norimah A Karim
International Medical University Mr. Tony Azman Hassan
Bukit Jalil, Kuala Lumpur Ministry of Youth and Sports
Putrajaya
Dr. Satvinder Kaur
UCSI University Dr. Ahmad Zawawi Zakaria
Cheras, Kuala Lumpur National Sports Institute
Bukit Jalil, Kuala Lumpur
Mr. Ng See Hoe
Taylor’s University Ms. Sumeeta Neelamegam
Subang Jaya, Selangor Ministry of Domestic Trade and Consumer Affairs
Putrajaya
Ms. Faizah Mansor
Ministry of Education Mr. Muslimun Md Yusof
Putrajaya Ministry of Domestic Trade and Consumer Affairs
Putrajaya
Mr. Mohd Imrizal Abdul Aziz
Ministry of Education Ms. Aisyah Anuar
Putrajaya Community Development Division
Putrajaya
Ms. Nur Muriza Musa
Ministry of Education Assoc. Prof. Dr. Khaizura Mahmud @ Ab Rashid
Putrajaya Institute of Tropical Agriculture and Food Security
Serdang, Selangor
Mr. Mohd Fakarudin Hussain
Ministry of Education Dr. Teng Kim Tiu
Putrajaya Malaysian Palm Oil Board
Kajang, Selangor
Ms. Wan Norhafiza Abdul Rahman
Ministry of Education Dr. Melia Abd Salam
Putrajaya Department of Veterinary Services
Putrajaya
Ms. Juita Md Lepi
Ministry of Agriculture and Food Industry Dr. Florence C Ginibun
Putrajaya Department of Agriculture
Putrajaya
Ms. Noraisha Abd Manan
Ministry of Agriculture and Food Industry Ms. Siti Nurul Haida Ibrahim
Putrajaya Federal Agricultural Marketing Authority
Batu Caves, Selangor
405
Dr. Thiyagar a/l Nadarajaw Assoc. Prof. Dr. Chemah Tamby Chik
Malaysian Medical Association Faculty of Hotel and Tourism Management,
Kuala Lumpur UiTM
Puncak Alam, Selangor
Dato’ Indrani Thuraisingham
Federation of Malaysian Consumers Assoc. Prof. Dr. Fatimah De’nan
Associations (FOMCA) SK Sungai Kechil Ilir
Petaling Jaya, Selangor Bandar Baru, Kedah
Dr. Hamizah Mohd Hassan

Malaysian Association of Adolescents Health
(MAAH)
Kuala Lumpur
Dr. Tee E Siong

Nutrition Society Malaysia
Petaling Jaya, Selangor
Ms. Lina Yeoh Gaik Li

Malaysian Association of Kindergartens
Ms. Megawati Suzari

Federation of Malaysian Manufacturers (FMM)
Kuala Lumpur
Ms. Wong Mei Cing

Kuala Lumpur
Mr. Lim Xiao Wen

Kuala Lumpur
Ms. Poh Kai Ling

Malaysian Diabetes Association
Assoc. Prof. Dr. Geeta Appanah

Malaysian Association for the Study of Obesity
(MASO)
Kuala Lumpur
Ms. Anisa Ahmad

Association of Registered Childcare Providers
Malaysia
Ms. Zarinah Mashuri

Association of Registered Childcare Providers
Malaysia
Mr. Khairuddin Hamzah

Association of Malaysian School Canteen
Operators
406
Nutrition Division
Level 1, Block E3, Complex E, Precinct 1,
Federal Government Administration Office,
62590 Putrajaya, Malaysia.
Tel: 03-8892 4503 • Fax: 03-8892 4511
http://nutrition.moh.gov.my

MDG For Children and Adolescents 2023

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

MDG For Children and Adolescents 2023

Uploaded by

Copyright:

Available Formats

MOH/K/BPM/20.

Ministry of Health Malaysia

National Coordinating Committee on Food and Nutrition (NCCFN)

National Coordinating Committee on Food and Nutrition (NCCFN)

First Published in 2013

Copyright © 2023 National Coordinating Committee on Food

Ministry of Health Malaysia, 2023

All rights reserved. No part of this publication may be

National Coordinating Committee on Food and Nutrition (NCCFN)

Foreword by Director-General of Health Malaysia ix

Preface by Deputy Director-General of Health (Public Health) Malaysia x

Preface by Chairman of Technical Working Group on Nutritional Guidelines xi

Technical Working Group on Nutritional Guidelines xiii

List of Authors xiv

Editorial Board xxii

Coordination and Documentation xxiii

List of Tables, Figures, Appendices xxiv

Executive Summary xxx

Key Message 2 : Give appropriate complementary foods to children between the 23

Key Message 3 : Eat a variety of foods within your recommended intake 49

Key Message 4 : Attain healthy weight for optimum growth 83

Key Message 5 : Be physically active everyday 125

Key Message 6 : Eat adequate vegetables and fruits everyday 161

Key Message 9 : Consume milk and milk products daily 233

Key Message 12 : Consume foods and beverages low in sugar 301

Key Message 13 : Drink plenty of water daily 329

Key Message 14 : Consume safe foods and beverages 345

List of Key Messages

Key Message 3 : Eat a variety of foods within your recommended intake

Key Message 4 : Attain healthy weight for optimum growth

Key Message 5 : Be physically active everyday

Key Message 6 : Eat adequate vegetables and fruits everyday

Key Message 9 : Consume milk and milk products daily

Key Message 11 : Limit intake of salt and sauces in daily meals

Key Message 12 : Consume foods and beverages low in sugar

Key Message 13 : Drink plenty of water daily

Key Message 14 : Consume safe foods and beverages

This guideline is not solely for the health sector. Thus,

On behalf of the Ministry of Health, I would like to

YB DR. ZALIHA MUSTAFA

The revision of the MDG C&A (2013) is indeed timely in

I hope this MDG C&A (2023) will be a useful reference for

DATUK DR. MUHAMMAD RADZI BIN ABU HASSAN

In Malaysia, various programmes have been implemented

It is hoped that this guideline will be used by the relevant

DATUK DR. NORHAYATI BINTI RUSLI

EMERITUS PROFESSOR DR. MOHD ISMAIL NOOR

A word of gratitude is also conveyed to the:

● Director, Disease Control Division, MOH

for their generous support and cooperation.

Technical Working Group on Nutritional Guidelines

Vice Chairman Ms. Rusidah Selamat

Secretary Ms. Rozalina Ismail

Dr. Mohd Haniff Jailani Dr. Yasmin Ooi Beng Houi

Ms. Nur Hidayatun Fadillah Mohd Noor Dr. Marhazlina Mohamad

1. Assoc. Prof. Dr. Zaharah Sulaiman (Lead Author)

2. Ms. Wan Fazlily Wan Mahmod

3. Dr. Ning Desiyanti Soehartojo

4. Dr. Nurul Husna Mohd Shukri

5. Dr. Norsyamlina Che Abdul Rahim

6. Ms. Rashadiba Ibrahim@Rahman

Give appropriate complementary foods to children between the

1. Prof. Dr. Zalilah Mohd Shariff (Lead Author)