nhms_2019.pdf

National Health and Morbidity Survey 2019 Technical Report − Volume I 100 Table 6.9: Prevalence of Noticing Anti-Cigarette Information in Newspapers / Magazines and Television in The Past 30 days Among Respondents Aged 15 Years and Above in Malaysia by Socio-Demographic Characteristics (cont’d) Sociodemographic Characteristics Newspapers/Magazines Television Count Estimated Population Prevalence (%) 95% CI Count Estimated Population Prevalence (%) 95% CI Lower Upper Lower Upper Bumiputera Sabah 206 516,623 48.5 41.90 55.22 335 762,245 68.0 62.27 73.23 Bumiputera Sarawak 135 354,190 47.4 38.92 55.99 209 525,640 69.3 60.62 76.72 Others 137 582,203 32.4 24.35 41.73 219 861,724 47.4 38.21 56.68 Marital Status Single 1,085 2,877,182 49.7 46.16 53.33 1,403 3,835,589 63.3 59.68 66.77 Married 2,730 4,880,832 49.5 46.87 52.05 3,719 6,605,232 64.5 62.03 66.92 Widow(er)/Divorcee 281 358,651 35.7 30.43 41.28 498 615,680 57.6 52.46 62.63 Education Level No Formal Education 80 113,755 17.4 12.98 22.99 218 310,539 45.0 37.96 52.18 Primary Education 736 1,380,039 40.6 35.99 45.45 1,168 2,022,089 58.0 53.22 62.71 Secondary Education 2,177 4,291,344 50.3 47.43 53.16 2,907 5,830,951 65.5 62.90 68.05 Tertiary Education 1,089 2,299,973 57.8 53.94 61.53 1,311 2,865,193 68.3 64.50 71.88 Occupation Government Employee 516 734,543 60.2 54.67 65.53 605 872,979 70.2 64.36 75.50 Private Employee 1,202 2,976,451 48.6 44.80 52.49 1,549 3,882,264 61.0 57.31 64.65 Self Employed 750 1,491,890 52.9 48.37 57.33 1,002 1,943,576 66.7 62.82 70.44 Unpaid Worker/Homemaker 699 1,102,689 45.9 40.60 51.34 1,058 1,677,843 66.5 61.51 71.08 Retiree 192 265,446 44.0 37.26 51.02 251 354,408 58.2 50.65 65.43 Student 337 859,798 53.1 47.35 58.76 434 1,153,963 68.4 63.13 73.23 Not Workingb 400 685,850 36.8 32.40 41.41 718 1,168,893 57.8 53.63 61.86 Household Income Group Less than RM 1,000 302 540,160 40.1 35.25 45.10 521 865,268 60.4 55.97 64.66 RM 1,000 - RM 1,999 783 1,399,188 42.0 37.86 46.27 1,118 2,086,537 60.8 56.57 64.85 RM 2,000 - RM 3,999 1,254 2,606,648 51.0 47.54 54.52 1,707 3,502,051 66.0 62.65 69.12 RM 4,000 - RM 5,999 670 1,336,724 51.9 46.80 57.04 893 1,877,766 68.0 63.33 72.41 RM 6,000 - RM 7,999 410 834,338 55.8 49.25 62.16 510 1,041,208 66.6 59.70 72.78 RM 8,000 - RM 9,999 185 387,944 58.3 49.80 66.33 224 448,463 64.6 55.46 72.76 RM 10,000 and above 317 647,872 53.6 43.24 63.70 374 737,749 59.1 48.48 68.95 Household Income Quintile Quintile 1 707 1,242,901 40.9 36.96 44.88 1,092 1,920,859 60.3 56.60 63.80 Quintile 2 787 1,523,351 47.1 42.34 51.91 1,086 2,088,723 62.9 58.30 67.24 Quintile 3 766 1,636,445 50.4 46.33 54.57 1,062 2,232,196 66.1 61.91 70.01 Quintile 4 749 1,480,024 52.1 47.21 56.96 999 2,089,844 68.6 64.30 72.59 Quintile 5 912 1,870,154 55.5 50.38 60.53 1,108 2,227,420 63.5 57.94 68.75 Household Income Category Bottom 40% 2,561 4,751,457 46.1 43.66 48.61 3,602 6,682,789 62.3 59.87 64.74 Middle 40% 1,003 2,253,785 55.6 51.10 59.92 1,318 2,980,512 69.6 65.63 73.28 Top 20% 357 747,633 54.5 45.62 63.15 427 895,741 62.3 52.53 71.18 *Prevalence with high RSE, interpret with caution a - Malay includes Orang Asli b - Not working includes Unemployed, and Old Age

Non-Communicable Diseases: Risk Factors and other Health Problems 101 Table 6.10: Prevalence of Noticing Cigarette Advertisement and Promotion Among Respondents Aged 15 Years and Above in Malaysia

Cigarette Advertisement and Promotion Total Male Female Count Estimated Population Prevalence (%) 95% CI Count Estimated Population Prevalence (%) 95% CI Count Estimated Population Prevalence (%) 95% CI Lower Upper Lower Upper Lower Upper Cigarettes advertising in store 2,004 3,653,288 21.2 19.47 23.03 939 2,080,166 21.8 19.50 24.39 1,065 1,573,122 20.4 18.34 22.60 Free cigarettes sample 156 283,231 1.3 1.01 1.79 85 196,552 1.8 1.31 2.45 71 86,679 0.9 0.49 1.50 Cigarettes at sale price 146 416,162 1.8 1.23 2.64 83 328,376 2.8 1.74 4.41 63 87,786 0.8 0.53 1.14 Coupons for cigarettes 71 123,535 0.6 0.34 1.00 23 73,579 0.7* 0.36 1.26 48 49,957 0.5* 0.22 1.13 Free gift or special discount on other products when buying cigarettes 66 116,014 0.5 0.33 0.90 24 66,857 0.6* 0.30 1.21 42 49,157 0.5* 0.24 0.96 Clothing or other items with a cigarette brand name or logo 128 227,070 1.1 0.82 1.40 65 138,518 1.3 0.88 1.79 63 88,551 0.9 0.56 1.35 Cigarette promotions in the mail 61 85,860 0.4 0.24 0.67 25 46,010 0.4 0.26 0.67 36 39,850 0.4* 0.17 0.90 *Prevalence with high RSE, interpret with caution

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Non-Communicable Diseases: Risk Factors and other Health Problems 103 Dietary Practices

National Health and Morbidity Survey 2019 Technical Report − Volume I 104 Dietary Practices 7.1 Intake Of Commercially Packed Ready To Drink Beverages / Premixed / Sugar Added Self-Prepared Drinks And The Consumption Of Sugar Contributors to this section: Cheong Siew Man, Lalitha Palaniveloo, Ruhaya Salleh, Norsyamlina Che Abdul Rahim, Hazizi Abu Saad, Evi Diana Omar, Nazli Suhardi Ibrahim, Fatimah Zurina, Leong Han Yin, Shirly Chai Sook Yi Introduction Consumption of sugar sweetened beverages (SSBs) has been linked with adult and childhood obesity, an increasing health burden in Malaysia. SSBs is defined as all types of beverages containing free sugars and these include carbonated or non- carbonated soft drinks, fruit/vegetable juices and drinks, liquid and powder concentrates, flavoured water, energy and sports drinks, ready-to-drink tea, ready-to-drink coffee, and flavoured milk drink [1]. Globally, SSBs intake was highest among younger adults aged between 20-39 years [2]. In a study conducted among undergraduates aged between 19-26 years in Malaysia, the proportion of consuming at least one SSBs in a week was 96.5% while consumption of at least one SSBs in a day was 89.3% [3]. Consumption of SSB is associated with obesity, type 2 diabetes mellitus and cardiovascular risks in adults [4].
Objectives General objective To determine the intake of commercially packed ready to drink (CPRD) beverages, premixed beverages and sugar added self-prepared drinks among adults in Malaysia. Specific objectives

1. To determine prevalence of CPRD beverages intake of at least once in a week among the respondents
2. To determine proportion of daily intake of CPRD beverages among respondents consuming commercially packed ready to drink beverages
3. To determine daily intake of sugar from CPRD beverages among respondents consuming commercially packed ready to drink beverages daily
4. To determine prevalence of premixed drinks intake of at least once in a week among the respondents
5. To determine proportion of daily intake of premixed drinks among respondents consuming premixed drinks
6. To determine daily intake of sugar from premixed drinks among respondents consuming premixed drinks daily
7. To determine prevalence of sugar added self-prepared drinks intake of at least once in a week among the respondents
8. To determine proportion of daily intake of sugar added self-prepared drinks among respondents consuming self- prepared drinks
9. To determine daily intake of sugar from sugar added self-prepared drinks among respondents consuming self- prepared drinks daily Methods Data on sugar added beverages was gathered from Malaysian adult respondents aged 18 years and above. Respondents were asked on the quantity of different types of sugar added beverages they consumed in the previous week. Three questions were designed to determine the intake of commercially packed ready to drink (CPRD) beverages, premixed beverages, and sugar added self-prepared drinks. Respondents were asked whether they consumed each type of the sugar added beverages in the previous week and the quantity of beverages if they reported consuming any sugar added beverage in the previous week. The questions were showed in the appendix.

Non-Communicable Diseases: Risk Factors and other Health Problems 105 Variable Definition

1. Commercially packed ready to drink beverages (CPRD beverages) • Carbonated and non-carbonated drinks (e.g. Coca- Cola, 100 plus, Sprite, soy milk, chrysanthemum tea, lemon tea, and milo)
2. Premixed drinks • Instant drink products containing sugar (e.g. premix coffee, tea, chocolate, soy, and cereal)
3. Sugar added self-prepared drink • Coffee, tea, chocolate or malted beverages added with sugar and/ or sweetened condensed milk or sweetened creamer *Based on Operational Definition by Nutrition Division, Ministry of Health Malaysia Findings Intake of Commercially Packed Ready to Drink (CPRD) Beverages and The Amount of Sugar Consumed
   The national prevalence of CPRD beverages intake of at least once in a week among the respondents was 38.9% (95% CI: 37.20, 40.60). Among the 16 states and federal territories in the country, Sarawak recorded the highest prevalence of CPRD beverages intake at least once a week with 55.0% (95% CI: 49.90, 60.00), while Pahang was the lowest with 27.0% (95% CI: 22.10, 32.60). By sex, males recorded higher prevalence at 43.1% (95% CI: 40.80, 45.50) than females [34.4% (95% CI: 32.30, 36.60)]. Respondents in the age group of 18-19 years old had the highest prevalence of CPRD beverages intake at 64.7% (95% CI: 57.50, 71.30) while those aged 75 years and above were the lowest with 13.8% (95% CI: 9.90, 18.80). Among the ethnic groups, Bumiputera Sarawak had the highest prevalence [52.0% (95% CI: 45.80, 58.20)] while Indians had the lowest [32.7% (95% CI: 27.50, 38.30)]. By marital status, respondents who were single recorded the highest prevalence at 55.6% (95% CI: 52.20, 58.90) while those who were widow(er) / divorced recorded the lowest prevalence at 25.3% (95% CI: 21.30, 29.80). The overall proportion of daily intake of CPRD beverages was 10.9% (95% CI: 9.40, 12.65) with a median sugar intake of 29.0 grams/ day (IQR: 20.69, 43.28). The median daily sugar intake from CPRD beverages among respondents was between 20-44 grams/ day. By gender, male respondents recorded higher proportion of daily CPRD beverages’ intake with 11.7% (95% CI: 9.73, 13.96) and the median sugar intake was 35.2 grams/ day (IQR: 22.26, 49.48). Among the ethnic groups, Bumiputera Sarawak recorded the highest daily proportion of CPRD beverages’ intake with 13.4% (95% CI: 8.90, 19.55) and median sugar intake of 31.7 grams/ day (IQR: 20.69, 69.74). By marital status, respondents who were single recorded the highest proportion of daily CPRD beverages’ intake with 13.1% (95% CI: 10.53, 16.26) and median sugar intake was 30.0 grams/ day (IQR: 21.17, 43.72). The proportion of daily CPRD beverages’ intake by educational level shows that respondents with no formal education recorded the highest with 16.7% (10.35, 25.81) and the median sugar intake was 41.4 grams/ day (IQR: 20.69, 62.07). Respondents from Bottom 40% income group recorded the highest proportion of daily CPRD beverages’ intake with 11.9% (95% CI: 10.06, 14.14) and median sugar intake of 27.1 grams/ day (IQR: 20.69, 43.72). Intake of Premixed Drinks and The Amount of Sugar Consumed The national prevalence of premixed drinks intake of at least once in a week among the respondents was 23.1% (95% CI: 21.50, 24.70). Sarawak recorded the highest prevalence of premixed drinks intake with 38.7% (95% CI: 33.70, 43.90) while Kelantan was the lowest with 14.2% (95% CI: 10.60, 18.80). Respondents in the age group of 45-49 years old had the highest prevalence of premixed drinks intake at 28.5% (95% CI: 24.70, 32.70) while those between the age of 18-19 years old were the lowest with 16.2% (95% CI: 12.00, 21.50). Among the ethnic groups, Bumiputera Sarawak had the highest prevalence [42.1% (95% CI: 36.10, 48.30)] while Indians were the lowest [13.8% (95% CI: 10.50, 17.90)]. Among those who reported to have consumed premixed drinks, the overall proportion of daily intake of premixed drinks was 29.2% (95% CI: 25.69, 32.94) with median sugar intake of 14.3 grams/ day (IQR: 14.26, 28.52). The proportion of daily intake of premixed drinks among the 16 states and federal territories in the country was between 16-49%, with Perak recorded the highest proportion with 48.4% (95% CI: 37.91, 59.12) and median sugar intake of 14.3 grams/ day (IQR: 14.26, 28.52). Male respondents recorded a higher proportion of daily intake of premixed drinks [30.7% (95% CI: 25.43, 36.42)] with median sugar intake of 14.3 grams/ day (IQR: 14.26, 28.52). The proportion of premixed drinks intake by age groups was between 24-47%, with respondents from the age group of 70-74 years had the highest proportion with 46.9% (95% CI: 31.63, 62.80) and median sugar intake of 14.3 grams/ day (IQR: 14.26, 28.52). National Health and Morbidity Survey 2019 Technical Report − Volume I 106 Among the ethnic groups, the Bumiputera Sarawak had the highest proportion of premixed drinks intake daily with 42.6% (95% CI: 31.86, 54.04) and the median sugar intake was 14.3 grams/day (IQR: 14.26, 28.52). By marital status, respondents who were widow(er) / divorced recorded the highest proportion of premixed drinks intake with 38.5% (95% CI: 30.23, 47.58) and median sugar intake of 14.3 grams/ day (IQR: 14.26, 28.52). The proportion by educational level shows that respondents with primary level education recorded the highest proportion of daily intake of premixed drinks with 39.5% (28.89, 51.11) and median sugar intake of 14.3 grams/day (IQR: 14.26, 28.52). Intake of Sugar Added Self-Prepared Drinks and The Amount of Sugar Consumed The national prevalence of sugar added self-prepared drinks intake of at least once in a week among the respondents was 85.6% (95% CI: 84.24, 86.78). Kelantan recorded the highest prevalence of sugar added self-prepared drinks intake with 97.7% (95% CI: 95.73, 98.75) while WP Labuan was the lowest with 72.4% (95% CI: 68.03, 76.36). Respondents in the age group of 35-39 years old had the highest prevalence of sugar added self-prepared drinks intake at 89.1% (95% CI: 86.30, 91.32) while those aged 75 years and above were the lowest with 80.0% (95% CI: 74.33, 84.61). Among the ethnic groups, Malays had the highest prevalence [91.0% (95% CI: 89.98, 91.94)]. Respondents with tertiary education had the highest prevalence of sugar added self-prepared drinks intake at 86.3% (95% CI: 83.75, 88.56) while those with no formal education were the lowest [79.5% (95% CI: 71.93, 85.42)]. The overall proportion of daily intake of sugar added self- prepared drinks was 62.2% (95% CI: 60.34, 63.96) with median sugar intake of 13.6 grams/day (IQR: 6.80, 25.43). The proportion of daily intake of sugar added self-prepared drinks among the 16 states and federal territories in the country was between 51-76%. Sarawak had the highest proportion with 75.5% (95% CI: 70.04, 80.23) and median sugar intake of 10 grams/day (IQR: 5.00, 20.00). The proportion by educational level shows that respondents with primary education recorded the highest proportion with 67.7% (95% CI: 64.09, 71.18) and the median sugar intake was 13.2 grams/day (IQR: 5.97, 27.20). Conclusion In general, sugar added self-prepared drinks were more commonly consumed compared to CPRD beverages and premixed beverages. However, the amount of sugar intake from CPRD beverages is higher compared to sugar intake from sugar added self-prepared drinks. Overall, adults from younger age groups tend to consume more sugar from all the type of beverages. Although consumption of sugar added self-prepared drinks were more common in Sarawak, the amount of sugar intake was higher in Peninsula Malaysia especially among the states from the East Coast; Terengganu, Kelantan and Pahang. Recommendations
4. Expand the current taxation of Sugar-Sweetened Beverages (SSBs) by imposing tax on sugar added self- prepared and premixed drinks.
5. Strengthen the SSBs tax implementation by imposing higher tax on the SSBs products that is high in sugar.
6. Reduce / restrict the procurement and availability of SSBs at anchor institutions.
7. Engagement with beverage industries to reformulate sugar content in SSBs or resize the packaging.
8. Strengthening the practise of reading nutrition facts labels among consumers to create awareness on sugar content in SSBs, indirectly educating them to reduce the intake of SSBs. References

Guideline: Sugars intake for adults and  children. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/149782/1/9789241549028_eng. pdf). 2. Singh, G.M., R. Micha, S. Khatibzadeh, P. Shi and S. Lim et al., 2015. Global, regional and national consumption of sugar-sweetened beverages, fruit juices and milk: A systematic assessment of beverage intake in 187 countries. Plos One, Vol. 10. 10.1371/journal.pone.0124845 3. Norliza-Ahmad, Muhammad Afiq-Md Zuki, Nur Azilah-Azahar, Boon Han-Khor and Halimatus Sakdiah-Minhat, 2019. Proportion and factors associated with sugar-sweetened beverage intake among undergraduate students in a public university in Malaysia. Pak. J. Nutr., 18: 354-363. 4. Malik, V.S. and F.B. Hu, 2015. Fructose and cardiometabolic health: What the evidence from sugar-sweetened beverages tells us. J. Am. College Cardiol., 66: 1615-1624.