nhms_2019.pdf

Non-Communicable Diseases: Risk Factors and other Health Problems 107 7.2 Dietary Practices Contributors to this section: Cheong Siew Man, Ruhaya Salleh, Ahmad Ali Zainuddin, Jayvikramjit Singh, Mohamad Hasnan Ahmad, Hazizi Abu Saad, Evi Diana Omar, Leong Han Yin, Shirly Chai Sook Yi, Nazli Suhardi Ibrahim Introduction Dietary practices that are incorporated into daily living could contribute significantly to human health. Poor choices in food consumption can increase the risk of certain diseases and conditions, such as diabetes, high blood pressure and obesity. In addition, some nutrients such as Vitamin C, Vitamin E and carotenoids can provide protection against certain health problems. In this study, dietary practices were assessed, including the intake of plain water, fruit and vegetables. In addition, knowledge and practice of the healthy plate concept was assessed. The World Health Organization (WHO) recommends intake of fruit and/or vegetables of at least 5 servings per day. The findings from the NHMS study (2011) showed that only 7.5% of Malaysians consumed adequate fruit and vegetables. The following NHMS study (2015) showed similar results: 94.0% of Malaysian adults did not consume adequate fruit and/or vegetables daily. The Malaysian Dietary Guidelines (MDG) 2010 recommends that adults consume 6 to 8 glasses of plain water daily. Findings from the Malaysian Adult Nutrition Survey showed that average intake of plain water among Malaysian was 6 glasses per day [1]. In the Malaysian Adult Nutrition Survey 2014, the results indicated that the mean intake of plain water was 7.1 glasses per day. In the latest NHMS report in 2015, the prevalence of adequate intake of plain water among adult Malaysian was reported to be 72.9%. To encourage Malaysians to eat healthily, the Malaysian Healthy Plate Guidelines were published in 2016 [2]. The understanding of the Malaysian Healthy Plate (suku-suku separuh) concept among the general public is important to educate people on portion size to consume in order to achieve a balanced and healthy diet. Objectives General objective To determine the dietary practices among adults in Malaysia. Specific objectives

1. To determine the prevalence of inadequate fruits and/or vegetables intake among adults in Malaysia
2. To determine the prevalence of inadequate and adequate plain water intake among adults in Malaysia
3. To determine the prevalence of awareness of Malaysian Healthy Plate Concept among adults in Malaysia
4. To determine the proportion of adequate knowledge of Malaysian Healthy Plate Concept
5. To determine the proportion of adults who practise Malaysian Healthy Plate Concept Methods Data on dietary practices was gathered from respondents aged 18 years and above. Fruit, and vegetable intake, were assessed by 4 questions. Respondents were asked the frequency and quantity of intake of fruits and vegetables in the previous week. They were also requested to report the quantity of plain water intake in a day. Three questions were designed to determine the awareness, knowledge and practice of the Malaysian Healthy Plate Concept. Respondents were asked whether they ever heard of the “Malaysian Healthy Plate”? Among those who are aware of this concept, they were requested to report what are the healthy plate concept and to provide the information whether they practice this concept. The questions were showed in the appendix. Variable Definition
6. Fruit, vegetable and fruit and vegetable intake • Inadequate fruit intake: consume less than 2 servings of fruit per day • Inadequate vegetable intake: consume less than 3 servings of vegetable per day • Inadequate fruit and/or vegetable intake: consume less than 5 servings of fruit and/or vegetable per day
7. Plain water intake • Inadequate plain water intake: drink less than 6 glasses per day • Adequate plain water intake: drink 6-8 glasses per day
8. Malaysian Healthy Plate concept • With awareness of Malaysian Health Plate Concept: ever heard or know about Malaysian Healthy Plate Concept

National Health and Morbidity Survey 2019 Technical Report − Volume I 108 • Knowledge among those with awareness: with adequate knowledge was defined as able to elaborate the concepts of Malaysian Healthy Plate correctly: i. Eat a quarter plate of rice / noodles / bread / cereal or grain products / tubers / other carbohydrate sources ii. Eat a quarter plate of fish / chicken / beef / legumes / other protein sources iii. Eat half of the plate with vegetable and fruit » Practice of Malaysian Healthy Plate Concept among those with awareness, whether they practise it every day, sometimes or not at all Findings Fruit and vegetable intake A total of 90.6% (95% CI: 89.36, 91.74) of respondents who did not consume adequate fruit. By state, Melaka recorded the highest prevalence of inadequate fruit intake with 96.0% (95% CI: 92.20, 97.99). In addition, the highest prevalence of inadequate fruit intake was among respondents from urban area [90.7% (95% CI: 89.16, 92.01)], males [90.8% (95% CI: 88.85, 92.40)] and adults aged between 18 -19 years old [95.3% (95% CI: 91.76, 97.36)]. In contrast, 90.0% (95% CI: 88.64, 91.30) of respondents who did not consume adequate vegetable. By state, Kelantan recorded the highest prevalence of inadequate vegetable intake with 98.1% (95% CI: 95.21, 99.27). Respondents from rural area had slightly higher prevalence of inadequate vegetable intake at 92.6% (95% CI: 90.98, 93.96). By sex, the females recorded higher prevalence at 90.7% (95% CI: 89.17, 92.07) than males [89.4% (95% CI:87.33-91.15). By age group, elderly aged 75 years and above [94.0% (95% CI: 90.58, 96.27)] showed the highest prevalence of not taking adequate vegetable intake. The findings showed that 94.9% (95% CI: 93.82, 95.79) of respondents did not take adequate fruit and/ or vegetable as recommended by WHO and MDG. The prevalence of inadequate fruit and/ or vegetable intake has increased from 92.5% in 2011 to 94.0% in 2015 among adults in Malaysia. By state, Kedah recorded the highest prevalence of inadequate fruit and/ or vegetable intake with 99.0% ((95% CI: 97.47, 99.59) while Sabah was the lowest with 91.0% (95% CI: 81.94, 95.72). Respondents from rural area had slightly higher prevalence of inadequate fruit and/ or vegetable intake at 95.9% (95% CI: 94.58, 96.87) compared to 94.6% (95% CI: 93.29, 95.72) among respondents from urban area. There was a higher prevalence of males [95.1% (95% CI: 93.14, 96.50)] with inadequate fruit and/ or vegetable compared with females [94.7 (95% CI: 93.44, 95.72)]. By age group, the highest prevalence of inadequate fruit and/ or vegetable intake was noted among adults between the age group of 18- 19 years old [98.9% (95% CI: 96.54, 99.68)]. Plain water intake The overall prevalence of adequate plain water intake (6-8 glasses per day) among respondents was 49.4% (95% CI: 47.84, 51.06). Pahang [58.8% (95% CI: 54.95, 62.50)] recorded the highest prevalence of adequate plain water intake followed by Perlis [57.2% (95% CI:51.62, 62.52)] and Melaka [55.1% (95% CI:48.79 ,61.17)]. The results revealed that there was a high prevalence of respondents from the urban area [50.5% (95% CI:48.60 ,52.40)] and females [51.4% (95% CI: 49.42, 53.41)] who consumed adequate plain water.
In this study, the prevalence of inadequate plain water intake among respondents was 25.8% (95% CI: 24.23, 27.33). The highest prevalence for inadequate plain water intake was in WP Putrajaya [39.9% (95% CI: 33.97, 46.15)]. The prevalence of inadequate plain water intake was higher in the rural area [28.6% (95% CI: 25.91, 31.49)] and among females [27.5% (95% CI: 25.67, 29.48)].
Malaysian Healthy Plate Concept About 20.4% (95% CI: 18.93, 22.03) or 1 in 5 respondents were aware of the Malaysian Healthy Plate Concept. The awareness was highest in WP Putrajaya [59.1% (95% CI: 53.71, 64.26)] followed by Perlis [31.5% (95% CI: 25.21, 38.54)] and WP Labuan [29.4 (95% CI: 22.83, 37.00)]. Sabah [13.0% (95% CI: 9.79, 17.01)] recorded the lowest prevalence of awareness of Malaysian Healthy Plate Concept. Respondents from the urban area [21.5% (95% CI: 19.64, 23.43)] were more aware of the Malaysian Healthy Plate Concept compared to rural area [16.8% (95% CI: 14.74, 18.98)] and females [28.0% (95% CI: 25.87,30.15)] were more aware compared to males [13.3% (95% CI: 11.80, 15.02)]. Non-Communicable Diseases: Risk Factors and other Health Problems 109 By age group, respondents in the age group of 35 to 39 years old [27.0% (95% CI: 22.88, 31.58) had the highest prevalence of awareness of Malaysian Healthy Plate Concept and the prevalence decreased as age increased, with the lowest prevalence was among elderly aged 75 years old and above [6.2% (95% CI: 3.75, 10.02)]. By education achievement, respondents with tertiary education level [33.4% (95% CI: 30.45, 36.48)] recorded the highest prevalence of awareness of Malaysian Healthy Plate Concept while respondents achieved secondary education level [19.7% (95% CI: 17.83, 21.66)] and primary education level [9.5% (95% CI: 7.67, 11.67)] recorded the lower prevalence. By occupation status, the government or semi government employees [42.7% (95% CI: 38.08, 47.45)] were more aware of Malaysian Healthy Plate Concept compared to other occupations. Respondents from Top 20% [28.4% (95% CI: 23.20, 34.24)] recorded the highest prevalence with awareness of Malaysian Healthy Plate Concept compared to the group of middle 40% [23.3% (95% CI: 20.43, 26.52)] and bottom 40% [18.3% (95% CI: 16.66, 20.05)]. Among respondents who were aware of Malaysian Healthy Plate Concept, 80.8% (95% CI: 78.01, 83.32) or four in five of them have adequate knowledge for interpreting all of the Malaysian Healthy Plate Concept. About 14.0% (95% CI: 11.73, 16.58) of those with awareness reported that they practiced the Malaysian Healthy Plate Concept in a daily basis and only 50.1% (95% CI: 46.95, 53.30) of them reported that practiced this concept sometimes. Conclusion Almost all Malaysian adults did not consume adequate fruit and/or vegetable in a day. Inadequate intake of fruit and vegetable were observed among respondents with lower education achievement and lower household income. This problem may be due to the high cost of fruit and vegetable as well as wide availability of unhealthy foods, such as energy- dense foods in affordable price in the stores [3]. Majority of the respondents drank plain water within the recommended quantity by MDG. Health promotion on drinking adequate plain water was successful and should continue to be implemented especially in rural areas as drinking adequate water is important for hydration and body function. In conclusion, the overall consumption of fruits and vegetables among Malaysian adults is still low. There is a crucial need for strategies and coordinated efforts by program managers and policy makers at all levels to promote adequate intake of fruits and vegetables among Malaysian adults. A total of 1 in 5 adults or a total of 2,160,915 adults in Malaysia were aware of the Healthy Plate Concept. The awareness is more popular in Putrajaya with 1 in 2 of them aware of this concept. Majority of the adults (80.8%) with this awareness have adequate knowledge for interpreting this concept and 64.1% of them practiced this concept. More efforts are needed to increase the awareness of healthy plate concept. Recommendations

1. Further studies / researches need to be conducted to determine the factors that cause inadequate intake of fruits & vegetables among Malaysians.
2. Increase the accessibility to affordable fruits & vegetables by expanding the number of Pasar Tani / Pasar Tamu / Pasar Malam / hypermarket / supermarket / equivalent outlets selling fruits & vegetables.
3. Price control / subsidise the local fruits & vegetables in the market in an affordable range.
4. Promote the consumption of plain water to replace the consumption of sugary drinks in various settings.
5. Strengthening the understanding and translation of Malaysian Healthy Plate Concept, the use of that knowledge to practice in main meals intake and make improvements on adequate intake of fruits and vegetables.
6. Strengthening the nutrition advocacy programmes / activities that focus on: Malaysian Healthy Plate Concept, adequate intake of fruits & vegetables and reduce sugar and sugary beverages intake. Table 7.1: Inadequate Fruit and/or Vegetable Intake Trend in Malaysia 2011 2015 2019 Indequate Fruit and/or Vegetable Intake 92.5 94.0 94.9 References

Nutrition Section, Family Health Development Division. (2008). Malaysian Adult Nutrition Survey 2003. Ministry of Health Malaysia. 2. National Coordinating Committee on Food and Nutrition. 2010. Malaysian Dietary Guidelines. Ministry of Health Malaysia. 3. Panduan Pinggan Sihat Malaysia #suku-suku separuh. 2016. Cawangan Penyakit Tidak Berjangkit Bahagian Kawalan Penyakit, Kementerian Kesihatan Malaysia. Putrajaya. 4. Institute for Public Health (IPH). 2011. National Health and Morbidity Survey 2011 (NHMS 2011). Vol. II: NonCommunicable Diseases; 2011: 188 pages 5. Institute for Public Health (IPH). 2015. National Health and Morbidity Survey 2015 (NHMS 2015). Vol. II: Non-Communicable Diseases, Risk Factors & Other Health Problems. 6. Kamphuis CB, Giskes K, de Bruijn GJ, Wendel-Vos W, Brug J, van Lenthe FJ. Environmental determinants of fruit and vegetable consumption among adults: a systematic review. British Journal of Nutrition. 2006; 96(4):620-35.