Mal J Nutr 24(4): 539-550, 2018 Nutritional status and complementary feeding among Penan infants and young children in rural Sarawak, Malaysia Bong MW1, Norimah A Karim1* & Ismail Mohd Noor2 1Nutritional Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia; 2Faculty of Social Sciences and Leisure Management, Taylor’s University, Subang Jaya, Malaysia. ABSTRACT Introduction: The Penan people are largely settled in rural and remote areas of Sarawak with high rates of undernutrition among the children. The study aimed to determine the nutritional status and infant and young child feeding (IYCF) practices of Penan children. Methods: Subjects consisted of 121 children, aged between 0-23 months, from 15 Penan longhouses in Belaga district. Malnutrition was assessed using anthropometric measurements of children and categorised according to the World Health Organization (WHO) Growth Standards (2006). Feeding practices were assessed using questionnaires based on WHO IYCF Indicators (2008). Results: The prevalence of underweight was 29.8%; stunting 43.0% and wasting 5.8%. Prevalence of exclusive breastfeeding under 6 months was 44.4%. About 86% of infants aged 6-8 months were already given solid, semi-solid and soft foods. The proportion of children aged 6-23 months achieving minimum dietary diversity (MDD) was 76.6%, while minimum meal frequency (MMF) was 83.0% (breastfed and non-breastfed). Among the children who achieved MDD, 64.9% of their meals were derived from 4-5 food groups. More than half (55.3%) of all subjects (breastfed and non-breastfed) received minimum acceptable diet (MAD). Achievement of iron-rich foods (IRF) indicator was 77.7%. There was no significant association between the IYCF indicators of MDD, MMF and MAD and underweight, stunting and wasting. Conclusion: A high prevalence of poor nutritional status was recorded among the Penan children. While the IYCF indicators apparently showed satisfactory complementary feeding practices, future studies should assess quantitatively the intake of complementary food among Penan infants and young children. Keywords: Infant and young child feeding, nutritional status, Penan, Sarawak INTRODUCTION increased morbidity and mortality (Black et al., 2013); as well as non- Global estimates show underweight communicable disease and productive (6.0%), stunting (22.9%) and wasting capacity in adulthood (Stewart et al., (7.7%) among children below 5 years old 2013). (UNICEF, WHO & World Bank Group, Recent reports revealed that while 2017). Undernutrition (underweight, global prevalence of stunting in children stunting, wasting) is linked with below 5 years has reduced from 37.2% __________________________ *Corresponding author: Prof. Norimah A. Karim Nutritional Science Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia. Tel: (6) (03)-9289 7622; Fax: (6) (03)-2694 7621; E-mail: [email protected] 540 Bong MW, Norimah AK & Ismail MN in 2000 to 22.9% in 2016, nevertheless a substantial increase compared to the a total of 154.8 million stunted children prevalence of 14.5% in 2006 (IPH, 2008). were reported in 2016, and disparities Meanwhile the national prevalence of still exist between different regions of timely complementary feeding among the world (UNICEF/WHO/World Bank children aged 6-10 months in 2006 was Group, 2017). A systematic review 41.5% (Khor et al., 2009). addressing child health inequities A study conducted in Klang District, revealed that income and economic Malaysia reported 43.1% prevalence status were the structural determinants of exclusive breastfeeding among of child health inequities. The reported infants aged 1-6 months (Tan, 2011). child health determinants include A study conducted among 173 “Orang shortcomings within the rural health Asli”2 children (Temuan and Mah Meri) care system and repercussions of food in Sepang district and Carey Island, poverty with low health literacy among Selangor reported that 33% of the parents (Schröders et al., 2015). mothers stopped breastfeeding before The national prevalence of stunting their infants were 6 months old, while among children below 5 years in Malaysia 31% breastfed their children for more was 20.7% in 2016, with Sarawak than one year (Wan Norlida et al., 2007). having a high rate at 23.1% compared to The authors also found insufficient the other states. Overall, the prevalence mean number of servings for all food of stunting was higher in rural localities groups and high under-nutrition rates (23.3%) than urban areas (19.2%). In among these Orang Asli children aged terms of ethnicity, “Other Bumiputera”1 1-3 years. recorded the highest prevalence of The Penan community is part of the stunting at 24.5% (IPH, 2016). Dayak group in Sarawak, Brunei and A cross-sectional study in Serian Kalimantan (Sercombe, 2008). Sarawak District, Sarawak reported 20.9% is home to an estimated 16,000 tribal underweight, 10.2% wasting and 11.9% Penans, living in remote areas of Baram stunting among children below 5 years and Belaga districts, with 77% living in (Eunice, Cheah & Lee, 2014). The study permanent settlements, 20% leading a also revealed only 64.4% of subjects semi-nomadic lifestyle, while another had been given complementary foods 3% live as nomads. Almost two thirds starting from the age of 6 months of the Penan population live in Baram, and above. In order to reduce child Tutoh and Limbang areas and have undernutrition and stunting, effective been referred to as Eastern Penans. nutrition-specific interventions such Meanwhile, Western Penans live mostly as breastfeeding and appropriate in the vicinity of Bintulu, and Belaga complementary feeding of children need district (Lyndon et al., 2013). to be scaled up, especially in children Primary health care is delivered to below 2 years. It has been estimated the rural community through various that nutrition-specific interventions modes, such as static health clinics, such as infant and young child feeding mobile health teams and flying doctor packages could save 221,000 lives service. Furthermore, to address when implemented together with other malnutrition among Penan children aged nutrition interventions at 90% coverage below 6 years, two community feeding (Bhutta et al., 2013). programmes were implemented in The National Health and Morbidity Sarawak from 2013 (Ministry of Health Survey (NHMS) (2016) reported the Malaysia, 2014). The community feeding prevalence of exclusive breastfeeding programmes comprise supplementary amongst infants below 6 months in feeding, provision of complementary Malaysia at 47.1% (IPH, 2016). This is foods, nutrition education and efforts __________________________ 1 “Other Bumiputera” meaning native tribes of Sarawak and Sabah, including Dayak 2 “Orang Asli” meaning aboriginal tribes of Peninsular Malaysia. Nutritional status and feeding practices among Sarawak Penan infants and children 541 to improve personal hygiene and months (n=69) were recruited based on environmental sanitation. the following inclusion criteria: i) Penan; The Third National Plan of Action ii) aged below 24 months; iii) free of for Nutrition Malaysia has identified physical disability and known diseases. specified targets to improve infant Written consent was obtained from and young child feeding practices and mothers and caregivers of the Penan nutritional status of children (NCCFN, children who participated in the study. 2016). There is a lack of data on the quality of complementary feeding in Data collection Malaysia (NCCFN, 2011). Anthropometric measurements including Despite high undernutrition rates, weight and length measurements of studies on infant and young child feeding the children were taken. Recumbent practices amongst Penan children, length measurements of children were especially complementary feeding performed using SECA 210 measuring practices, have not been extensively mat and recorded to the nearest 0.1 cm. carried out. Two previous studies that Children’s weight measurements were included assessment of nutritional status carried out using SECA 803 weighing amongst children were undertaken in scale. Weight measurement was recorded the 1970-1980s (Anderson, 2015; Chen, to the nearest 0.01 kg. Infants were 1984). weighed together with their mothers, and This study focused on complementary after that, their mothers were weighed, feeding in children aged below 24 months, with the difference being recorded as the based on the World Health Organization child’s weight. Body length and weight (WHO) infant and young child feeding measurements consisted of two readings (IYCF) indicators of minimum dietary for each child, and the average value was diversity (MDD), minimum meal then recorded. frequency (MMF) and minimum adequate Nutritional status of children was diet (MAD). The objective of this study categorised according to the WHO Child was to determine the nutritional status Growth Standards (WHO, 2006), based and infant and young child feeding on three indicators namely, weight-for practices in a sample of Penan children age z-scores (WAZ), length/height-for- in Belaga district, Sarawak. age z-scores (HAZ) and weight-for-height z-scores (WHZ), which were calculated MATERIALS AND METHODS using WHO Anthro software (version 3.2.2). For WAZ, HAZ and WHZ, a cut- Study design off value of below 2 standard deviations This is a cross-sectional study which was (SD) from the median value for the carried out in Belaga district, Sarawak.