The report, titled Stunting in Malaysia: Costs, Causes, and Courses for Action, was compiled by the Jeffrey Cheah Institute (JCI) on Southeast Asia (Sunway University's independent public policy think tank) and the Jeffrey Sachs Centre (JSC) on Sustainable Development.
In it, lead author Derek Kok highlighted that according to 2018 World Bank data, Malaysia's rate of stunting among children under five was 20.7% — higher than in Ghana (18.8%) and much higher than in Gaza and the West Bank (7.4%).
With the exception of Iraq (22.6%), Malaysia's stunting prevalence was higher than that in other middle-income countries included in the data, such as Macedonia (4.9%), Kazakhstan (8%) and Mexico (12.4%).
Despite overall global childhood stunting rates having fallen in the last 20 years, Malaysia's stunting prevalence has risen back to its 1999 level, and far exceeds the 11% 2025 target set by the country's National Plan of Action for Nutrition 2015 — 2025.
Stunted despite socio-economic status
But perhaps the most striking detail in this situation is that childhood stunting in Malaysia is a significant problem regardless of factors such as household income, parental education level and parental occupation.
While the issue is expectedly more prevalent in lower income households (29.8% among households with a monthly income of under RM1,000), the prevalence of childhood stunting is 17.4% among households with a monthly income exceeding RM5,000.
With regards to parental education level, the more highly educated a mother is, the less likely her child is to be stunted. However, the stunting rate among children of Malaysia's most highly educated mothers (tertiary education and beyond) is 18.6%, compared to 28.7% among children of uneducated mothers.
Similarly, children of unemployed mothers face the highest stunting rates at 38.3%. Still, among working mothers in different industries, the rates of childhood stunting are significant, as well as largely similar — be it the public sector (21.7%), private sector (19.4%), self-employment (19.6%), or among homemakers (20.8%).
Childhood stunting is also prevalent across the different states in Malaysia, with the lowest incidence in Kuala Lumpur (10.5%) and the highest in Kelantan (34%).
In terms of the country's different ethnic groups, childhood stunting is least prevalent among the Chinese (14.1%) and most prevalent among 'other' ethnic groups, i.e., non-Chinese, non-Malay and non-Indian groups (29.5%).
Kok wrote: "From the data, it is clear to see that stunting in Malaysia cuts across ethnicities, income levels, occupations, education levels, states, and even the urban-rural devide.
"The conclusion that these figures show cannot be ignored — Malaysia has a national malnutrition problem."
The multiple factors of malnutrition
The report stated that stunting was "a manifestation of maternal and child under-nutrition" resulting from a "complex interaction of household, environmental, socio-economic and cultural influences".
One such factor is household food security. A study conducted in Kelantan discovered that children in food-insecure households were three times more likely to be stunted than children in food-secure households.
Household food insecurity also increases the prevalence of diarrhoea, which can directly cause stunting.
In 2014, the Khazanah Research Institute found that many Malaysians are unable to afford a nutritionally adequate diet, especially in urban households with incomes near the poverty line.
Despite this, food in Malaysia constitutes a large proportion of household expenditure. The Khazanah Research Institute found that in 2014, 94.6% of total household expenditure was on food.
This makes Malaysians particularly sensitive to changes in food prices, something that is compounded by food price inflation, especially as Malaysia's food price inflation has been higher than overall inflation.
Between 2011 and 2015, the country's food price inflation was 3.6% on average, compared to overall inflation of 2.4%. This meant greater expenditure on food, but in spite of this, the quantity of food consumed within that period was reported to have fallen.
Another factor is care and feeding practices, which are often lacking for both mother and child. While there is insufficient data on the status of under-nutrition among mothers in Malaysia, maternal anaemia and insufficient iron, folic acid and vitamin D intake are common issues in the country.
These have resulted in the prevalence of low birth weight, among other developmental problems — since 1998, the rate of low birth weight in Malaysia has hovered around 10%, and is currently 9.7%.
Child nutrition is also hindered by a lack of adherence to the WHO's guideline of two daily meals (six to eight months old) or three daily meals (nine months to two years old) from four or more food groups.
The report stated that 19.2% of Malaysian children aged six months to two years were not fed at the recommended frequencies, and 33.6% did not consume food from at least four food groups.
There is also a cultural component to the matter: children's short stature is often wrongly attributed to Malaysian or general Asian genetics, a misconception exacerbated by a lack of awareness of childhood stunting amid the media's focus on child obesity.
To combat these issues, Kok proposed several recommendations, one of which was to "establish high-level political mechanisms" in order to drive initiatives to prioritise the problem of stunting.
He emphasised the need for inter-ministry cooperation to monitor the direction of the government's National Children's Wellbeing Roadmap, which aims to develop strategic programmes covering education, nutrition and poverty to improve Malaysian children's health and overall quality of life.
Kok proposed implementing "nutrition-specific interventions at scale and with better coordination", based on 10 key interventions published in the Lancet, which can apparently reduce stunting by 20% if 90% of the target population is covered.
"Malaysia has already implemented many of the recommended interventions, but these lack scale and coordination," wrote Kok.
He also suggested setting clear goals with measurable targets, such as a 40% reduction in childhood stunting prevalence by 2025, and ramping up nutrition-related training for healthcare workers.
In addition, he said, growth monitoring should be standard practice during all child visits to health facilities, and nutrition surveys should be conducted more frequently.
He further proposed more research on child malnutrition and stunting, as well as the mandatory fortification of staple foods.
Apart from greater public and private sector involvement, Kok suggested financial assistance in the form of an "unconditional cash transfer scheme covering the 1,000-day window" from the time a child is born.
This would be preferable to vouchers or food-based assistance, he explained, as the "fungibility of cash lends it a flexibility that vouchers and in-kind assistance simply do not provide".
"Families can choose which needs to prioritise (and) caregivers can make financial decisions. Cash also avoids the stigma associated with food stamps.
"Cash transfers are a tool in line with the broader holistic approach of addressing the multi-pronged determinants of stunting. Common misconceptions — such as how cash promotes dependency and leads to abuse — have been debunked by extensive evidence."
Finally, Kok recommended public awareness campaigns as a way to educate and influence consumers on stunting and nutrition.
Despite the existence of programmes such as the Malaysian Healthy Plate Initiative and Healthy Eating through Healthy Shopping, "there is limited reach and low public participation".
To solve this problem, home-based growth charts and length mats could be used to complement existing communications campaigns by prompting caregivers to encourage better dietary habits in children, which has already been seen in Cambodia and Indonesia.
"Growth charts with information on stunting and nutrition can therefore be a cheap and highly effective tool for Malaysia, not only to promote awareness of stunting, but to also directly improve stunting rates."