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  1. Srichan W, Thasanasuwan W, Kijboonchoo K, Rojroongwasinkul N, Wimonpeerapattana W, Khouw I, et al.
    Eur J Clin Nutr, 2016 08;70(8):894-7.
    PMID: 26508460 DOI: 10.1038/ejcn.2015.180
    BACKGROUND/OBJECTIVES: Quantitative ultrasound (QUS) is used to measure bone quality and is known to be safe, radiation free and relatively inexpensive compared with dual-energy X-ray absorptiometry (DXA) that is considered the gold standard for bone status assessments. However, there is no consensus regarding the validity of QUS for measuring bone status. The aim of this study was to compare QUS and DXA in assessing bone status in Thai children.

    SUBJECTS/METHODS: A total of 181 Thai children (90 boys and 91 girls) aged 6 to 12 years were recruited. Bone status was measured by two different techniques in terms of the speed of sound (SOS) using QUS and bone mineral density (BMD) using DXA. Calcium intake was assessed by 24 h diet recall. Pearson's correlation, κ-statistic and Bland and Altman analysis were used to assess the agreement between the methods.

    RESULTS: There was no correlation between the two different techniques. Mean difference (s.d.) of the Z-scores of BMD and SOS was -0.61 (1.27) that was different from zero (P<0.05). Tertiles of Z-scores of BMD and QUS showed low agreement (κ 0.022, P=0.677) and the limits of agreement in Bland and Altman statistics were wide.

    CONCLUSIONS: Although QUS is easy and convenient to use, the SOS measurements at the radius seem not appropriate for assessing bone quality status.

  2. Widodo Y, Sandjaja S, Sumedi E, Khouw I, Deurenberg P
    Asia Pac J Clin Nutr, 2016;25(2):356-67.
    PMID: 27222420 DOI: 10.6133/apjcn.2016.25.2.09
    To study the associations between nutrient intake, dairy intake and socioeconomic variables.
  3. Harahap H, Sandjaja S, Soekatri M, Khouw I, Deurenberg P
    Asia Pac J Clin Nutr, 2017 12 10;27(1):211-216.
    PMID: 29222901 DOI: 10.6133/apjcn.032017.05
    BACKGROUND AND OBJECTIVES: Indonesia is currently facing double burden malnutrition in children. As overweight and obesity are due to a disturbed energy balance, this study aimed to assess the association of total energy intake and physical activity with the prevalence of overweight among Indonesian children.

    METHODS AND STUDY DESIGN: The data used for this analysis were from 1143 children, 6-12 years old, that participated in the South East Asian Nutrition Survey (SEANUTS). Physical activity (PA) was measured using pedometers for 2 consecutive days and was categorized low, moderate and high. Child nutritional status was categorized based on body mass index for age z-scores (BAZ) into normal weight (-2 SD ≤BAZ≤1 SD) or overweight (BAZ >1 SD). Energy intake was calculated from a one day 24 hour recall and compared to the Indonesian recommended dietary allowance (RDA) for energy.

    RESULTS: Children with low PA had higher risk (ODDs 3.4, 95% CI: 2.0, 6.0) of being overweight compared to children who had high PA. Children with moderate PA and energy take >100% RDA had higher risk (ODDs 4.2, 95% CI 1.9, 9.3) of being overweight than children with high PA and energy intakes ≤100% RDA.

    CONCLUSIONS: Low physical activity independently or moderate physical activity and high energy intake are risk factors for Indonesian children to get overweight. Program intervention such as increasing physical activity at school and home is needed to reduce overweight among children.

  4. Tay CW, Chin YS, Lee ST, Khouw I, Poh BK, SEANUTS Malaysia Study Group
    Asia Pac J Public Health, 2016 07;28(5 Suppl):47S-58S.
    PMID: 27252248 DOI: 10.1177/1010539516651475
    Problematic eating behaviors during childhood may lead to positive energy balance and obesity. Therefore, this study aims to investigate the association of eating behaviors with nutritional status and body composition in Malaysian children aged 7 to 12 years. A total of 1782 primary schoolchildren were randomly recruited from 6 regions in Malaysia. The multidimensional Children's Eating Behaviour Questionnaire (CEBQ) was reported by parents to determine the 8 different dimensions of eating styles among children. Body mass index (BMI), BMI-for-age Z-score, waist circumference, and body fat percentage were assessed. Linear regression analyses revealed that both food responsiveness and desire to drink subscales were positively associated with a child's body adiposity, whereas satiety responsiveness, slowness in eating, and emotional undereating subscales were negatively associated with adiposity (all P < .05). A multidimensional eating style approach based on the CEBQ is needed to promote healthy eating behaviors in order to prevent excessive weight gain and obesity problems among Malaysian children.
  5. Le Nguyen Bao K, Tran Thuy N, Nguyen Huu C, Khouw I, Deurenberg P
    Asia Pac J Public Health, 2016 07;28(5 Suppl):94S-102S.
    PMID: 27052301 DOI: 10.1177/1010539516641506
    In a population sample of 385 children, 6 to 11 years old, venous blood parameters-hemoglobin (Hb), ferritin, red blood cell count (RBC), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), C-reactive protein (CRP), and α1-acid glycoprotein (AGP)-were determined to get insight into the iron status. The prevalence of anemia was 11.4%; 5.6% had iron deficiency (ID), whereas 0.4% had ID anemia. Correction for inflammation based on CRP and AGP did not markedly change the overall prevalence of ID and ID anemia. Stunted children had lower Hb and ferritin values compared with nonstunted children, and thin children had lower values compared with normal-weight or overweight and obese children. Many nonanemic children had alert values for RBC, MCV, MCH, and MCHC. It is concluded that although the prevalence of anemia is of the magnitude of a mild public health problem, the iron status of many nonanemic children is borderline, as indicated by a high number of children with low values for red blood cytology.
  6. Purttiponthanee S, Rojroongwasinkul N, Wimonpeerapattana W, Thasanasuwan W, Senaprom S, Khouw I, et al.
    Asia Pac J Public Health, 2016 07;28(5 Suppl):85S-93S.
    PMID: 27183975 DOI: 10.1177/1010539516647774
    The study investigated the association between breakfast types consumed, daily energy intake, and body mass index for age Z-score (BAZ). Cross-sectional data from 1258 children aged 7 to 12.9 years were analyzed for breakfast type, nutrient intakes, BAZ, and proportion of overweight or obesity. Analysis of covariance was used to compare energy and nutrient intakes, BAZ, and proportion of overweight/obese children between breakfast groups. Only 19% of children had adequate energy intake from breakfast. Those consuming snacks had a significantly lower BAZ (Z = -0.73), with 5% of them being overweight/obese. Those consuming beverages and desserts had the lowest total daily energy intake (1314 kcal) and lowest protein intake (8.4 g). The results suggest that breakfast type is associated with daily energy intake and BAZ. Most breakfasts are not adequate. School-based nutrition education programs involving families, teachers, and health professionals can contribute to improve this situation.
  7. Chong KH, Lee ST, Ng SA, Khouw I, Poh BK
    Nutrients, 2017 Jul 31;9(8).
    PMID: 28758956 DOI: 10.3390/nu9080723
    This study aimed to assess fruit and vegetable intake patterns and their associations with sociodemographic characteristics, anthropometric status and nutrient intake profiles among Malaysian children aged 1-6 years. Using the Malaysian dataset of South East Asian Nutrition Surveys (SEANUTS Malaysia), a total of 1307 children aged 1-6 years with complete datasets were included in this analysis. Dietary intake was assessed using age-specific, validated food frequency questionnaires. On average, Malaysian children consumed 0.91 and 1.07 servings of fruits and vegetables per day, respectively. Less than one-fifth of the children achieved the daily recommended servings of fruits (11.7%) and vegetables (15.8%). Fruit intake was associated with age, parental educational level and geographical region, and vegetable intake was associated with ethnicity and geographical region. There was little evidence of an association between fruit and vegetable intake and children's anthropometric status, but an adequate intake of fruits and vegetables contributed significantly and differently to children's micronutrient intake. Future nutrition interventions should focus on addressing the sociodemographic determinants and be tailored to the needs of the low consumers to more effectively promote and encourage the adequate intake of fruit and vegetables among young children.
  8. Joan C, Koh D, Wong JE, Khouw I, Poh BK, SEANUTS II Malaysia Study Group
    Am J Hum Biol, 2024 Mar 28.
    PMID: 38548924 DOI: 10.1002/ajhb.24076
    BACKGROUND: Adhering to 24-h movement guidelines (24-hMG) have health benefits for young children; yet research on Malaysian preschoolers' movement behaviors is limited. This study investigates the association between adherence to 24-hMG and sociodemographic factors of Malaysian preschoolers.

    METHODS: Data from 939 preschoolers aged 3-6 years (mean age = 4.83 ± 0.04 years, 53.7% boys) from the Second South East Asian Nutrition Surveys (SEANUTS II) Malaysia study was analyzed. Socio-demography, physical activity, sedentary behaviors, and sleep were parent-reported via questionnaire. Associations between adherence of 24-hMG and sociodemographic factors were analyzed using complex samples logistic regression.

    RESULTS: Only 12.1% of preschoolers adhered to the overall 24-hMG, and 67.1%, 54.7%, and 42.7% of preschoolers adhered to physical activity, sleep, and sedentary behavior guidelines, respectively; while 6.8% did not meet any guidelines. Compared to 3-4-year olds, preschoolers aged 5-6 years had higher odds of adhering to physical activity guidelines, sedentary behavior guidelines, and overall 24-hMG, but lower odds of adhering to sleep guidelines. Chinese and Indian preschoolers were more likely to adhere to sedentary behavior guidelines than Malay preschoolers; however, Chinese preschoolers had lower odds of adhering to physical activity guidelines. Paternal tertiary education was associated with a higher likelihood of adherence to sleep guidelines.

    CONCLUSION: Our findings suggest that adherence to 24-hMG among Malaysian preschoolers is associated with age, ethnicity, and paternal education level. This underscores the importance of targeted interventions and health awareness program to promote healthy movement behaviors, particularly among children under 5, ethnic minorities, and educationally disadvantaged families.

  9. Yeo GS, Lee ST, Wong JE, Khouw I, Safii NS, Poh BK, et al.
    Appetite, 2024 Oct 01;201:107607.
    PMID: 39029531 DOI: 10.1016/j.appet.2024.107607
    Malaysian children often skip breakfast, an important meal providing essential nutrients for optimal growth and maintaining proper nutritional status. Therefore, this study aims to investigate the associations between breakfast skipping with dietary intake, diet quality, and adiposity indicators among primary schoolchildren aged 6.0-12.9 years. This study involved 1383 children from the South East Asian Nutrition Surveys (SEANUTS II) Malaysia. Information collected through questionnaires included sociodemography and breakfast consumption, defined as the first meal before noon. Breakfast skipping was identified as skipping breakfast at least once a week. Anthropometric measures, including height, body weight, and waist circumference, as well as percentage of body fat, were collected. Body mass index (BMI) and waist-to-height ratio were calculated, and BMI-for-age-z-scores was determined using WHO (2007) growth reference. A one-day 24-hour dietary recall was employed to assess dietary intake, and diet quality was analyzed using Malaysian Healthy Eating Index. Binary logistic regression was applied to examine relationship between breakfast skipping on diet quality and adiposity indicators. Over one-third (36.0%) of children skipped breakfast at least once a week, resulting in lower intakes of energy, nutrients, cereals/grains, vegetables, and milk/dairy products, though not affecting total diet quality score. Breakfast skipping was associated with higher odds of overweight/obesity (aOR 2.04, 95%CI: 1.52-2.76) and central obesity (aOR 1.87, 95%CI 1.34-2.61). In conclusion, primary schoolchildren in Peninsular Malaysia who skipped breakfast tended to have lower consumption of nutrients and specific basic food groups, as well as increased body fat. This study highlights the importance of continuing to educate parents and children about healthy eating habits, especially the need to adhere to dietary recommendations, with an emphasis on breakfast consumption.
  10. Poh BK, Ng BK, Siti Haslinda MD, Nik Shanita S, Wong JE, Budin SB, et al.
    Br J Nutr, 2013 Sep;110 Suppl 3:S21-35.
    PMID: 24016764 DOI: 10.1017/S0007114513002092
    The dual burden of malnutrition reportedly coexists in Malaysia; however, existing data are scarce and do not adequately represent the nutritional status of Malaysian children. The Nutrition Survey of Malaysian Children was carried out with the aim of assessing the nutritional status in a sample of nationally representative population of children aged 6 months to 12 years. A total of 3542 children were recruited using a stratified random sampling method. Anthropometric measurements included weight, height, mid-upper arm circumference, and waist and hip circumferences. Blood biochemical assessment involved analyses of Hb, serum ferritin, and vitamins A and D. Dietary intake was assessed using semi-quantitative FFQ, and nutrient intakes were compared with the Malaysian Recommended Nutrient Intakes (RNI). The prevalence of overweight (9·8%) and obesity (11·8%) was higher than that of thinness (5·4%) and stunting (8·4%). Only a small proportion of children had low levels of Hb (6·6%), serum ferritin (4·4%) and vitamin A (4·4%), but almost half the children (47·5%) had vitamin D insufficiency. Dietary intake of the children was not compatible with the recommendations, where more than one-third did not achieve the Malaysian RNI for energy, Ca and vitamin D. The present study revealed that overnutrition was more prevalent than undernutrition. The presence of high prevalence of vitamin D insufficiency and the inadequate intake of Ca and vitamin D are of concern. Hence, strategies for improving the nutritional status of Malaysian children need to consider both sides of malnutrition and also put emphasis on approaches for the prevention of overweight and obesity as well as vitamin D insufficiency.
  11. Schaafsma A, Deurenberg P, Calame W, van den Heuvel EG, van Beusekom C, Hautvast J, et al.
    Br J Nutr, 2013 Sep;110 Suppl 3:S2-10.
    PMID: 24016763 DOI: 10.1017/S0007114513002067
    Nutrition is a well-known factor in the growth, health and development of children. It is also acknowledged that worldwide many people have dietary imbalances resulting in over- or undernutrition. In 2009, the multinational food company FrieslandCampina initiated the South East Asian Nutrition Survey (SEANUTS), a combination of surveys carried out in Indonesia, Malaysia, Thailand and Vietnam, to get a better insight into these imbalances. The present study describes the general study design and methodology, as well as some problems and pitfalls encountered. In each of these countries, participants in the age range of 0·5-12 years were recruited according to a multistage cluster randomised or stratified random sampling methodology. Field teams took care of recruitment and data collection. For the health status of children, growth and body composition, physical activity, bone density, and development and cognition were measured. For nutrition, food intake and food habits were assessed by questionnaires, whereas in subpopulations blood and urine samples were collected to measure the biochemical status parameters of Fe, vitamins A and D, and DHA. In Thailand, the researchers additionally studied the lipid profile in blood, whereas in Indonesia iodine excretion in urine was analysed. Biochemical data were analysed in certified laboratories. Study protocols and methodology were aligned where practically possible. In December 2011, data collection was finalised. In total, 16,744 children participated in the present study. Information that will be very relevant for formulating nutritional health policies, as well as for designing innovative food and nutrition research and development programmes, has become available.
  12. Nguyen Bao KL, Sandjaja S, Poh BK, Rojroongwasinkul N, Huu CN, Sumedi E, et al.
    Nutrients, 2018 Jun 13;10(6).
    PMID: 29899251 DOI: 10.3390/nu10060759
    Despite a major decrease in undernutrition worldwide over the last 25 years, underweight and stunting in children still persist as public health issues especially in Africa and Asia. Adequate nutrition is one of the key factors for healthy growth and development of children. In this study, the associations between dairy consumption and nutritional status in the South East Asian Nutrition Survey (SEANUTS) were investigated. National representative data of 12,376 children in Indonesia, Malaysia, Thailand, and Vietnam aged between 1 and 12 years were pooled, representing nearly 88 million children in this age category. It was found that the prevalence of stunting and underweight was lower in children who consumed dairy on a daily basis (10.0% and 12.0%, respectively) compared to children who did not use dairy (21.4% and 18.0%, respectively) (p < 0.05). The prevalence of vitamin A deficiency and vitamin D insufficiency was lower in the group of dairy users (3.9% and 39.4%, respectively) compared to non-dairy consumers (7.5% and 53.8%, respectively) (p < 0.05). This study suggests that dairy as part of a daily diet plays an important role in growth and supports a healthy vitamin A and vitamin D status.
  13. Nik Shanita S, Siti Hanisa A, Noor Afifah AR, Lee ST, Chong KH, George P, et al.
    PMID: 30360488 DOI: 10.3390/ijerph15112332
    The present study aimed to report the prevalence of anaemia and iron deficiency (ID) and to explore the associations among socio-demographic characteristics, nutritional status and inflammation status in the occurrence of anaemia and ID in a nationally representative sample of Malaysian primary schoolchildren. Using data from the South East Asian Nutrition Surveys (SEANUTS), 544 Malaysian children aged 7 to 12 years were included in this secondary analysis. Blood samples were drawn for haemoglobin and serum ferritin analysis while C-reactive protein (CRP) and α-1-acid glycoprotein (AGP) were measured to detect inflammation. Prevalence of anaemia and ID were 4.0% and 5.2%, respectively. There were significantly more anaemic indigenous bumiputra children (9.9%) than Chinese children (0.6%). Correction for inflammation did not change the prevalence of ID. More overweight/obese children than thin/normal weight children were found to have elevated acute phase protein (APP). Children with elevated inflammatory markers had significantly higher ferritin level than children without inflammation. Periodic health assessments of anaemia and ID at the population level to monitor and clarify the epidemiology of health problems are required to inform public health policies and strategies.
  14. Chan KS, Farah NM, Yeo GS, Teh KC, Lee ST, Makbul IAA, et al.
    PMID: 39251408 DOI: 10.1139/apnm-2023-0621
    Increased cardiometabolic risk among children is increasingly becoming a concern, with evidence indicating that obesity, diet, and serum 25-hydroxyvitamin D (25(OH)D) are associated with cardiometabolic risk. However, such studies among Malaysian children are scarce. Thus, this study explores the associations between adiposity, dietary quality, and 25(OH)D, with cardiometabolic risk factors among Malaysian children aged 4-12 years. Data of 479 children (mean age: 8.2 ± 2.3 years old, 52% females) from the South East Asian Nutrition Surveys (SEANUTS II) Malaysia, were included in this analysis. Adiposity (percentage of body fat) was assessed with bioelectrical impedance technique. Dietary quality was assessed using 24 h dietary recall and calculated as mean adequacy ratio. Vitamin D was assessed based on serum 25-hydroxyvitamin D (25(OH)D). Measurements of cardiometabolic risk factors included waist circumference (WC), mean arterial pressure (MAP), fasting blood glucose (FBG), high-density lipoprotein (HDL), triglyceride, and high-sensitivity C-reactive protein, and cardiometabolic risk cluster score (siMS) was calculated. Overall, higher adiposity was positively associated with all cardiometabolic risk factors (WC, ß = 0.907; 95% CI = 0.865, 0.948; MAP, ß = 0.225; 95% CI = 0.158, 0.292; HDL, ß = -0.011; 95% CI = -0.014, -0.009; Triglyceride, ß = 0.012; 95% CI = 0.009, 0.016; FBG, ß = 0.006; 95% CI = 0.002, 0.011) and siMS score (ß = 0.033; 95% CI = 0.029, 0.037). Serum 25(OH)D was inversely associated with siMS score (ß = -0.002; 95% CI = -0.004, -0.000008) and positively associated with HDL (ß = 0.002; 95% CI = 0.0001, 0.003). Our findings suggest that adiposity is a key determinant of adverse cardiometabolic risk factors in children, while serum 25(OH)D may be associated with overall cardiometabolic health. Interventions to reduce obesity are needed to mitigate the deleterious consequences of cardiometabolic dysregulation in children.
  15. Tan SY, Poh BK, Sekartini R, Rojroongwasinkul N, Tran TN, Wong JE, et al.
    Public Health Nutr, 2024 Apr 19.
    PMID: 38639132 DOI: 10.1017/S1368980024000910
    OBJECTIVE: To assess the nutritional status, growth parameters and lifestyle behaviours of children between 0.5-12 years in nationally representative samples in Malaysia, Indonesia, Thailand, and Vietnam.

    DESIGN: A cross-sectional study was conducted in the four countries, between May 2019 and April 2021. Data collected can be categorized into four categories: (1) Growth - anthropometry, body composition, development disorder, (2) Nutrient intake and dietary habits - 24-hour dietary recall, child food habits, breast feeding and complementary feeding, (3) Socio-economic status - food insecurity and child health status/environmental, and (4) Lifestyle behaviours - physical activity patterns, fitness, sunlight exposure, sleep patterns, body image and behavioural problems. Blood samples were also collected for biochemical and metabolomic analyses. With the pandemic emerging during the study, a COVID-19 questionnaire was developed and implemented.

    SETTING: Both rural and urban areas in Malaysia, Indonesia, Thailand, and Vietnam.

    PARTICIPANTS: Children who were well, with no physical disability or serious infections/injuries and between the age of 0.5-12 years old were recruited.

    RESULTS: The South East Asian Nutrition Surveys II recruited 13,933 children. Depending on the country, data collection from children were conducted in schools and commune health centres, or temples, or sub-district administrative organizations.

    CONCLUSIONS: The results will provide up-to-date insights into nutritional status and lifestyle behaviours of children in the four countries. Subsequently, these data will facilitate exploration of potential gaps in dietary intake among Southeast Asian children and enable local authorities to plan future nutrition and lifestyle intervention strategies.

  16. Poh BK, Wong JE, Lee ST, Chia JSM, Yeo GS, Sharif R, et al.
    Public Health Nutr, 2023 Nov 07.
    PMID: 37932916 DOI: 10.1017/S1368980023002239
    OBJECTIVE: This paper aims to report South East Asian Nutrition Surveys (SEANUTS) II Malaysia data on nutritional status, dietary intake, and nutritional biomarkers of children aged 6 months to 12 years.

    DESIGN: Cross-sectional survey conducted in 2019-2020.

    SETTING: Multistage cluster sampling conducted in Central, Northern, Southern, and East Coast regions of Peninsular Malaysia.

    PARTICIPANTS: 2989 children aged 0.5-12.9 years.

    RESULTS: Prevalences of stunting, thinness, overweight, and obesity among children aged 0.5-12.9 years were 8.9%, 6.7%, 9.2%, and 8.8%, respectively. Among children below 5 years old, 11.4% were underweight, 13.8% had stunting, and 6.2% wasting. Data on nutritional biomarkers showed a small proportion of children aged 4-12 years had iron (2.9%) and vitamin A deficiencies (3.1%). Prevalence of anaemia was distinctly different between children below 4 years old (40.3%) and those aged 4 years and above (3.0%). One-fourth of children (25.1%) had vitamin D insufficiency, which was twice as prevalent in girls (35.2% vs. boys: 15.6%). The majority of children did not meet the recommended dietary intake for calcium (79.4%) and vitamin D (94.8%).

    CONCLUSIONS: Data from SEANUTS II Malaysia confirmed that triple burden of malnutrition co-exists among children in Peninsular Malaysia, with higher prevalence of overnutrition than undernutrition. Anaemia is highly prevalent among children below 4 years old, while vitamin D insufficiency is more prevalent among girls. Low intakes of dietary calcium and vitamin D are also of concern. These findings provide policymakers with useful and evidence-based data to formulate strategies that address the nutritional issues of Malaysian children.

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