1. Introduction
Malaysia is facing a rise of diet-related non-communicable diseases (NCDs) [
1], imposing socioeconomic burdens, especially among lower income households [
2]. An updated meta-analysis revealed that good diet quality was associated with significantly decreased risks of NCDs and all-cause mortality [
3]. It was well documented that NCDs could be prevented by dietary components, such as lowering the consumption of refined grains and increasing the intake of whole grains, fruits, vegetables, and legumes, which were associated with decreased risk of obesity and type 2 diabetes [
4]. Reduced sodium intake was associated with decreased risk of hypertension and cardiovascular diseases (CVD) [
5]. The accumulated scientific evidence clearly showed that the intake of vegetables and fruits had protective effects against CVD risks, however, Alissa and Ferns suggested that vegetables and fruits should be taken as part of a balanced diet, because a set of nutrients may interact with genetic factors synergistically to reduce CVD risks [
6].
Conventionally, one single nutrient or food group was used in studies to examine the associations between diet and health. However, realizing that an individual’s complete diet is comprised of a variety of foods, a new approach of studying dietary patterns, and consequently diet quality, had emerged to better capture the interactions and synergistic effects of foods and nutrients on health [
7]. The Healthy Eating Index (HEI) is one of the indexes of overall diet quality based on both nutrients and food groups, unlike indexes that are based on either nutrients or food groups only, for example Nutrient Adequacy Ratio and Diet Diversity Score, respectively. The Malaysian HEI is one of the many existing indicators to measure the overall diet quality of Malaysian adults based on the degree of compliance to dietary recommendations in the Malaysian Dietary Guidelines (MDG) [
8].
Several studies in America and Canada have found that food insecurity was associated with diet quality as measured by Healthy Eating Index [
7,
9,
10]. Multiple demographic and socioeconomic characteristics, including age, sex, marital status, education, occupation, and income, were also shown to be associated with diet quality [
11]. Various epidemiological studies depicted that the quality of diet followed a socioeconomic gradient, suggesting that the social disparities in diet quality may be explained by food prices and diet cost [
12]. Individuals with lower socioeconomic positions were found to be associated with lower diet quality, as characterized by low consumption of nutrient-rich foods and high intake of energy-dense foods [
13]. Nutrient-rich foods are defined as foods with a high content of vitamins and minerals, such as vegetables, fruit, lean meat, and fish. Conversely, energy-dense foods are food high in calories, such as refined grains and fats [
12].
In Malaysia, the aboriginal people are called Orang Asli. Based on our current knowledge, this was the first attempt to study the diet quality of Orang Asli women using the Malaysian HEI. This study also aimed to determine the relationship between socioeconomic characteristics, nutrition knowledge, food security status, and diet quality among this vulnerable group.
4. Discussion
In this study, only 30.6% of the
Orang Asli completed secondary school, which was less than half the national average of 72.0% [
29]. Around 37.8% of the Mah Meri women were working, with a majority of them engaging in fishing-related occupations and jobs related to cultural activities, such as dancing, weaving, and carving [
30,
31]. Among the Mah Meri households, 26.1% were considered to be poor and 36.8% were hardcore poor, which was far higher than the national poverty rate of 3.8% for the poor and 0.7% for the hardcore poor [
32]. This study indicated that the diet quality of the Mah Meri women was poor (lower HEI score), specifically for vegetables, fruits, meat, poultry and eggs, legumes, and dairy product components. Factors such as marital status, household income, food security status, and fat intake influenced the diet quality of the Mah Meri women in this study.
The respondents in this study reported poor diet quality compared to their non-indigenous women counterparts (Malay, Chinese, and Indian) [
26,
33,
34]. This condition could be explained by the majority of the respondents who were not able to achieve the recommended minimum servings of food groups in their diet, including vegetables, fruits, meat, poultry and eggs, legumes and milk. In this study, the respondents consumed less vegetables (1.1 serving) and fruits (0.1 serving) as compared to the average Malaysian women who consumed vegetables (1.5 serving) and fruits (1.4 serving) [
35]. The low consumption of vegetables and fruits could be due to the limited variety of vegetables around the
Orang Asli settlements, and most of the available fruits in the area were seasonal ones, such as rambutan and mangosteen. Vegetables and fruits were infrequently consumed, as they could not afford to buy local and imported vegetables and fruits at the market. They mostly consumed wild vegetables (tapioca shoots and swamp cabbage) and non-seasonal fruits, such as banana and papaya, which were either grown locally or gathered in the forest [
36].
Furthermore, the respondents in this study consumed 0.6 serving of meat and 0.1 serving of legumes, which was considered to be less satisfactory based on the MDG. They rarely consumed chicken and other meats sold in the market due to the high prices. They also seldom consumed legumes and milk products due to the lack of availability, acceptability, and cultural practices that limited the choices of these food items in their diet [
36,
37]. Like any other Malaysian, the
Orang Asli also liked to consume coffee, tea, and malted beverages added with sweetened condensed milk or evaporated milk during breakfast and teatime [
38]. The low Malaysian HEI scores for the components of vegetables, fruits, meat, legumes, and milk products could be attributed to nutritional inadequacy, whereby a majority of the respondents did not meet the RNI for minerals (calcium, iron, zinc, and selenium) and vitamins (thiamine, riboflavin, and niacin). Older women obtained higher nutrient intakes compared to their younger counterparts, as they were not only equipped with better knowledge and understanding of nutritional benefits, but they also had more experience in preparing nutrient-rich meals [
39].
Nutrition knowledge was found to be positively correlated with diet quality, especially the intake of vegetables and fruits, as well as the overall diet quality [
40,
41]. Within the
Orang Asli culture, the women (wives) traditionally play the caretaker’s role, who prepare meals and look after the family [
42]. The low education attainment among the
Orang Asli women posed a serious limitation for acquiring nutrition knowledge [
43]. Women with low nutrition knowledge may have inadequate awareness and understanding of nutrition information, probably due to their illiteracy and language barrier, as most of the food labels, as well as commercial and educational materials on healthy foods, were in English [
14,
44]. Women with lower education most probably had poor nutrition knowledge and low awareness and understanding of nutrition information. In addition to lower income, they were predisposed to select food which were cheaper, thus their diet quality might have been compromised [
40,
45].
Poor diet, as measured by the Malaysian HEI, was associated with women either being single, divorced, or widowed. This result corresponded with a study by Alkerwi et al. (2015) [
11] that found Luxembourg women living alone (single, divorced, or widowed) were associated with poorer dietary diversity score. The possible explanation might be the lack of family support and limited financial resources, which restricted their access to a variety of food choices [
11]. In addition, several other studies found that food insecure respondents from lower-income households were associated with poor diet quality, and this finding could be explained by food prices and diet cost [
9,
10,
12]. Individuals from food insecure households made choices of food that best served their own utility, depending on their daily energy requirements, socio-economic status, as well as budget allocated for food [
12,
46]. The high food prices and the financial constraint faced by the food insecure households not only limited the food choices, but also caused an overall reduction in food intake, and ultimately, poor diet quality [
34,
47].
Furthermore, the increment of the Consumer Price Index of food and non-alcoholic beverages (4.6% from December 2014 to December 2015) was mainly applied to healthy food groups, such as vegetables, fruits, meat, poultry and eggs, as well as fish [
48]. These healthy food groups were less consumed mainly due to the cost factor, as healthy food items were more costly than the less healthy options [
49]. Therefore, due to budget constraints, consumers from low-income households could only afford less healthy food groups, which were usually energy dense and nutrient poor food items, such as refined grains and fats [
50]. This is in agreement with the results in this present study, which showed that an increased fat intake was associated with poor diet quality.
This cross-sectional study could not determine the cause–effect relationship, and the findings from this study could not be generalized to the rest of the Orang Asli populations in Malaysia. The 2-day 24-h dietary recall method was used to estimate the dietary intake of respondents; thus, the data was not based on accurate dietary intake. Therefore, there was a likelihood of data misreporting due to the respondents either under- or over-reporting their dietary intake. This study showed that 31.5% of the respondents were under-reporters. The Malaysian HEI used to measure diet quality did not evaluate the excess levels of carbohydrate and protein intake. Nevertheless, to the best of our knowledge, this was the first study that attempted to assess diet quality using the Malaysian HEI among Orang Asli in Malaysia, and this study also determined factors contributing to the diet quality of this particular population.