Fruits and vegetables have been recognised as the key components of a healthy diet because of their high levels of health-promoting nutrients and bioactive compounds, including vitamins, minerals, fibres and phytochemicals [1
]. A minimum daily intake of 400 g of fruits and vegetables (excluding potatoes and other starchy tubers) is recommended for the prevention of chronic diseases and micronutrient deficiencies, particularly in less developed countries [2
]. More recent reviews in adult populations have concluded that the increased consumption of fruits and vegetables not only reduces the risks of obesity or weight gain [3
] and various types of chronic diseases (e.g., hypertension, coronary heart disease, and stroke) [4
], but is also associated with a lower risk of all-cause mortality, particularly cardiovascular mortality [5
]. In children and adolescents, emerging but as yet inconclusive evidence exists for the protective effect of fruit and vegetable intake on adiposity or obesity [6
Despite their well-documented health benefits, the intake of fruits and vegetables remains low worldwide, particularly among children and adolescents. For example, in the United States, approximately 60% of children and adolescents did not meet the recommended servings for fruit, despite a significant increase (12%) in total fruit intake from 2003 to 2010. For vegetable intake, 93% of children and adolescents did not meet recommendations, with total intake remaining unchanged during the same time period [8
]. A similar situation was also reported for the adolescent population in Asian countries (India, Indonesia, Myanmar, Sri Lanka and Thailand), in which 76.3% reportedly consumed less than five servings of fruits and/or vegetables per day [9
]. In Malaysia, the limited data available for the childhood population also reported that fruit and vegetable intakes were far below recommended levels [10
]. Given that food intake patterns established during childhood may track into adulthood [12
] and the potential associations of fruit and vegetable intake with other eating [13
] and health behaviours (e.g., physical activity and sedentary behaviour) [9
], increasing the intake of fruits and vegetables among children is therefore a public health priority.
To the best of our knowledge, limited data are available on fruit and vegetable intake in young children, especially among toddlers and pre-schoolers, in Asian countries and little is known about the extent to which the intake of fruit and vegetables influences their anthropometric status and dietary nutrient intake. A better understanding of these associations is particularly important for providing insights towards the development of more effective strategies and approaches to target the double burden of malnutrition occurring in many developing countries [16
], including in Malaysia [19
]. In addition, fruit and vegetable intake has been previously reported to be closely related to sociodemographic characteristics [21
]. Identifying the associated sociodemographic determinants is thus important for designing and implementing population-specific interventions to promote and encourage fruit and vegetable intake beginning in early childhood.
Thus, the purpose of the current study was to assess fruit and vegetable intake patterns and their associations with sociodemographic characteristics, anthropometric status and nutrient intake profiles among a nationally-representative sample of Malaysian young children aged 1–6 years.
The current analyses include data from 1307 children (mean age 3.9 ± 0.1 years), which represents an estimated 2.44 million Malaysian children aged 1–6 years. Table 1
presents the sociodemographic characteristics of children and their daily intakes of fruit and vegetables. On average, children consumed 0.91 servings/day of fruit, and only 11.7% achieved the recommended two servings per day. The intake of fruit was reported to be significantly higher among the oldest children (5–6 years old: 1.14 servings/day) and those whose fathers (0.98 servings/day) or mothers (1.00 servings/day) had completed secondary education. Significantly more children who achieved the fruit intake recommendation were in the oldest age group (16.2%) and in the Sarawak region (17.4%). For vegetables, the mean daily intake was 1.07 servings/day, and 15.8% of children reportedly achieved the recommended two servings per day. The Malay ethnic group (0.87 serving/day; 11.3%) and those living in Sabah (0.85 serving/day; 8.9%) both showed significantly lower mean intakes of vegetables and had smaller proportions of children who achieved the intake recommendations compared to their respective counterparts. Only 3.4% of the children consumed two servings of fruits and two servings of vegetables, and thus achieved the intake recommendations for both fruit and vegetable groups.
shows the anthropometric characteristics of the children based on their fruit and vegetable intake patterns. Height and HAZ differed significantly between the fruit intake groups. Children who consumed fewer than the recommended two servings per day had significantly higher values (height: 98.7 vs. 97.8 cm, p
< 0.05; HAZ: −0.63 vs. −0.85, p
< 0.05) than those who consumed two or more servings per day, after adjusting for sociodemographic and energy intake variables. However, no significant differences were observed for other anthropometric measures or the prevalence of stunting, thinness, overweight and obesity between the children who achieved their fruit intake recommendations and the children who did not. For vegetable intake, no significant differences were observed in the anthropometric measures and the prevalence of stunting, thinness, overweight and obesity was not significantly different between the two intake groups.
presents the dietary energy and nutrient intakes of children relative to their fruit and vegetable intake patterns. Daily energy intake was reported to be significantly higher among children who achieved their fruit (p
< 0.001) or vegetable (p
< 0.001) intake recommendations after adjusting for sociodemographic variables. After further adjustment for daily energy intake (in addition to sociodemographic variables), children who achieved their fruit intake recommendation were found to have significantly higher intakes of carbohydrates (p
< 0.001) and vitamin C (p
< 0.001), but lower intakes of fat (p
< 0.001), thiamine (p
< 0.05), riboflavin (p
< 0.01), calcium (p
< 0.05), iron (p
< 0.05) and zinc (p
< 0.001) compared to children who did not achieve the recommendation. On the other hand, children who achieved their vegetable intake recommendations consumed significantly more vitamin A (p
< 0.001), vitamin C (p
< 0.001), calcium (p
< 0.05) and iron (p
< 0.01), but less thiamine (p
< 0.05) and riboflavin (p
< 0.01) compared with those who did not.
This study is one of the first to provide nationally-representative data on daily intakes of fruits and vegetables in standard serving sizes according to the dietary guidelines, and their associations with sociodemographic characteristics, anthropometric status and nutrient intake profiles among Malaysian children aged 1–6 years. Overall, the children’s mean intakes of fruits and vegetables were found to be approximately only half of the recommended number of daily servings, with less than one-fifth achieving the daily fruit or vegetable intake recommendations. Fruit intake was found to be associated with age, parental educational level and geographical region, and vegetable intake was associated with ethnicity and geographical region. The intake of fruits, but not vegetables, was associated with anthropometric measures, but the association was only observed with height and HAZ variables and was likely not clinically significant. Moreover, there were no significant associations between fruit and vegetable intake and children’s stunting and body weight status. In terms of the nutrient intake profile, a daily intake of two or more servings of fruit was associated with greater intake of carbohydrates and vitamin C, while daily intake of two or more servings of vegetables was associated with higher intake of vitamin A, vitamin C, calcium and iron, regardless of total daily energy intake.
Our study revealed that age was a significant determinant for fruit intake, but not vegetable intake. The mean daily intake of fruit increased significantly across the age groups, and the percentage of children achieving intake recommendation was 2.5 times higher among the oldest age group (5–6 years: 16.3%) relative to the youngest age group (1–2 years old: 6.6%). Similar results were also noted in a previous analysis of the primary school-aged children who participated in SEANUTS Malaysia [10
], whereby a significantly higher proportion of older children (10–12 years: 19.6%) were found to have achieved the dietary recommendations for fruit intake than younger children (7–9 years; 13.4%). Altogether, the results seem to suggest that Malaysian children tend to eat more fruits as they get older. This finding is, however, in contrast to previously published data from European and American populations [22
], which have shown an age-associated decline in total fruit and vegetable intake among children and adolescents. The inter-population variation and cultural differences in food intake patterns could be a possible explanation for the inconsistency of findings from different parts of the world. Moreover, a study of urban children in Kuala Lumpur in year 2015 found that children aged 1–3 years consumed approximately 700 mL or 3.5 cups of milk per day, which exceeds the current recommendation of 2–3 cups daily (200 mL/cup), and also reported that milk alone contributed to 50–63% of their daily energy requirement [36
]. Over-consumption of milk could lead to lower dietary diversity in young children, especially in terms of the intake of fruit, which is commonly perceived by the Malaysian population as “dessert” rather than as a part of main meals. It is also important to note that the recommended serving sizes for the fruit and vegetable groups in the Malaysian Dietary Guidelines are the same for all age groups [25
], but younger children usually consume a smaller portion size than older children, which may explain the lower achievement rates of fruit intake recommendation among the younger age group.
Parental educational level was also found to be associated with children’s fruit intake in this study. Higher or more frequent intake of fruits and vegetables has been previously reported to be associated with higher parental educational levels in European populations [37
]. However, our analysis showed that the mean intake of fruit was highest among children whose father or mother had completed secondary education, although the proportions of children that achieved fruit intake recommendation did not vary significantly across educational attainment levels. The lower intake of fruit among those whose mother had tertiary education could be because young children usually depend on their parents for food provision, but most of the more highly educated parents would have limited time to prepare food for their children as they are more likely to have full-time employment. Nevertheless, more studies are required to explore the factors that could possibly mediate this association.
Consistent with our previous results in the SEANUTS Malaysia primary school-aged children [10
], the present findings among children aged six year and below showed that vegetable intake differed significantly between ethnic groups. Malay children showed the lowest mean daily intake of vegetables, with significantly less children achieving vegetable intake recommendation compared to Chinese and Indian children. This finding is also comparable to those reported by Nurul-Fadhilah et al. in 2016 [39
], in which the healthy-based food pattern characterised by high intakes of fruits and vegetables, dairy products, nuts and cereal-based foods was significantly more common among the Chinese than the Malay adolescents in Kelantan, Malaysia. These differences in food preferences or practices may reflect the variations in socio-cultural practices or religious beliefs across the various ethnic groups in Malaysia [40
]. In addition, the current study also found that fruit and vegetable intake varied significantly by geographical region, which is consistent with the findings of other national population-based surveys on the influence of the location of residence on fruit and vegetable intakes in the Malaysian adult population [41
]. Although we speculate that this could be due to cultural differences or geographical variations in the availability of fruits and vegetables, the underlying reasons for these differences are still not well-understood and warrant further investigation.
This study provides little evidence of an association between fruit and vegetable intake and anthropometric status in children. Although children who did not achieve the fruit intake recommendation were found to be taller and to have larger HAZ values than those who did achieve the recommendation, the differences between the two groups were relatively small and were likely not clinically significant (height: 0.9 cm, HAZ: 0.22 unit). In fact, no significant differences were observed in the prevalence of stunting, thinness, overweight or obesity between the two groups, suggesting that fruit and vegetable intake may not have any significant influence on a child’s anthropometric status. This finding is comparable to those reported by Norimah et al. [43
] in 2014 that found no significant association between BMI-for-age with the frequency of fruit and vegetable intake among preschoolers in Peninsular Malaysia. Nevertheless, studies conducted in Western populations have yielded mixed results [44
]. Using the dataset of the Third National Health and Nutrition Examination Survey (NHANES III), Bradlee and colleagues [45
] found no significant associations between the mean intakes of fruit and vegetables and central adiposity measures among children aged 5–11 years; however, the combined intake of fruit and vegetable was reported to be inversely associated with central obesity among adolescents aged 12–16 years. On the other hand, Matthews et al. [46
] found that, in children and adolescents aged 6–19 years in Southern California, higher intake of vegetables, but not fruits, was associated with lower risk of being overweight. One possible reason for the mixed findings is that the large inter- and intra-population variations in food preparation methods could contribute to significant changes in the energy and nutrient content of fruits and vegetables, thus modifying their effects on anthropometric or adiposity status [6
]. In addition, the overall dietary intake pattern and other sociodemographic and lifestyle variables could also partly explain the inconsistent results, given the complex and multifaceted nature of the determinants of children’s nutritional status.
Another significant finding that emerged from this study is that the nutritional contributions of fruits and vegetables vary significantly, especially with regard to intake of micronutrients. The consumption of fruit was found to generally contribute more to carbohydrate and vitamin intake, whereas the consumption of vegetables resulted in greater intake of vitamins and minerals, which lend further support to the importance of consuming a wide variety of fruits and vegetables to ensure adequate intake of different micronutrients or bioactive compounds [1
]. Interestingly, children with fruit or vegetable intakes below the recommended levels showed significantly higher energy-adjusted intakes of thiamine and riboflavin than those who achieved the recommendations. We have also analysed the same data without energy-adjustment, which appear to give contradictory results [47
]. The results of the energy-unadjusted analysis showed that children with an inadequate intake of fruits or vegetables had similar intake levels of thiamine and riboflavin, but lower intakes of minerals (such as calcium and iron). They were also more likely than the children who achieved fruit or vegetable intake recommendations to be at risk of inadequate intakes for most micronutrients [47
]. We theorise that these differences could be because the intake of most nutrients is usually correlated with total energy intake (either through their direct contribution to energy intake or because of higher food consumption resulting in higher energy intake) [48
]. Therefore, failing to account for the variations in total energy intake could possibly confound the true effect of dietary patterns (i.e., fruit and vegetable intake) on the intake of all micronutrients. Our results seem to confirm the importance of adjusting for total energy intake when conducting epidemiologic analyses of nutrient intakes.
The observed higher intakes of thiamine and riboflavin suggests the possibility that children with inadequate intakes of fruits and vegetables tend to eat more from other food groups, such as meat and poultry, which are known to be important food sources of thiamine [49
] and riboflavin [50
]. This hypothesis is supported by previous observations that a large majority of Malaysian children had adequate intake of the meat/poultry group, but not other food groups, including fruits and vegetables [10
]. Excessive reliance on milk and dairy products as the primary food sources in young children [36
] could also explain the higher intakes of specific micronutrients among those with low fruit and vegetable intake in the present study.
The main limitation of this study is that the dietary intake data were collected using parent or caregiver proxy-reporting method because the children involved were too young and unable to provide accurate self-reports. In this case, some misreporting of total food intake could occur since the parent or caregiver may not be able to accurately report their child’s dietary intake during the time they spent out-of-home; e.g., at preschool, kindergarten, or childcare centre. Nevertheless, the use of age-specific and validated semi-quantitative FFQs adds credibility to the findings of this study as it provides a more representative picture of the habitual dietary intake of children from different age groups compared to other assessment methods (e.g., 24-h or three-day diet recall). Next, we did not evaluate seasonal variations in the availability of fruits and vegetables in different regions of the country, which could possibly influence the intake of the population throughout the period of data collection. However, this is the first nationwide study that focuses not only on assessing the fruit and vegetable intake patterns but also on determining their associations with sociodemographic characteristics, anthropometric measures and nutrient intake profiles among young children. These data provide important background information to health professionals and policy-makers that could aid in the development of suitable and effective strategies to promote fruit and vegetable intake as part of healthy dietary habits in Malaysian children.