Is the Diet of a Middle Income Country Sustainable ? An Exploratory Study from Malaysia

A sustainable diet which is healthy and environmental friendly is a climate change mitigation option in addition to being a health promoting diet. However, there is a scarcity of information if the Asian diets are sustainable. Therefore, this study aimed to investigate if the diet of the Malaysian population is healthy and sustainable. This is a cross sectional study using dietary data generated from food frequency questionnaires (FFQ). The carbon footprint data were linked with the food items/ food groups in the FFQ. The nutrients of the participants’ diet were computed and the proportions of those who met the recommended nutrients intake were established. Contribution of carbon footprint for different food groups and total carbon footprint for each participant’s diet were computed and expressed as kgCO2eq. Comparison of carbon footprint from participants’ diets between age, sex and ethnicity were carried out. A total of 4825 participants were included in the analysis. Majority were Malays (66.4 %), females (84.0%), married (80.0%) and in the age groups of 30s to 40s (68.8%). The mean total energy intake was 2485+1000 kcal/day. Only 40 to 60% of all participants achieved the Malaysia Recommended Nutrient Intake (RNI) for calcium and less than half of the female participants who were aged 50 years and below fulfilled the RNI for iron. The most commonly consumed food groups were vegetables (270g/day), wheat, rice, fruits, sugar, seafood, poultry, legumes, snacks, milk and beef (46g/day). Total carbon footprint from the participants’ diets were 2.96 kgCO2eq/day, with the highest contributions of carbon footprint from rice, vegetables, beef, sugar, other cereals, poultry, seafood, wheat, milk, fruits, legume and snacks. Subgroups such as males, Malays and younger participants were more likely to consume diets with higher carbon footprint, compared to their counterparts. The participants’ diet was low in carbon footprint and environmentally friendly, however the quality of diet may need to be improved. Education measures should be targeted for all population and specifically for the sub-groups that consumed diets with higher carbon footprint.


Abstract: 13
A sustainable diet which is healthy and environmental friendly is a climate change mitigation option in 14 addition to being a health promoting diet. However, there is a scarcity of information if the Asian diets 15 are sustainable. Therefore, this study aimed to investigate if the diet of the Malaysian population is 16 healthy and sustainable. This is a cross sectional study using dietary data generated from food frequency 17 questionnaires (FFQ). The carbon footprint data were linked with the food items/ food groups in the FFQ. 18 The nutrients of the participants' diet were computed and the proportions of those who met the 19 recommended nutrients intake were established. Contribution of carbon footprint for different food 20 groups and total carbon footprint for each participant's diet were computed and expressed as kgCO2eq. 21 Comparison of carbon footprint from participants' diets between age, sex and ethnicity were carried out.

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A total of 4825 participants were included in the analysis. Majority were Malays (66.4 %), females (84.0%), 23 married (80.0%) and in the age groups of 30s to 40s (68.8%). The mean total energy intake was 2485+1000 24 kcal/day. Only 40 to 60% of all participants achieved the Malaysia Recommended Nutrient Intake (RNI) 25 for calcium and less than half of the female participants who were aged 50 years and below fulfilled the 26 RNI for iron. The most commonly consumed food groups were vegetables (270g/day), wheat, rice, fruits, 27 sugar, seafood, poultry, legumes, snacks, milk and beef (46g/day). Total carbon footprint from the 28 participants' diets were 2.96 kgCO2eq/day, with the highest contributions of carbon footprint from rice, 29 vegetables, beef, sugar, other cereals, poultry, seafood, wheat, milk, fruits, legume and snacks. Subgroups 30 such as males, Malays and younger participants were more likely to consume diets with higher carbon 31 footprint, compared to their counterparts. The participants' diet was low in carbon footprint and 32 environmentally friendly, however the quality of diet may need to be improved. Education measures 33 should be targeted for all population and specifically for the sub-groups that consumed diets with higher 34 carbon footprint. 35 (330 words) 36 that dietary intakes of population need to be changed in order to achieve these targets (Macdiarmid, 48 2013). 49

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Food system contributes to 19%-29% of the anthropogenic GHGE globally (Vermeulen,Campbell,& 51 Ingram, 2012). Shift on dietary pattern was recommended to reduce environmental impact from food 52 system (Hallström, Carlsson-Kanyama, & Börjesson, 2015). Shifting the typical Western diet to a more 53 sustainable dietary pattern may reduce 70% to 80% of GHGE and land use with 50% reduction in water 54 use (Aleksandrowicz, Green, Joy, Smith, & Haines, 2016). Western diet is commonly labelled as diets with 55 high calorie, high consumption in red meat (such as beef and mutton), saturated fat, sodium or salt, sugar 56 or sweetened beverages, highly processed foods; and low consumption in complex carbohydrates (such 57 as wholemeal products, nuts, legumes, fruits and vegetables). According to the latest commissioned 58 report by EAT and Lancet (W. Willett et al., 2019), diets with an appropriate caloric intake and consist of 59 a diversity of plant-based foods, low amounts of animal source foods, unsaturated rather than saturated 60 fats, and small amounts of refined grains, highly processed foods, and added sugars; are the solutions for 61 the human health and environmental sustainability goals. 62

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The current global focus is to improve diet quality while reducing the environmental impact 64  Malaysian diet has changed to be higher in total calorie, fat and sodium as well as lower fibre intake; and 121 coupled with a sedentary lifestyle; the prevalence of obesity and non-communicable diseases (NCDs) has 122 increased markedly. In 2015, the prevalence of overweight and obesity was 30% and 17.7% respectively, 123 with the prevalence of diabetes being 17.5% and hypertension 30.3% (Institute for Public Health, 2015). 124 125 There is a lack of awareness in sustainable diet as a driver for health promotion and climate change 126 mitigation in the Malaysian setting. There is also a scarcity of research in the assessment if the Malaysian 127 diet is healthy and sustainable. Information on the contribution of GHGE from the Malaysian diet is lacking. 128 Therefore, this study was initiated to investigate if the current diet of the Malaysian population is healthy 129 and sustainable by studying both environmental and nutritional aspects. The FFQ consisted of 136 food items with a combination of raw, cooked and mixed dishes. Information 159 on beef, poultry, and fish was categorized by typically used cooking methods such as deep-fried, cooked 160 with coconut milk, cooked without coconut milk, grilled/roasted, or steamed. The serving sizes were 161 based on the usual household measurements according to the food atlas from Shahar et al (Shahar,Safii,162 Manaf, & Haron, 2009). Colour photographs of serving size for selected food items were attached with 163 the FFQ to improve the estimation of serving size. The participants were required to write for each food 164 item the number of times per day, week, month or year as well as the number of serving size in a specified 165 unit that they typically consumed over the past year. The frequency intake specified as weekly, monthly 166 and yearly was converted to daily. The daily intake of the nutrients for each food item was calculated 167 using the product-sum method (WC. Willett, 2012 Energy, macro-and micro-nutrients 220 From the obtained secondary data, diets with total calorie less than 500 and more than 5,000 kcal 221 (extreme values) were excluded. The total energy intake was 2485.6+1000.3 kcal/day with males taking 222 higher calories than the females ( Table 2). The contribution of macronutrients for total calorie were about 223 48% for carbohydrates, 18% protein and 33% fat. The mean nutrients intakes in total energy, protein, 224 vitamin C, calcium and iron are presented in Table 2. There were significant differences in energy, % 225 macronutrients and micronutrients between gender. When the participants' nutrients (vitamin C, calcium 226 and iron) intake were compared with the Malaysian Recommended Nutrients Intake (RNI) (Nutrition, 227 2017), only 40 to 60% of all participants achieved the RNI for calcium ( Figure 1) and less than half the 228 female participants who were aged 50 years and below fulfilled the RNI for iron (Figure 2). On the other 229 hand, all participants fulfilled the RNI for vitamin C (Figure 3). 230 231 Commonly consumed food groups 246 The most commonly consumed food groups were vegetables (270g/day), wheat, rice, fruits, sugar, 247 seafood, poultry, legumes, snacks, milk and beef (46g/day) (Figure 4). Total vegetables were contributed 248 by leafy vegetables (74%) and root vegetables (26%). For wheat, 70% were from noodles and 30% from 249 bread. Fish contributed 75% of total seafood consumption, with the rest from shellfish. Snacks were 250 mainly local dessert /"kuih" (56%), curry puffs (16%), doughnuts (13%), biscuits (12%) and cakes (4%). 251    Most of the participants' intakes in vitamin C and iron fulfilled the Malaysian RNI (Nutrition, 2017) except 283 females less than 50 years old who did not achieve the RNI for iron. The participants' intake in calcium 284 only achieved about half of the Malaysian RNI. The participants' diet had lower carbon footprint 285 compared to the West. The reasons could be due to the participants' diets had very low intakes in beef, 286 milk and dairy products. Although the dietary carbon footprint was low, subgroups such as males, Malays 287 and younger participants were more likely to consume diets with higher carbon footprint, compared to 288 their counterpart. These findings may be the first in the country as well as the South East Asia region, and 289 may serve as a platform for future research. 290 291 The participants were in the age groups of 30s to 50s, majority females, with tertiary education. These 292 were the characteristics of teachers in Malaysia. Their diets were higher in fats (more than 30%) while 293 protein and carbohydrates were within recommendations. Most participants achieved the Malaysian RNI 294 (Nutrition, 2017) for vitamin C and iron, except females aged less than 50 years old. Similar findings were 295 reported from the Malaysian Nutrition Survey which found lower intake of iron and calcium than the 296 Malaysian RNI, particularly among women (Mirnalini et al., 2008). Females in their reproductive age 297 group had higher RNI for iron, recommended to cater for their needs during pregnancy and lactation. 298 These women should be educated on the types of iron rich foods and ways to increase these foods. 299 300 Half of the participants did not achieve the RNI for calcium. As these participants did not consumed much 301 milk and dairy products due to their cultural dietary pattern, intervention measures should be taken to 302 encourage them to consume calcium rich vegetables such as mustard leaves, spinach and cabbage. In 303 addition, milk consumption of at least one to two servings per day should also be promoted to increase 304 the calcium content in their diets. The moderate recommended milk consumption is based on the 305 compromise of its health / nutrition and environmental impact. Large increase of milk consumption will 306 inevitably increase the carbon footprint of a diet. Therefore, a combination of plant and animal sources 307 of calcium will improve the quality as well as reduce the environmental impact of the diet. The main contributors of greenhouse gas in this study were rice, vegetables and beef. Although rice 337 contributed to low amount of greenhouse gas (Xu & Lan, 2016), the high quantity of rice consumption 338 contributed to the high level of carbon footprint in the diet. The same was applied to vegetables. On the 339 other hand, although beef consumption was low, the high carbon footprint of beef per se contributed 340 large amount of carbon footprint in the diet. Similar pattern was also found in a study on greenhouse gas 341 emission from food consumption in India (Vetter et al., 2017). 342 343 As Malaysia is located by the coast, fish is the main source of protein in our diet. Although the carbon 344 footprint from fish may be lower than beef and poultry, there is some concern in the high consumption 345 of fish. the Chinese and Indian participants who did not consume beef, the Indian participants' diet had higher 359 carbon footprint compared to the Chinese, probably due to the higher energy consumption among the 360 Indians which contributed to higher carbon footprint. Females and older age group (> 50 years) had lower 361 carbon footprint may be due to their lower intake in total calories, or they were more health conscious 362 and opted for less meat or animal source protein in their diets. Similar findings on gender and age 363 differences were reported among Irish adults ( In addition, carbon footprint as a proxy for GHGE does not represent the full range of environmental 376 impacts associated with a diet. Water deprivation, land degradation, and biodiversity loss which are 377 environmental areas of concerns were not included. However, all the above mentioned data are 378 unavailable and that was not part of our research questions. 379 380 On the other hand, this study may be the first of its kind in Malaysia or South East Asia. To the best of the 381 authors' knowledge, we have yet to find a similar published paper form Malaysia or South East Asia. These 382 findings may provide the platform for future research to build on. More work should also be started on 383 the issues of sources of fish and its consumption. 384 385

Conclusions: 386
The participants' diet was low in carbon footprint and environmentally friendly, however the quality of 387 diet may need to be improved. Although most participants achieved the RNI for the public health 388 important nutrients (iron, calcium and vitamin C), the intakes of refined carbohydrates such as white rice, 389 noodles and sugar were high. High intake of fish may be good for health but poses threat in sustainability 390 issues for the future generation. Certain sub-groups (Malays, younger age group and males) tended to 391 consume diets with higher carbon footprint, compared to their counterparts. Education measures should 392 be targeted for all population and specifically for the above-mentioned sub-groups. 393 394