This article was downloaded by: [University of Tasmania]On: 15 November 2014, At: 05:42Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

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Dietary practices innutritional transition: Thecase of Malaysian urbanChineseG.L. Khor a , B.H. Hsu‐Hage b & M.L. Wahlqvistb

a Associate Professor, Department of Nutritionand Community Health, Faculty of Biomedicaland Health Sciences , Universiti PutraMalaysia , Serdang, 43400, Selangor DarulEhsan, Malaysiab Department of Medicine , Monash University ,Monash, AustraliaPublished online: 31 Aug 2010.

To cite this article: G.L. Khor , B.H. Hsu‐Hage & M.L. Wahlqvist (1998) Dietarypractices in nutritional transition: The case of Malaysian urban Chinese, Ecologyof Food and Nutrition, 36:6, 463-489, DOI: 10.1080/03670244.1998.9991532

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Ecology of Food and Nutrition, Vol. 36, pp. 463^189 © 1998 OPA (Overseas Publishers Association)Reprints available directly from the publisher Amsterdam B.V. Published under licensePhotocopying permitted by license only under the Gordon and Breach Publishers imprint.

Printed in India.

DIETARY PRACTICES INNUTRITIONAL TRANSITION:THE CASE OF MALAYSIAN

URBAN CHINESE

G.L. KHOR1,*, B.H. HSU-HAGE2

and M.L. WAHLQVIST2

1 Associate Professor, Department of Nutrition andCommunity Health, Faculty of Biomedical andHealth Sciences, Universiti Putra Malaysia,

43400 Serdang, Selangor Darul Ehsan, Malaysia;2 Department of Medicine, Monash University,

Monash, Australia

(Received June 7, 1996; in final form May 12, 1997)

In this study involving 336 urban Chinese adults, more than 40% belong to atleast the second generation in Malaysia. The result shows the persistence ofseveral Chinese traditional dietary habits. Almost all the subjects take ricedaily and an assortment of noodles weekly. A wide variety of vegetables areconsumed frequently. Soup is consumed daily or weekly. Steaming and stirfrying are preferred methods of cooking. Majority reported adding salt lightlyin cooking, eating little fat on meat, and not adding sugar to tea or coffee, butthey use sweetened condensed milk. Urban Malaysian Chinese do not appearto manifest a high-fat high-meat diet that is becoming characteristic of rapidlydeveloping countries. Their dietary practices seem to reflect an inclination to-wards the "behavioural change" dietary pattern away from the "degenerativedisease" pattern according to the concept of nutritional transition as describedby Popkin.

KEY WORDS: Dietary practices, nutritional transition, Malaysian urbanChinese adults

* Corresponding author.

463

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464 G.L. KHORETAL.

INTRODUCTION

Dietary practices of rapidly developing countries such asMalaysia are described as being in the nutritional transition.The concept of nutritional transition may be delineated as anevolving process in which a sequence of broad dietary and nu-tritional changes occur at the population level. These dietarychanges as propounded by Popkin (1993) commence with the"collecting food" pattern as practised by hunter-gatherers re-sulting in a diet that is high in carbohydrates and fiber and lowin fat. This may be accompanied by the "famine" dietary pat-tern which is subject to periods of food shortage leading tostunted stature. The "receding famine" pattern that follows con-verges on an increased intake of animal protein, fruits and veg-etables and lesser consumption of starchy staples. The nutritiontransition straddles the preceding stage and the following stagenamely, the "degenerative diseases" pattern, which is character-ised by a diet high in total fat, cholesterol and sugar, and low infiber and polyunsaturated fatty acids. In turn, the "degenerativediseases" stage may be replaced by the "behavioural change"pattern.

Underlying this change could be a multitude of reasons in-cluding the desire to reduce the risks of degenerative diseases.According to Popkin's concept of nutritional transition, thebehavioural change pattern give rise to increased intakes ofcomplex carbohydrates, fruits and vegetables, and reduced con-sumption of refined foods and saturated fats.

In countries where rapid transition in diet occurs, the variousstages of dietary patterns described above may exist side byside. For example, in Malaysia, the "collecting food" pattern isevident among some inland indigenous groups (Khor, 1994),while the "famine" dietary pattern can be found among poorhouseholds in rural areas (Chong et al., 1984), and in urbanareas as reported in under-served squatter communities (Khor,1992) and among low-cost flat dwellers (Malo et al., 1993).

While the country is still beset with the "old" problemof under-nutrition, as manifested by a relatively high preva-lence of underweight and stunting among young children, and

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DIET OF URBAN MALAYSIAN CHINESE 465

iron-deficiency anaemia in children and women (Tee and Cavalli-Sforza, 1992), the emergence of diet-related non-communicablediseases in Malaysia in the past two decades suggests the preva-lence of the "degenerative diseases" dietary pattern at the countrylevel. Diseases of the circulatory system have been the leadingcause of mortality in Malaysia since 1975. Heart diseases anddiseases of pulmonary circulation constitute the principal causesof death in government hospitals. These diseases togetherwith cerebrovascular disease made up 26% of such deaths inPeninsular Malaysia (Ministry of Health Malaysia, 1993). Therisk factors of cardiovascular diseases have been reported to bemore prevalent in the urban community (Teo et ah, 1988; Ismailet dl., 1995). As industrialization continues to expand rapidly inthe urban areas mainly, the proportion of the urban populationin Malaysia also has been on the increase, rising from 27% in1970 to 51% in 1991 (Department of Statistics Malaysia, 1995).

Out of a population of approximately 19.5 million inMalaysia, the Chinese constitutes about 28% compared toabout 61% Malays and 8% Indians. The majority of the Chineselive in urban areas. The coronary heart disease (CHD) mortalityrate for the Chinese lies between the levels for the Malays andIndians. In 1970 the CHD mortality rate of the Chinese was12.1 per 100,000, and the level increased to 22.6 in 1980 and26.0 in 1985 (Khor, 1994). Since then, the Chinese mortalityrate appears to hover between 26-27 per 100,000.

The food balance sheets data published by Food and Agri-culture Organisation (Food and Agriculture Organisation,1992) also indicates the course of nutritional transition inMalaysia. The total available calories has increased from 2,200per capita in 1965-66 to 2,880 in 1992. This increase of 31%available dietary energy over the past three decades has beendue to increases in calories from oils and fats, meat and sugar.These dietary items have increased by 149%, 145% and 38% re-spectively between 1964-66 to 1992 (Table I). Meanwhile, cal-ories from cereals has declined from 57% of total calories in1965-66 to 40% in 1992. The proportions of available energyfrom vegetables, fruits, pulses, nuts and oilseeds have also beenon a decline in recent decades.

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466 G.L. KHOKETAL.

TABLE IKilocalories per caput per day by food groups in

1964-1966 and 1992 in Malaysia

CerealsOils and fatsMeatFish and seafoodVegetablesFruitsEggsSugarTotal kilocalories

1964-1966

1,248214

8940209312

264

2,200

1992

1,233534218

38266656

364

2,880

Change(%)

- 1+ 149+ 145- 5+ 30- 2 9+ 56+ 38+ 31

Source: Food Balance Sheets, various years, Food andAgriculture Organisation, Bangkok.

To what extent is the dietary pattern of the urban MalaysianChinese reflective of the "degenerative diseases" and "behav-ioural change" dietary pattern stages? A case study was under-taken in 1994/95 to assess the dietary and other lifestyle riskfactors of cardiovascular disease in a sample of urban Chinese.This report discusses the dietary practices of the Chinese in thecontext of dietary transition.

METHODOLOGY

The town of Sri Kembangan located about 15 km south ofKuala Lumpur, the capital city of Malaysia was purposively se-lected for the study due to its predominant Chinese population.Sri Kembangan has an estimated population of 150,000 withmodern amenities and services. The town has expanded vastlyin recent years in tandem with the rapid economic developmenttaking place in the country, especially in areas close to the citiessuch as Kuala Lumpur and Penang. As a reflection of the fastgrowth in this town, increasingly more factories and houses arebeing built, while old houses (with wooden walls and zinc roofs)are being replaced with brick houses.

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DIET OF URBAN MALAYSIAN CHINESE 467

Approximately 500 houses which are located within abouthalf a kilometer radius of the town center of Sri Kembanganconstituted the sampling frame. Based on previous experiences,it was known that it would not be easy to obtain the coopera-tion of urban residents. Thus, leaflets explaining about thestudy were given to the targeted houses prior to the onset of thestudy. Enumerators were recruited particularly for their com-munication skill in Mandarin and the Chinese dialects. Theywent from house to house to carry out the interview using astructured questionnaire. Only one adult (aged 20 and above)from each house who agreed to be interviewed was included.This approach was used in view of the difficulty in getting sub-ject cooperation. This study had aimed at obtaining a total of400 respondents with an equal number of men and women. Atthe end of the study, a total of 336 respondents comprising of149 men and 187 women were interviewed.

The questionnaire used included questions on the socio-economic characteristics of the respondents, dietary habits,health-related habits, medical history and condition, day-to-dayactivities, social activities and food intake pattern.

Food Intake Pattern

The food intake pattern was assessed using the MelbourneChinese Health Study food frequency questionnaire (MCHS-FFQ), which was validated for use in Chinese populations asdescribed in Hsu-Hage and Wahlqvist (1992). The MCHS-FFQ was based on the CSIRO* food frequency questionnaire(FREQPAN) (Record and Baghurst, 1987). A list of Chinesefood items was added to the FREQPAN food list resulting in atotal of 220 food items. The units of measure for the food itemswere based on (a) common household measures such as theChinese rice bowl, (b) serving sizes (e.g. half slice of papaya), or(c) natural units (e.g. half salted egg). The weight (in grams) ofthese reference portions for all the food items were included in

† Commonwealth Scientific Institute and Research Organization based inAdelaide, Australia.

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468 G.L. KHORETAL.

the MCHS-FFQ food list. For example, the weight of one bowlof steamed rice is 192g, and this amount or its equivalent (e.g.half a bowl or two bowls) was recorded accordingly for theusual intake of rice as reported by the respondents.

In the present study, the MCHS-FFQ food list was modifiedslightly by substituting rarely consumed items with those thatare more frequently consumed by Malaysian Chinese (e.g. lo-cally grown fruits and vegetables). The weight of the referenceportions for the additional food items used in this study werecomputed and included in the MCHS-FFQ list.

The respondents were asked to estimate over the past yearthe intake frequency for each type of food and beverage on thebasis of per day, per week or per month. The respondents werealso asked to estimate the usual amount taken for each ofthe food and beverage items in the modified MCHS-FREQfood list.

As part of the overall study, anthropometric measurements,biochemical determinations and clinical examination were alsoincluded. The respondents were examined by a physician for theclinical assessment. Only the dietary results are reported in thispaper.

RESULTS

Demographic and Socioeconomic Characteristics

A total of 147 men and 187 women were interviewed. Themajority of them belong to the first or second generationMalaysian Chinese (Table II). The main spoken dialects of themen are Hokkien, Cantonese and Hakka, while the women aremostly Cantonese and Hakka. The mean age for both gender isbetween 36-37 years. Most of the women (91%) and 65% of themen are married. They have an average of three children withabout one-third having 4-6 children. More than half of themhave a household size with less that six members, with the oldersubjects having a larger household size.

While almost one-third of the men in the study have attainedcollege education, only 5.9% of the women have attained this

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DIET OF URBAN MALAYSIAN CHINESE 469

TABLE IIDemographic and socioeconomic characteristics of

respondents by gender

Age (years)MeanAge

Marital statusPresently marriedNot married beforeDivorced/widowed

Number of children (JV=260)Mean1-34-8

Chinese dialectHokkienCantoneseHakkaOthers

Generation in MalaysiaFirstSecondThird and more

Educational levelNever attended school1-6 years (primary)7-11 years (secondary)College/University

Monthly household income(US$l«RM2.50)

RM500 and lessRM501-RM1000RM1001-RM2000RM2001-RM4000More than RM4000

Men(Ar =149)

36.425-57

97 (65.1%)52 (34.9%)0

316496

50 (33.6%)41 (27.5%)41 (27.5%)17(11.4%)

35 (23.5%)80 (53.7%)34 (22.8%)

2(1.3%)36 (24.2%)66 (44.3%)45 (30.2%)

12 (8.1%)14 (9.4%)71 (47.7%)39 (26.2%)13 (8.7%)

Women(iV= 187)

37.225-55

170 (90.9%)13 (7.0%)4 (2.1%)

(63.1%)(36.9%)

22(11.8%)62 (33.2%)95 (50.8%)

8 (4.2%)

111 (59.4%)61 (32.6%)15 (8.0%)

30 (16.0%)75 (40.1%)71 (38.8%)11 (5.9%)

12 (6.4%)32 (17.1%)

104 (55.6%)36 (19.3%)3 (1.6%)

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470 G.L. KHOR ETAL.

TABLE II (Continued)

Employment status1 Self-employed2 Full-time paid employment3 Part-time paid employmentNot employedHousewivesStudents

Men(TV =149)

48 (32.3%)83 (55.7%)

—3 (2.0%)

—15 (10.1%)

Women( # = 1 8 7 )

35 (18.7%)40 (21.4%)35 (18.7%)13 (7.0%)62 (33.1%)

2(1.1%)

1 Hawkers, tailors, carpenters, contractors, cobblers, baby sitters, busi-nessmen.

2 Teachers, executives, clerks, managers, factory operators, shopkeepers.3 Insurance agents, salesmen.

level. About 40% of the latter studied up to secondary schoollevel while an equal proportion reached only primary schooleducation. More than half of the men (55.7%) are employed fulltime in positions such as teachers, executives and managers,while 21.4% of the women are full time workers e.g. as factoryoperators and clerks. One-third of the women are housewives.A sizable percentage of the men (32.3%) and women (18.7%) areself-employed e.g. as hawkers and in business. About half of themen (47.7%) and women (55.6%) have a monthly householdincome of between RMtl,001-RM2,000. The households ofmore than one-quarter of the men and one-fifth of the womenearn between RM2,000-RM4,000 monthly. Only a small per-centage of the study population have monthly householdincome exceeding RM4,000. While the majority of the house-holds may be classified as being from the middle income group,there is a note-worthy proportion from the low income bracketnamely, 17.5% of the men and 23.5% of the women withmonthly household earnings less than RM 1,000.

†Ringgit Malaysia (Malaysian dollars); US$1 ~ RM2.50.

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DIET OF URBAN MALAYSIAN CHINESE 471

Food Intake Pattern

The food intake pattern of the urban Chinese is described in thissection according to the types of food taken on a daily, weeklyor monthly basis. The mean usual intake is computed based onthe reported usual amount of intake for each food item by therespondents (n = 336). The types of food consumed are pres-ented in five categories namely, cereals and cereal products, ani-mal products, vegetables, fruits, and the last group comprises ofbeverages, snacks and soups.

Cereals and Cereal Products (Table HI (a))

As typical of Chinese households, steamed rice is consumeddaily by almost all the respondents (95.2%). The mean usualamount of steamed rice consumed is 384 g which is equivalentto two bowls (each 300 ml). As for rice porridge, it is consumeddaily by less than 5% of the respondents. Whether plain or withmeat, rice porridge is more commonly consumed either weekly(31.6%) or monthly (46.7%). The usual amount of porridgetaken averages 160g or one bowl.

TABLE III(a)Food intake pattern - cereals and cereal products

Daily Weekly Monthly Mean usualusers* (%) users* (%) users* (%) intake (g)

1. Rice steamed2. Rice porridge plain3. Rice porridge with

meat4. Bread sandwich white5. Rice/wheat noodles6. Egg noodles7. Rice vermicelli8. Mungbean noodles9. Rice pasta flat

10. Biscuit plain

95.22.4

1.82.4

14.06.0

14.01.23.38.0

1.017.6

14.011.060.130.760.112.539.627.7

022.0

24.78.3

11.017.015.521.725.014.9

384160

16050

27027022518031556

" Number of respondents = 336.

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472 G.L. KHOR ETAL.

Noodles of various types are popular among the Chinese.Rice noodles, wheat noodles and rice vermicelli are eaten dailyby 14% of the respondents, while egg wheat noodles are con-sumed by 6% daily. The majority of the respondents takenoodles on a weekly or monthly basis. The mean usual intake ofrice or wheat noodles is 270 g or 1.5 bowls. Mungbean noo-dles are also popular being taken by 21.7% monthly. Bread isnot taken regularly by most of the respondents, whilst biscuitsand cakes are eaten more on a weekly or monthly basis.

Animal Products (Table III(b))

Pork and chicken are the preferred types of meat of most of therespondents. Only a minority of them consume beef, mutton or

Food

1. Pork lean stir-fried2. Pork ribs stewed/

boiled3. Chicken stir-fried4. Chicken steamed5. Chicken roast/BBQ6. Duck roast7. Sausages Chinese8. Eggs chicken fried9. Eggs chicken boiled

10. Eggs duck salted11. Fish fresh12. Fish canned13. Fish salted14. Fish ball15. Squid16. Crabs/prawns17. Shrimps dried18. Hamburger19. Milk skim

TABLEintake pattern

Dailyusers * (%) i

27.7

2.74.21.51.0006.01.01.0

31.3<1.0<1.0

5.103.05.10

11.6

IH(b)- animal products

Weeklyusers * (%)

48.8

55.440.243.514.93.94.8

56.029.212.853.011.37.4

38.710.732.140.83.96.6

Monthlyusers* (%)

6.9

18.211.630.728.325.929.220.512.832.86.0

19.516.423.823.230.421.419.61.2

Mean usualintake

150g

113g293 g135g248 g

30 g15g

HOg55 g55g

240 g30 g33 g14 g90 g

263 g45 g

180g200 ml

'Number of respondents = 336.

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DIET OF URBAN MALAYSIAN CHINESE 473

lamb. Respondents who are Buddhists do not take beef on reli-gious grounds. Lean pork is usually stir fried with vegetables orby itself. More than three-quarters of the respondents take suchpork either daily or weekly. The mean usual intake of lean porkamounts to 150 g. Pork ribs are also favoured either stewed orboiled, and are consumed weekly by more than half of the re-spondents. Chicken that is stir fried or steamed is popular andis eaten by more than 40% on a weekly basis. The mean usualintake for chicken ranges from 135 g for steamed chicken to293 g for stir-fried chicken.

Fried eggs are more popular than boiled eggs and both areconsumed more on a weekly or monthly basis rather than daily.Fifty-six percent take fried eggs weekly compared to 29.2% forboiled eggs. Salted duck eggs are part of the Chinese diet and itis usually taken with porridge or steamed rice. About one-thirdof the respondents (32.8%) consume salted eggs on a monthlybasis.

Fresh fish is a popular food being consumed daily by aboutone-third of the respondents (31.3%). The average usual intakeof fish appears quite substantial at 240 g. Most of the respond-ents (53%) eat fresh fish on a weekly basis. Canned fish andsalted fish appear not as popular as fresh fish. These are con-sumed by 19.5% and 16.4% respectively monthly. In compari-son, fish ball is consumed by more respondents, that is, 38.7%weekly and 23.8% monthly. Crabs, prawns and dried shrimpsare also favoured by a significant proportion of the respond-ents. Almost one-third consumes crabs and prawns weekly,whilst 40.8% take dried shrimps on a weekly basis.

Vegetables (Table III(c))

It is note-worthy that the respondents consume regularly a widevariety of vegetables. More than 31 different types of vegetablesare consumed daily or weekly. Vegetables that are taken dailyby at least 10% of the respondents include onions, capsicum,leek, carrot and potato. Small onions (shallots) are usually usedin stir-frying which is a common form of cooking amongChinese, while big onions are added in soups, curries and in

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TABLE IH(c)Food intake pattern - vegetables

1. Onions2. Capsicum3. Leek4. Carrot5. Potato6. Mustard leaves7. Lettuce fresh8. Cucumber9. Bitter gourd

10. Cabbage11. Spinach12. Chinese cabbage13. Swamp cabbage14. Bean sprouts15. Broccoli16. Sweet corn17. Eggplant18. Chinese mushroom19. Cauliflower20. Tomato fresh21. Celery22. String beans23. Pea shoot/leaf24. Green peas25. Mushroom fresh26. Mushroom canned27. Lotus roots28. Radish fresh29. Snow peas30. Sweet potato31. Water chestnut

Dailyusers* (%)

32.127.415.510.110.19.57.44.54.23.02.72.41.81.51.51.51.21.21.01.00.9

<1.0<I.O<1.0<1.0<1.0

00000

Weeklyusers* (%)

38.437.553.039.510.476.839.649.743.240.241.431.640.244.623.220.238.135.136.055.728.339.923.221.112.815.239.325.920.813.710.1

Monthlyusers* (%)

13.78.0

17.625.525.3

9.219.125.628.927.129.530.727.127.727.427.426.230.728.935.726.525.934.828.036.030.432.726.533.632.429.8

Mean usualintake (g)

485345504540728070404262406130654033363336353033201590753375

100

* Number of respondents = 336.

omelets among other dishes. Popular leafy vegetables consumedinclude mustard leaves (Brassica juncea) ("choy sum"), cab-bage, spinach, and Chinese cabbage (Brassica chinensis) ("pakchoi"). Vegetables that are consumed weekly by at least 50% of

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DIET OF URBAN MALAYSIAN CHINESE 475

the respondents include leek, mustard leaves, cucumber, soybeancurd ("tau fu") and tomato. The most preferred leafy vegetable ismustard leaves with 76.8% of the respondents reported taking itweekly at an average usual intake of 40 g. Meanwhile, leafy androot vegetables that are eaten by more than one-third of the re-spondents on a monthly basis include mushrooms, pea shoot leaves("tau miu"), snow peas, lotus root, sweet potato and tomato.

Fruits (Table III(d))

A wide variety of locally grown and imported fruits are con-sumed in Malaysia. In this study, imported fruits con-sumed weekly or monthly include apples, pears, citrus orangesand grapes, while popular local tropical fruits include guava(Psidium guajava), "chiku" or sapodilla (Achras zapota), "nangka"(Artocarpus heterophyllus) and "cempedak" (Artocarpus inte-ger). Various types of oranges or citrus fruits are eaten by 12.2%daily and by 58.9% weekly. The mean usual quantity of citrusfruits taken is 165 g. Apples are taken by 61.9% weekly. Thevariety of fruits consumed would be even more if seasonal lo-cally grown fruits had been included in this study. These include"durians" (Durio zibethinus), "rambutans" (Nephelium lappaceum),

TABLE III(d)Food intake pattern - fruits

Daily Weekly Monthly Mean usualusers* (%) users* (%) users* (%) intake (g)

1. Oranges2. Apples/pears3. Banana4. Papaya5. Melon/honey dew6. Watermelon7. Mango8. Pineapple9. Grapes

12.29.26.62.71.81.81.01.0

<1.0

58.961.957.450.033.632.121.412.814.6

15.514.919.626.232.433.635.417.331.0

16514028010024028040

11020

* Number of respondents = 336.

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"mangosteens" (Gardinia mangostana) and "langsat" (Lansiumdomesticus). Thus, like vegetables, a wide assortment of fruitsare available to Malaysians.

Beverages/Snack/Soups (Table III(e))

Almost all the respondents (94.6%) reported drinking a fairlylarge amount of water daily with a mean usual intake of 200 ml.Other types of beverages appear not to be taken by many on adaily basis. Approximately one-fifth of the respondents drinkcoffee daily. One cup (150 ml) is the mean usual amount con-sumed. Chinese and English tea are taken by more respondentson a weekly basis. Soya drink is a popular drink being taken by43.8% weekly with a mean usual intake of 75 ml. Snacks such asice cream, potato crisps and salted nuts are not taken frequentlyby many. However, Chinese pastry snacks such as "dim sim",

TABLE IH(e)Food intake pattern - beverages/snacks/soups

Daily Weekly Monthly Mean usualusers * (%) users * (%) users * (%) intake

1. Water2. Mineral water3. Coffee4. Tea Chinese5. Tea English6. Soya drink7. Fruit juice8. Chocolate9. Ice cream

10. Carbonated drink11. Potato crisps12. Salted nuts13. Dim sim steamed14. Dim sim fried15. Home made soup16. Double boiled soup

94.67.7

22.613.45.73.00.3

24.102.400.91.81.2

24.7<1.0

5.45.1

22.022.311.343.815.227.79.5

14.98.08.6

36.026.553.911.9

011.97.19.54.5

24.115.26.6

25.914.617.021.431.930.46.0

38.1

200 ml75 ml

150 ml200 ml150 ml75 ml75 ml25 g30 g60 ml30 g60 g60 g60 g

100 ml60 ml

* Number of respondents = 336.

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DIET OF URBAN MALAYSIAN CHINESE 477

whether steamed or fried, are consumed by about one-thirdeither weekly or monthly.

Soup constitutes an important component of the Chinesediet. Home-made soups usually comprise meat with one ormore types of vegetables. One-quarter of the respondents takesoup daily while more than half take it weekly. The doubleboiled soup is also popular. It is cooked over a.slow fire andusually consists of some herbal preparation with meat (such aschicken or duck). Such soups are believed to have health pro-moting properties. About 38% of the respondents consumedouble-boiled soup monthly.

Food Preferences

When asked for their favourite types of food, the most popularfood chosen by both men (31.8%) and women (49.1%) is veg-etables in general (Table IV). The popularity of vegetables is re-flected by the wide variety of vegetables consumed frequently bymany respondents as described previously. The main reasonsgiven by both gender for liking vegetables are because veg-etables are (i) good for health as they contain much nutrients,

TABLE IVFood preferences by gender

Foods likedVegetablesChicken and porkFruitsFish and seafood

Foods dislikedGreasy foodBeef and muttonSour foodFat meat

Men(AT =149)

31.818.26.84.3

15.07.57.55.0

Women(AT =187)

49.15.7

13.216.0

4.123.5

8.29.2

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478 G.L.KHOR ETAL.

(ii) easy to digest, (iii) low in cholesterol, and (iv) non-fatteningas they are low in calories. The next favourite food item amongthe men (18.2%) is meat (chicken and pork) while fish is prefer-red by the women (16%). The respondents reported liking fishbecause it is tasty and nutritious.

Food items which are disliked by men are greasy food (15%)followed by beef and mutton, and sour food. Oily food and fatmeat are said to have high cholesterol. The women mostly dis-like beef (23.5%) followed by fat meat and sour food. The mainreasons for the women's dislike for beef are because (i) they donot like its smell and taste, and (ii) beef is fattening and bad forhealth.

The respondents were also asked for their perception of whatfoods they thought are good or bad for health. The highestnumber of respondents selected vegetables as good for healthfollowed by fruits and fish. Beer is deemed an unhealthy foodby many of the men and women, because one can become ad-dicted to it, it is a "cooling" food, and some believe that beerhas high cholesterol. "Cooling" foods (e.g. certain types offruits, vegetables and beverages) are regarded by the subjects asnot healthy foods because such foods can give rise to ailmentsthat affect the lungs and bones. The women also consider softdrinks, fat meat and oily food as "bad" foods. Soft drinks aresaid to be not nutritious at all while fat meat and oily food arebelieved to have high cholesterol.

The majority of the subjects (65.8%) reported that they nor-mally eat little or none of the fat on meat (Table V). However,about one-third of them said they usually eat half to all of thefat in meat. As for the type of fat used as spread on bread, mar-garine is most commonly used. Almost three-quarters of the re-spondents use margarine, while the rest reported that they donot use any type of fat on bread.

With regards to the use of milk in tea (black or English-type)or coffee, 29.2% and 43.2% of the respondents usually add milkto tea and coffee respectively. The preferred type of milk forbeverages is sweetened condensed milk. Hence, the majority ofthose who drink coffee and tea do not add sugar as they usesweetened condensed milk.

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DIET OF URBAN MALAYSIAN CHINESE

TABLE VSome dietary habits of the respondents (N = 336)

479

When you eat meat with fat, do you eatAll of the fatMost of the fatAbout half the fatLittle or none of the fatDo not eat meat at all

Type of bread usually eatenWhiteWholemeal1/2 whole meal, 1/2 whiteOther types of breadDo not eat bread

Type of fat usually used on bread (N=296)MargarineOther types of fatOther types of spread

Use of milkYesNoDo not drink

Use of sugar

01 teaspoon2 teaspoonsMore than 2 teaspoons

Tea98 (29.2%)

131 (39.0%)107 (31.8%)

Tea(AT =229)*154 (67.3%)32 (14.0%)35 (15.3%)8 (3.4%)

Yes

16 (4.8%)21 (6.3%)68 (20.2%)

221 (65.8%)10 (3.0%)

208 (61.9%)8 (2.4%)

71 (21.1%)9 (2.7%)

40(11.9%)

219 (74.0%)29 (9.8%)48 (16.2%)

Coffee145 (43.2%)104 (31.0%)87 (25.9%)

Coffee(AT = 249)*197 (79.1%)23 (9.2%)22 (8.8%)

7 (2.9%)

* Only tea/coffee drinkers.

Food Preparation

Most of the respondents use a mixed blend of vegetable oils forcooking. The types of vegetable oil commonly used are palm oiland peanut oil. The cooking method used depends upon the typeof food cooked. For example, steaming is the most popularmethod for cooking fish (78.3%), whereas stir-fry is favoured forcooking vegetables (93.5%), pork (86.9%) and poultry (79.5%)(Table VI). Deep fry is used mostly for cooking poultry. Poultry

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480 G.L. KHOR ETAL.

and pork are also cooked by stewing. On the other hand, bakingis not a common method of cooking among these Chinese.

In relations to the use of salt in cooking, most of these sub-jects (83%) reported that they always add salt or salty sauce(Table VII). Nonetheless, the majority uses salt lightly only andthey do not normally add salt to cooked food or would do soonly after tasting. It is noted that monosodium glutamate isused frequently in cooking, ranging from sometimes by 42% ofthe respondents to always by 44.6%.

TABLE VICooking method usually used in household (N=336)

PorkPoultryFishVegetables

Steam

50.354.878.3

7.7

Stir-fry

86.979.5

5.193.5

Deep fry

27.156.06.30.3

TABLE VII

Boil

8.33.60.90.2

Stew

61.152.7

1.221.1

Use of salt/salty sauce/monosodium glutamate

Bake

12.59.81.51.2

(a) Do you add salt/salty sauce in cooking?NeverAlwaysSometimes

(b) How often do you add salt to cooked food before eating?Rarely or neverOnly after tastingAlways or nearly always

(c) If salt is added to cooking, are the foodsLightly saltedMedium saltedHeavily saltedSalting is highly varied

(d) Do you add monosodium glutamate in cooking?NeverAlwaysSometimes

8 (2.4%)279 (83.0%)49 (14.6%)

165 (49.1%)158 (47.0%)13 (3.9%)

229 (68.2%)71 (21.1%)4 (1.2%)

32 (9.5%)

45 (13.4%)150 (44.6%)141 (42.0%)

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DIET OF URBAN MALAYSIAN CHINESE 481

Meal Pattern

Meal time The majority of the respondents (81.5%) considermeal time as an important part of their lives. Amongst themen, having a regular meal time is considered important for(i) getting energy and nutrients, (ii) preventing epigastric pain,(iii) good for the digestive system and health in general, and (iv) inorder to have an organised lifestyle with set times for meals(Table VIII). As for the women, preventing epigastric pain andgood for the digestive system rank high among the reasons forconsidering mealtime important. As for having meals with theirfamilies, about one-quarter of the respondents take breakfastor lunch with their family members. This may be attributed tofactors such as work outside the home. Eating with the familyoccurs most frequently during dinner as reported by three-quarters of the respondents. It is found that being married is as-sociated significantly with the practice of eating dinner withfamily members (Table IX). Age and educational achievementare also associated significantly with eating with the family.More of the older respondents and those with educational at-tainment lower than college or university level tend to have din-ner with family. It is found that household income is notassociated in a significant manner with the practice of having

TABLE VIIIReasons for considering meal time important

1. To get energy and nutrients2. To prevent epigastric pain3. Good for the digestive system4. Good for general health5. To have an organised lifestyle

with set time for meals6. Not to be hungry

*The number of respondents who gave reasons.

Men(AT = 1 0 4 ) *

28.323.917.415.2

15.2

Women(JV=148)*

3.341.531.711.4

5.76.5

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TABLE IXRelationship * between socioeconomic status and dietary practices (N = 336)

Socioeconomic status

GenderMenWomen

Marital statusSingleMarried

Age (years)25-2930-59

Eating out <food

Yes1

62.445.0

/xO.0001

72.343.6

p<0.0001

67.645.7

p< 0.0001

Chinese

No2

37.655.0

27.756.4

32.454.3

Take away friedchicken

Yes

24.811.2

p< 0.001

33.813.3

j7<0.0001

39.711.6

n<0.0001

No

75.288.8

66.28.7

60.389.4

Having dinner withfamily

Yes

75.276.5

49.282.2

/><0.0001

57.480.5

p< 0.0003

No

24.823.5

50.817.8

42.619.5

Taking vitaminsupplements

Yes1

34.948.7

/><0.05

36.943.9

42.646.7

No2

65.151.3

63.156.1

57.453.3

Oraoh5

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EducationCollege levelLess than collegelevel

Household monthlyincome (RM)Above 2,0002,000 and below

EmploymentSelf-employed andemployees

Not employed(housewives, students)

78.6

43.2p< 0.0001

76.942.7

p<0.05

52.1

39.2

*p value is shown for case where I2 is1 At least once a week.

21.4

56.8

23.157.3

47.9

60.8

significant.

39.3

12.9/xO.0001

23.114.1

17.5

16.5

60.7

87.1

76.985.9

82.5

83.5

55.4

80.0p< 0.0001

81.374.3

75.9

76.0

44.6

20.0

18.725.7

24.1

24.0

46.4

41.8

54.937.3

P<om

42.4

43.0

53.6

58.2

45.162.7

57.6

57.6

0fTiHO

d7>S3

r

nIINE

S

Pi

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484 G.L. KHORETAL.

dinner with family. The practice of having dinner with one'sfamily appears to be more influenced by socio-cultural factorsthan economic considerations.

Eating Out

Increased frequency of eating out and eating take away food arereflective of an urban lifestyle, especially of households withboth spouses working away from home. Ready-to-eat food areeasily available in urban areas in Malaysia from a wide range offood outlets ranging from expensive hotels and medium-pricedrestaurants to affordable road-side stalls. The respondents inthis study appear to eat out quite frequently especially forChinese food (Table X). More than one-quarter of them eat outChinese food more than once a week, while another 21.1% doso at least once a week. Nonetheless, about one-quarter of therespondents said they rarely eat out Chinese food. Meanwhileeating out non-Chinese food is not as frequently practiced.Three-quarters of the respondents reported that they seldom orrarely do so. Among those who do, almost all prefer westernfast food to foods of other ethnicities e.g. Malay and Indianfoods.

Eating take-away food is quite a common practice among therespondents. Almost half of the men and women eat take-awayfood more than once a week (Table XI). The popular types oftake-away food for the majority of the men are Chinese foodfollowed by western fast food such as fried chicken and burgers.

TABLE XFrequency of eating out (N = 336)

More than once a weekOnce a weekOnce a fortnightOnce a monthSeldomRarely

Chinese food

94 (28.0%)71 (21.1%)19 (5.7%)37(11.0%)26 (7.7%)89 (26.5%)

Non-Chinese food

18(5.4%)10 (3.0%)13 (3.9%)48 (14.3%)53 (15.8%)

194 (57.7%)

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DIET OF URBAN MALAYSIAN CHINESE 485

TABLE XI

Frequency of eating take-away foodMore than once a weekOnce a weekOnce a fortnightOnce a monthSeldomRarely

Types of take-away foodChinese foodFried chickenBurgersPizzasOthers

Male(N= 149)

70 (47.0%)10 (6.7%)6 (4.0%)9 (6.0%)

14 (9.4%)40 (26.9%)

89 (59.7%)37 (24.8%)33 (22.1%)11 (7.4%)27 (18.1%)

Female(N=187)

90 (48.1%)22(11.8%)

1 (0.5%)7 (3.7%)3 (1.6%)

64 (34.3%)

118(63.1%)21 (11.2%)9 (4.8%)7 (3.7%)

17 (9.2%)

Most of the women prefer Chinese food and to a lesser extentwestern fast food.

Gender, age, marital status and educational attainment of therespondents play a significant influence on the practice of eatingout (Table IX). Respondents who are male, single, younger es-pecially those below 30 years old, and possessing a higher edu-cational attainment tend to eat out Chinese food and take awayfried chicken frequently. As most of the men work outside thehome, it is probably more convenient for them to eat out. Eat-ing western fast food such as fried chicken is usually popularwith the younger age groups.

Discussion

This study based on a sample of urban Chinese indicates the per-sistence of several aspects of Chinese traditional dietary habits.One of these is the significant level of consumption of cereals andvegetables. Almost all eat rice daily and various types of noodlesweekly. Rice is eaten predominantly as steamed rice and occa-sionally as porridge. It constitutes the principal component (main

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486 G.L. KHOR ET AL.

dish) of a meal while the side dishes usually include vegetables,meat and fish. The subjects in this study consume a wide varietyof vegetables either daily or weekly. Vegetables are perceived asrich in nutrients and non-fattening. Pork, chicken and fresh fishare taken by the majority of the respondents at least on a weeklybasis. The average daily intake of fresh fish is note-worthy.

Another Chinese dietary custom that is adhered to amongthese respondents is the daily or weekly consumption of soup ofone kind or another. The soup complements the side dishes("t'sai") and together with the rice ("fan") constitute a whole-some family meal as elaborated in Hsu-Hage (1992).

Some of the dietary practices reported in this study appear toreflect a certain level of awareness for healthful food prepara-tions and preferences for food good for health. The majority ofthe respondents reported avoiding eating fat on meat; preferringfood that is cooked by steaming and stir frying rather than deepfrying (with the exception for chicken); adding salt lightly incooking, and most do not add sugar to tea or coffee, althoughthey do use sweetened condensed milk instead. There is a gen-eral awareness of the association between fatty foods and heartproblems and between sweet foods and diabetes.

The majority of both males (85.2%) and females (79.1%) con-sider their diet adequate and healthy. Could this be one of thefactors underlying the low prevalence of taking nutrient supple-ments among the respondents? Two-thirds of the men and halfof the women rarely or never take nutrient supplements. Takingnutrient supplements on a daily basis is reported by only 15.4%men and 24.1% women. Another factor may be because nutri-ent supplements are generally expensive in Malaysia as mostbrands are imported. This study found that taking nutrientsupplements regularly is found to be practised more amongstthe respondents with a higher income (Table IX).

The country-level data from the FAO food balance sheets forthe past decades indicates trends of an increased availability ofenergy from fat and decreased energy from cereals and vegeta-bles. These are characteristics of the dietary transition reported inrapidly developing countries such as China. The diet of theChinese in China is changing to one similar to the typical high-fat,

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DIET OF URBAN MALAYSIAN CHINESE 487

high-sugar diet of the west (Popkin et al., 1992; Chen, 1995).The percent of energy from fat and the proportion of meat inthe diet of the Chinese in China are expected to increase as in-come continues to increase.

The subjects in this study from the low to middle incomegroups do not appear to manifest a high-fat, high-meat diet.It is not necessarily because they cannot afford meat. InMalaysia, meat such as chicken and pork are relatively afford-able compared to fish. The finding appears to reflect a greaterpreference for cereals, vegetables and fish in general. The sub-jects also reported some encouraging dietary practices reflec-tive of an awareness of the relationships between diet andhealth. In the context of the evolving process of nutritionaltransition, dietary habits appear to be moving towards the"behavioural change" dietary pattern, amidst national-leveldata that point towards a "degenerative diseases" pattern inMalaysia.

Caution needs to be exercised in extrapolating these findingsto the general Chinese urban community. This study involved arelatively small sample size of urban Chinese from low to middleincome. Their "behavioural change" pattern observed may notnecessarily be prevalent among Malaysian Chinese from higherincome brackets, who are likely to show a more cosmopolitanlifestyle and dietary habits. The finding here may also not be re-flective of Chinese living in smaller towns where there is perhapsgreater food acculturation with other ethnic communities.

While much have been written on the nutritional status of thecommunities in the rural areas of Malaysia, there is relativelyless documentation on the nutritional situation in the urbancommunities. In the 1980s with the expansion of the squattersettlements in Kuala Lumpur, there were some studies on thehealth and nutritional status of these squatter settlements(Chee, 1989). In recent years, nutritional studies of urban popu-lation groups have begun to focus on the indicators related todegenerative diseases. Dietary studies are still lacking for thecountry as a whole and especially for the urban communities.Such data is imperative for the development of dietary guidelinesthat are sensitive to meet the needs of the general population as

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488 G.L.KHOR £T,4Z..

well as specific subgroups. A sufficient body of dietary informa-tion for various subgroups is needed towards ensuring the effec-tiveness and safety of dietary, recommendations (Harper, 1987).In the context of a multi-ethnic country such as Malaysia, sub-groups include not only various socio-economic categories butalso the different ethnic components.

ACKNOWLEDGEMENTS

The financial support provided by Palm Oil Research Institute of Malaysia(PORIM) is gratefully acknowledged. Appreciation is extended to Dr B.K. Nandi,Regional Food Policy and Nutrition Officer of FAO in Bangkok for theFood Balance Sheets (1992-94). Appreciation also goes to S.C. Heah, S.W. Teeand Wan Norizan for their assistance in data collection and analysis.

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Chen, C. (1995). Eating patterns—a prognosis for China. Asia Pacific J. Clin.Nutr. 4 (suppl. 1), 24-8.

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