Characteristics associated with the consumption of malted drinks among Malaysian primary school children: findings from the MyBreakfast study

Beverage consumption contributes to diet quality and overall nutrition [1]. Trends in beverage consumption among children have changed over the past several decades [2]. Nationally representative data from the United States (1977 – 2001) found that nutrient-poor beverages such as soft drinks have displaced more nutritious beverages such as milk among children [2, 3]. A large body of literature has sought to examine the relationship between health status and the consumption of beverages such as milk, fruit and vegetable juice, and sugar-sweetened beverages [4, 5]. These beverages have been linked to body weight status in a positive and/or negative manner across studies and beverage types [4, 5]. However, malted drinks, one of the most widely consumed beverages among children and adolescents in Asia [6, 7] have received limited attention.

Malted drinks are malt-based foods manufactured by mixing malt with other cereal and legume flour with or without whole milk or milk powder and/or cocoa powder [8]. Malted drinks are positioned as nutritious beverages in the market [8]. They are often marketed as containing various nutrients, such as carbohydrate, protein, fats, vitamin A, B, C and E, calcium, iron, phosphorus and potassium [8]. Nonetheless, there is a lack of published literature on malted drink consumption. A study from Singapore indicated that more than 50 % of children aged 7 to 10 years consumed malted drinks during weekdays and weekends [6]. A recent study from Malaysia demonstrated that combined circuit training with chocolate malt drink supplementation had a significant effect on reducing a bone resorption marker, which imposed positive effect on bone health [9]. To our knowledge, no epidemiological study has focused on examining the associations of malted drink consumption with nutritional status and lifestyle behaviour.

To address this gap in the literature, our study provides new evidence on malted drink consumption patterns and related characteristics using a nationally representative sample of Malaysian primary school children. We estimated the prevalence of malted drink consumption and explored the associations of sociodemographic characteristics, nutrient intakes, weight status, physical activity levels and screen time with malted drink consumption. Findings from the current study are important to determine which are the sociodemographic characteristics that relate to malted drink consumption, to understand whether and by how much the consumption of malted drinks by children contributes to them meeting nutrient requirements, and whether it is associated with healthier characteristics of children in Malaysia. Epidemiological data show that children of lower socioeconomic status consume diets of lower quality and are therefore less likely to meet nutritional requirements [10]. Thus, the data provided in the current study will inform the need for and the targeting of intervention programs around the consumption of malted drinks by Malaysian children.

A total of 9592 children were invited to participate in the study and 5785 agreed to take part, resulting in a response rate of 60.3 %. Of the 5785 children who agreed to take part, we only included those who had completed data for two days food record (n = 2998) or 24-h dietary recall (n = 2334) in this study. Out of 5332 children with completed dietary data, only 38.7 % of them were found to have acceptable reported dietary data, resulting in a final sample of 2065 children.

Table 1 shows the distribution of malted drink consumption status by participant characteristics. Overall, it was found that 73.5 % of children aged 6 to 12 years consumed malted drinks at least once per week. Percentage of malted drink consumption in both age groups were similar (74.1 % in children aged 6 to 9 years; 72.7 % in children aged 10 to 12 years). Univariate analysis revealed that malted drink consumption was significantly associated with regions (χ ²  = 45.64 p < 0.001), gender (χ ²  = 4.41, p = 0.036), ethnicity (χ ²  = 13.74, p = 0.008) and physical activity levels (χ² = 6.92, p = 0.031). Screen time during weekends was found to be higher among malted drink non-consumers than consumers (m = 4.44 vs. 4.11 h, p = 0.020). No significant differences in malted drink consumption were shown across area, household income and weight status.

Table 2 shows the distribution of median daily intake (g/day) of malted drinks according to the various socio-demographic, behavioural and weight status characteristics. The highest median daily intake of malted drinks was found among children from the East Coast region of Malaysia (M = 30.0 g) and this was significantly higher than among children from the other regions in Malaysia. Among children aged 6 to 9 years, the median intake of malted drinks in the rural area was significantly higher than the urban area (M = 22.4 g vs. 19.1 g respectively, p < 0.001). Also, 6 to 9 year-old children who were overweight had the highest median intake of malted drinks (p = 0.019). No significant differences in the median intake of malted drinks were observed across gender, ethnic groups, household income and physical activity levels. A larger amount of malted drinks were consumed during weekends compared to weekdays.

Table 3 presents the comparison of median daily energy and nutrient intakes between malted drink consumers and non-consumers among different age groups. Malted drink consumers were found to have similar daily intakes of energy, protein, fat, sodium and vitamin D, but significantly higher intakes of vitamin C, thiamin, riboflavin, niacin, calcium, iron and phosphorus compared to non-consumers in both age groups. A larger daily carbohydrate intake was observed in malted drink consumers compared to non-consumers among children aged 10 to 12 years (M = 227.21 g vs. 216.21 g respectively, p = 0.023). Larger proportions of malted drink consumers were found to meet the RNI for total energy intake, protein, vitamin A, vitamin C, thiamin, riboflavin, niacin, calcium and iron as compared to non-consumers. More than 90 % of children from both groups did not meet the RNI for vitamin D (Table 4).

Table 5 shows the association of BAZ, physical activity level and screen time with malted drink consumption. There were no significant associations between BAZ and malted drink consumption in either age group. Physical activity level and screen time during weekends were independently associated with malted drink consumption among 6 to 9 year-old children. Children who participated in high physical activity levels had significantly higher odds for consuming malted drinks than those who were involved in low physical activity levels (OR = 1.77, 95 % CI = 1.06, 2.99). Children who spent more time on watching television or using computer had significantly lower odds for consuming malted drinks (OR = 0.93, 95 % CI = 0.87, 1.00).

The present study is one of the first to examine malted drink consumption and associated factors among Malaysian primary school children. Nationally, 73.5 % of children reported consuming malted drinks at least once a week. Boys, indigenous children, and those who lived in the East Coast region of the country had a higher prevalence of malted drink consumption. In addition, malted drink consumers were found to have similar total daily energy intake but higher daily micronutrient intakes compared to non-consumers. High physical activity level and less screen time were associated with greater likelihood of malted drink consumption after adjustment for region, area, gender, ethnicity and household income. No association was observed between malted drink consumption and weight status among children.

There was a differential effect of gender on malted drink consumption among the younger age group of children only. This might reflect gender differences in food preferences [21] and parental influences on food choices in the early childhood stage [22]. Higher prevalence of malted drink consumption among indigenous people could be attributed to the implementation of the Malaysian Food Basket programme [23]. Malted drinks are included as one of the food items in this programme and are received by a majority of the indigenous people due to food insecurity. From this aspect, malted drinks could be perceived as healthy by indigenous parents and therefore, encouraged amongst their children. A study from the United States showed that consumption of beverages such as sports and energy drinks were more prevalent in higher income populations [24]. Another study from Canada reported that consumption of soft drinks and fruit juices were more prevalent in lower socio-economic status population as determined based on education, household income and employment status [25]. However, our results did not show any association between malted drink consumption and household income. This finding may be potentially explained by the acceptable price range of malted drinks in the market.

Our study revealed that total daily energy intake was comparable between malted drink consumers and non-consumers, and no association was found between malted drink consumption and weight status. These findings suggest that malted drink consumption did not contribute to positive energy balance and weight gain during childhood. This is in contrast to the findings from other studies which examined the association between sugar-sweetened beverages and body weight. A review article from the United States concluded that consumption of sugar-sweetened beverages promoted excess energy intake and reducing the intake of these beverages had beneficial effects on body weight [26]. On the other hand, a study from Australia reported that milk consumption among children was not associated with adverse effects on body weight measures [27]. The possible explanation can be the differential effects on satiety due to nutritional and sensorial differences between beverages [28]. Our findings support the literature around the lack of satiety of more liquid beverages such as soft drinks and greater satiety of more viscous beverages such as milk to protect against overweight [28]. It seems likely that malted drinks may be considered as more viscous beverages which may have high satiation and fullness effects, hence do not contribute to overconsumption, excess energy intake then to weight gain [29].

Children who consumed malted drinks generally had greater micronutrient intakes than non-consumers. Furthermore, malted drink consumers were more likely to meet the RNI for total energy intake, protein, vitamin A, vitamin C, thiamin, riboflavin, niacin, calcium and iron. These findings suggest that malted drink consumption can be an effective and simple dietary strategy to improve overall diet quality. However, we recognize that there is a possibility of other food choices that might drive the association with greater micronutrient intakes among the malted drink consumers, and this warrants further investigation. In the current market, most malted drinks are fortified with multiple micronutrients [8] and as such, they are commonly used as multivitamin supplementation products in several intervention studies [9, 30]. An improvement in micronutrient status of thiamin, riboflavin, niacin, vitamin C and iron were reported among 7 to 10 year-old Indian children after supplementation with fortified chocolate malt drinks [30], which is consistent with our findings. However, low vitamin D intake was prevalent in all children, suggesting that malted drinks and most other foods consumed by the children are poor sources of vitamin D. As reported by Khor et al. (2011) [31], only a few foods in Malaysia have been fortified with vitamin D. This explains the low intake of vitamin D among children which is supported by high prevalence of serum vitamin D deficiency in previous studies [31, 32]. It is possible that malted drinks could be fortified with vitamin D and used as one of the medium to improve children’s vitamin D status.

It has been reported that sedentary behaviour and extended periods of media use are associated with less healthy food preferences [25, 33]. However, our study found that high physical activity level and less screen time were associated with greater likelihood of malted drink consumption. These associations were only shown to be statistically significant among children aged 6 to 9 years, revealing the importance of life stage factors. An intervention study demonstrated that fortified chocolate malt drink supplementation improved physical performance measures in Indian children aged 7 to 10 years [30]. Our study indicated that malted drink consumption was linked with physically active behaviour in younger children, suggesting this group of children or parents may perceive malted drinks as healthful beverages. The parental and children’s perceptions on the health benefits of malted drinks may be further influenced by the malted drink advertisements which show pictures of athletes on the packaging and in mass media in Malaysia.

There are several limitations of this study that should be acknowledged. Many participants were excluded due to incomplete dietary information and misreporting of dietary data, and therefore generalizability of the findings may be limited. Only two days of 24-h dietary recalls or records were collected and this may not reflect habitual consumption patterns. Fluctuation of food intakes from day to day may lead to misclassification of participants according to malted drink consumption (i.e. those who reported no malted drink consumption during the past 24 h may not imply that they did not consume it at all). Different nutritional assessment methods were used between age groups, though the study attempts to orient the respondent to recall/record the food accurately, nevertheless, under or over report may occurs and not reflecting actual food intake. In addition, parental reports of dietary intake may be subjected to errors if the children attended day care. Moreover, data on vitamin D intake should be interpreted cautiously. Values of vitamin D were obtained from nutrition information panels only which could lead to under-estimation. This is due to the unavailability of vitamin D content information in the Malaysian Food Composition database. Nevertheless, it highlights an important issue and concern about dietary vitamin D deficiency in our population. Ultimately, the cross-sectional nature of study design restricted our ability to establish causal inferences. It has been proposed that the relation between food intake and body weight may vary with different life stages due to alterations in physiological development, social and environmental factors [34]. Therefore, longitudinal studies are required to assess malted drink consumption pattern over time and health outcomes. Despite these limitations, the current study is important to provide valuable information to public health efforts targeting consumption of nutritious beverages.

In conclusion, malted drink consumption is prevalent among Malaysian primary school children, particularly among boys, indigenous children and those who lived in the East Coast region of Malaysia. It was found that malted drink consumers had better micronutrient intakes and were more physically active than non-consumers of malted drinks. There was no observed association between malted drink consumption and weight status. These findings suggest that malted drinks are a micronutrient-rich beverage which are unlikely to promote excess energy intake and obesity risk, at the consumption pattern in the population assessed.