• Cause: Inadequate iron intake, chronic blood loss (e.g. menstruation, gastrointestinal bleeding), or increased demand (e.g. pregnancy, growth).

• Mechanism: Iron is required for haemoglobin synthesis; deficiency leads to reduced haemoglobin production and smaller (microcytic), paler (hypochromic) red blood cells.

2. Folate Deficiency Anaemia

• Cause: Poor dietary intake (common in malnutrition or alcoholism), malabsorption (e.g. coeliac disease), or increased requirement (e.g. pregnancy, haemolysis).

• Mechanism: Folate is essential for DNA synthesis during red blood cell formation; deficiency leads to impaired cell division, resulting in large, immature (megaloblastic) red cells.

3. Anaemia of Chronic Disease (ACD)

• Cause: Chronic infections, inflammation (e.g. rheumatoid arthritis), or malignancy.

• Mechanism: Inflammatory cytokines cause reduced iron availability (via increased hepcidin), decreased erythropoietin production, and impaired bone marrow response — leading to normocytic or microcytic anaemia.

4. Anaemia due to Multiparity

• Cause: Repeated pregnancies increase maternal iron and folate requirements, often exceeding dietary intake.

• Mechanism: Frequent pregnancies deplete iron and folate stores faster than they can be replenished, leading to combined iron and folate deficiency anaemia.

Furthermore, infants born to anaemic mothers often have lower iron stores, predisposing them to infant anaemia after birth. This can lead to impaired growth, delayed motor skills, and reduced cognitive development, affecting learning ability and overall health throughout childhood. In severe cases, chronic oxygen deprivation can even impact brain development, contributing to long-term neurological and behavioural issues.

1. Common Nutrient Deficiencies During Pregnancy

Pregnancy significantly increases the body’s demand for nutrients to support both maternal health and fetal development. Nutritional deficiencies are one of the major causes of maternal anaemia and poor pregnancy outcomes, especially among low-income women (B40 group).(1)

a. Iron Deficiency
Iron deficiency is the most common nutritional deficiency in pregnant women. It occurs when iron intake is insufficient to meet the increased demand for haemoglobin synthesis. Iron-deficiency anaemia leads to fatigue, reduced immunity, and an increased risk of preterm birth and low birth weight.

b. Folate Deficiency
Folate (vitamin B9) is essential for DNA synthesis and neural tube formation in the developing fetus. Folate deficiency during early pregnancy increases the risk of neural tube defects such as spina bifida. In Malaysia, folic acid supplementation is routinely recommended for all pregnant women.

c. Protein Deficiency
Protein is required for the growth of fetal tissues, placenta, and maternal blood volume expansion. Insufficient protein intake can cause intrauterine growth restriction and low birth weight. Low-income families may struggle to afford high-quality protein sources such as red meat or fish.

d. Other Micronutrients
Deficiencies in calcium, vitamin D, and vitamin B12 are also common. These nutrients play vital roles in bone formation, energy metabolism, and red blood cell production.

Low-cost food choice

benefit

iron

anchovies , chicken liver, spinach, legumes

Prevent anemia, support oxygen transport

Folate 

Dark leafy greens (kangkung), fortified rice

Prevent neural tube defects, support cell division

Protein 

Egg, tofu, tempeh

Support tissue repair and fetal growth

Calcium 

Sardine, tofu, fortified milk powder

Strengthens bones and teeth

Vitamin C

Guava, papaya, orange

Enhance iron absorption and boost immunity

These meals typically include:

• A carbohydrate source (rice or noodles)
  
  

• A protein source (chicken, fish, or tofu)
  
  

• Vegetables and fruits
  
  

This not only helps low-income individuals meet their daily nutrient needs but also raises public awareness about affordable healthy eating habits.

Other relevant government programs include:

• PeKa B40: Provides free health screening and nutrition counselling.
  
  

• Klinik Kesihatan (MOH clinics): Offer free or low-cost prenatal check-ups and supplements (iron and folic acid tablets).
  
  

• Subsidised Food Programs: Some states provide fortified rice or milk for pregnant and lactating mothers.

References 

1.https://pmc.ncbi.nlm.nih.gov/articles/PMC8988411/ 

2.https://hq.moh.gov.my/nutrition/wp-content/uploads/2024/08/01.Buku-MDGM-web_02.08.2024.pdf

3.https://www.kpdn.gov.my/en/faq/menu-rahmah-programme

For example, folic acid which is also known as Vit B9, is required for DNA replication. Thus, we need to explain to the public about the function of folic acid which is important for growth and development of the fetus. 

Besides the folic acid, iron also plays an important role in the production of hemoglobin, which functions in the delivery of oxygen from the lungs to the tissues of the foetus.

In this case, the reason Puan ST is diagnosed with anaemia might be due to the lack of knowledge of the importance of those nutrients. 

• Limited low-wage jobs (construction, manual labor)

• Job insecurity (seasonal/temporary)

• Few opportunities for career advancement

2. Working Hours

• Long, irregular hours leave little time for healthcare or family

• Physical strain impacts health

• Lack of flexibility for medical appointments

3. Construction Labor Wages

• Low pay, not enough for basic needs

• Income instability due to seasonal work

• No benefits (health insurance, paid leave)

4. Impact on SES

• Traps family in poverty, limits healthcare & education access

• Poor health outcomes due to financial strain

• Intergenerational poverty cycle

- Competing needs: Her income is mostly spent on daily essentials such as food, housing, and children’s school expenses. In this situation, healthcare costs are often seen as less urgent compared to immediate survival needs.

HIES 2022 provides percentile distributions → more precise way to analyse income spread within B40.

- Higher educational attainment often leads to better-paying jobs (or higher income status). With higher income, people can afford better healthcare (private clinics/hospitals), more frequent check-ups, medicines, healthier food, better living conditions, etc.

- Income also affects geographic accessibility: those with higher income can live nearer to good healthcare facilities, or afford transportation to reach them. Poorer/less-educated individuals often live in rural or under-served areas, where healthcare quality is poorer, fewer specialists are available and waiting times are longer.

- In 2024, ProtectHealth’s PeKa B40 scheme screened 301,650 individuals from the B40 group; about 70% had at least one NCD such as diabetes, hypertension, high cholesterol, or obesity. From the same group: ~25% had two or more NCDs. Also, 4.38% had three NCDs.

- Those from low SES may drop out earlier (for economic reasons), may not have the same exposure to mentoring, extra-curriculars, or options to pursue tertiary education.

- Educational attainment in turn affects what kinds of jobs one is eligible for (skill level, qualification requirement). Low-SES people may end up in low-skill / informal / unstable jobs with low wages.

- From the 12th Malaysia Plan and other strategy papers: Malaysia aims to increase the percentage of B40 households with tertiary educational attainment from 9% in 2014 to 20% in 20

20.

- Expand health protection schemes like PeKa B40 (screening, subsidised services, medical equipment)

- MySalam scheme (one-time payouts for critical illness, hospitalisation) to reduce out-of-pocket risk for B40.

- Subsidies to reduce cost of living, cash aids (e.g. Sumbangan Tunai Rahmah) to increase disposable income for B40. These reduce financial barriers to accessing healthcare (costs, transport, time)

B. Education / Human Capital

- Improve access to quality education for low-income households (scholarships, tuition help, mentorship) so that more can attain tertiary or technical/vocational education.

- Expand and improve Technical & Vocational Education and Training (TVET) to match industry demand, enabling quicker entry into decent paying jobs.

C. Expand mobile clinics / outreach services in rural / under-served regions.

- Subsidised or free screening, preventive services for B40 (e.g. through PeKa B40).

- Contracting private clinics to provide basic services for B40/M40 under government schemes (e.g. Skim Perubatan MADANI).

We will be comparing in different categories:
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- better access to resources like nutritious food, quality healthcare, and safer living conditions that are facilitated by higher disposable income and social status.

- economic hardships that can lead to poor health outcomes and shorter life expectancies

Example: states with higher income (higher GDP per capita) have higher life expectancies. For example, Selangor has one of the highest in the country (~78.0 yrs) and poorer states like Terengganu, Kelantan, Perlis are lower (~72-73 yrs).

- lower physical activity levels, mainly due to limited access to recreational spaces, long working hours, and unsafe environments.

- higher income have better access to exercise facilities, such as membership to the gymnasium.

- create opportunities for them to buy their own health equipment, which contributes to more PA.

- may spend more time in their workplace

- not have the time to increase PA

Diet:

- cheaper, energy-dense foods high in refined carbohydrates and saturated fats, and consume fewer fruits and vegetables

- increasing NCD risk

- more dietary diversity and higher intake of nutrient-rich foods, reducing chronic disease prevalence.

- lead to hypertension, obesity, and diabetes

- conditions that lower life expectancy, especially in low-income groups

Mental health:

- The NHMS 2019 reported that 42% of low-income adults experienced symptoms of depression or anxiety, compared with 22% among higher-income adults.

Occupational risks:

- more frequently employed in manual or high-risk sectors (construction, manufacturing, agriculture), exposing them to heat stress, dust, noise, and chemical hazards

- T20 employees are more often in office-based, lower-risk jobs.

- The Department of Occupational Safety and Health (DOSH) Annual Report 2023 reported the highest rate of workplace accidents in manufacturing and construction sectors—industries dominated by lower-income workers.

- Higher socioeconomic status might lead to increased use of dietary supplements.

- The Ministry of Health (MOH) leverages #SihatMalaysia and #KitaJagaKita social media campaigns

- promote mental health, vaccination, and healthy lifestyle habits, particularly targeting youth and lower-income audiences.

2. Community-Based Initiatives (KOSPEN)

- The Komuniti Sihat Perkasa Negara (KOSPEN) program

- recruits volunteers from local communities

- promote healthy living through blood pressure checks, BMI monitoring, nutrition, education and smoking cessation.

3. Role of NGOs and Peer Outreach

- NGOs such as MERCY Malaysia and Women’s Aid Organisation (WAO)

- provide outreach on nutrition, reproductive health, and psychosocial support, especially for B40 and rural populations.

- bridging information gaps and encouraging preventive health behaviors.