Perceptions, attitudes and beliefs towards soya among healthy Asian women participating in a soya randomised controlled trial

The soya-breast cancer risk relationship remains controversial in Asia due to limited and inconsistent research findings and is exacerbated by difficulties in recruiting and retaining participants in intervention trials. Understanding public perceptions towards soya is important for designing effective intervention trials. Here, we administered a close-ended, quantitative survey to healthy, peri- and post-menopausal Asian women in the Malaysian Soy and Mammographic Density (MiSo) Study to assess perception towards soya and explore motivators and barriers that affect study adherence using the Capability, Opportunity, Motivation and Belief (COM-B) Model and Theoretical Domains Framework (TDF). Of 118 participants, the majority reported the belief that soya promotes good health (Supplement = 85⋅7 %, Diet = 90⋅0 %, Control = 87⋅9 %). Most participants reported obtaining information about soya from the internet (Supplement = 61⋅0 %, Diet = 55⋅3 %, Control = 35⋅9 %), while health professionals were least reported (Supplement = 9⋅8 %, Diet = 7⋅9 %, Control = 5⋅1 %). Stratified analyses by study completion and adherence status yielded comparable findings. By the end of the study, dietary arm participants reported a strong belief that soya has no impact on their health (Supplement = 7⋅1 % v. Diet = 20⋅0 % v. Control = 0⋅0 %, P = 0⋅012). Motivation and opportunity strongly facilitated soya consumption, while psychological capability was the most common barrier to consumption though less evident among dietary arm participants. While most Asian women have a positive perception towards soya, theory-based intervention trials are warranted to understand the perception-study adherence relationship and to accurately inform the public of the health effects of soya.

Abstract P2-06-02: A randomized controlled trial of soy isoflavone intake on mammographic density among Malaysian women

Introduction: Soy intake is associated with lower breast cancer risk in observational studies of Asian women, but clinical trials of soy isoflavone (ISF) supplements report no effect on biomarkers of breast cancer risk among Caucasian women. To date, there are no such trials among Asian women living in Asia. We conducted a three-armed, randomized controlled trial (RCT) to assess the effects of one-year intervention of soy isoflavone supplements (100mg/day) or soy isoflavones through diet (50mg/day) on mammographic density (MD) change among peri- and postmenopausal Malaysian women. Methodology: Healthy women between 45-65 years old were enrolled between November 2018 and December 2019 at a private tertiary hospital in Malaysia. Women were randomly assigned into the 100mg/day ISF Supplement arm, 50mg/day ISF Diet arm, or Control arm. Dense area was assessed from digital mammograms conducted at enrolment and after 12 months. We compared absolute and relative change in dense area over the study period by study arm using Kruskal Wallis tests. Results: Of the 118 women who received the intervention, 91 women completed the study whilst 27 women (23%) were lost to follow up. After 12 months of intervention, women in the ISF Supplement arm observed a marginally larger decline in dense area (-1.3cm2), compared to women in the ISF Diet arm (-0.5cm2) and Control arm (-0.8cm2), but this difference was not statistically significant (p=0.479). Notably, these effects appear to be stronger and limited to women who enrolled within 5 years of menopause, where up to 6cm2 decline in MD was observed in the ISF Supplement arm, compared to < 1.0cm in the Control arm (p=0.131). Conclusion: This RCT demonstrates a possible causal association between soy ISF intake and lower breast cancer risk among Asian women, specifically around the time of menopause, but these findings will require confirmation in a larger trial.

Citation Format: Nadia Rajaram, Beverley Yap, Mikael Eriksson, Shivaani Mariapun, Lee Mei Tan, Hamizah Saat, Evelyn Ho, Nur Aishah Mohd Taib, Geok Lin Khor, Cheng Har Yip, Weang Kee Ho, Per Hall, Soo Hwang Teo. A randomized controlled trial of soy isoflavone intake on mammographic density among Malaysian women [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-06-02.

A Randomized Controlled Trial of Soy Isoflavone Intake on Mammographic Density among Malaysian Women

Soy intake is associated with lower breast cancer risk in observational studies concerning Asian women, however, no randomized controlled trials (RCT) have been conducted among Asian women living in Asia. This three-armed RCT assessed the effects of one-year soy isoflavone (ISF) intervention on mammographic density (MD) change among healthy peri- and postmenopausal Malaysian women. This study was registered at ClinicalTrials.gov (NCT03686098). Participants were randomized into the 100 mg/day ISF Supplement, 50 mg/day ISF Diet, or control arm, and assessed for change in absolute and relative dense area from digital mammograms conducted at enrolment and after 12 months, compared over time across study arms using Kruskal-Wallis tests. Out of 118 women enrolled, 91 women completed the intervention, while 27 women (23%) were lost in follow up. The ISF supplement arm participants observed a larger decline in dense area (−1.3 cm2), compared to the ISF diet (−0.5 cm2) and control arm (−0.8 cm2), though it was not statistically significant (p = 0.48). Notably, among women enrolled within 5 years of menopause; dense area declined by 6 cm2 in the ISF supplement arm, compared to <1.0 cm2 in the control arm (p = 0.13). This RCT demonstrates a possible causal association between soy ISF intake and MD, a biomarker of breast cancer risk, among Asian women around the time of menopause, but these findings require confirmation in a larger trial.

The Amount of Folic Acid in Weekly Iron-Folic Acid Supplements Should Be Increased From 0.4 to 2,8 mg to Reduce Neural Tube Defects (NTD)

Objectives

Weekly iron–folic acid (IFA) supplements are recommended for all menstruating women in countries where anaemia prevalence is > 20%. Anaemia caused by folate deficiency is low worldwide, and the need to include folic acid is in question. Including folic acid might reduce the risk of a neural tube defect (NTD) should a woman become pregnant. Most weekly supplements contain 0.4 mg folic acid; however, WHO recommends 2.8 mg because it is seven times the daily dose effective in reducing NTDs. There is a reluctance to switch to supplements containing 2.8 mg of folic acid because of a lack of evidence that this dose would prevent NTDs. Our aim was to investigate the effect of two doses of folic acid, compared with placebo, on red blood cell (RBC) folate, a biomarker of NTD risk.

Methods

We conducted a three-arm double-blind efficacy trial in Malaysia. Non-pregnant women (n = 331) were randomized to receive 60 mg iron and either 0, 0.4, or 2.8 mg folic acid once weekly for 16 weeks.

Results

At 16 weeks, women receiving 0.4 mg and 2.8 mg folic acid per week had a higher mean RBC folate than those receiving 0 mg (mean difference (95% CI) 84 (54 to 113) and 355 (316 to 394) nmol/L, respectively). Women receiving 2.8 mg folic acid had a mean RBC folate 271 (234 to 309) nmol/L greater mean RBC folate than those receiving 0.4 mg. Moreover, women in the 2.8 mg group were seven times (RR 7.3, 95% CI 3.9 to 13.7) more likely to achieve an RBC folate > 748 nmol/L, a concentration associated with a low risk of NTD, compared with the 0.4 mg group.

Conclusions

IFA supplements containing 2.8 mg folic acid increases RBC folate more than those containing 0.4 mg. Increased availability and access to the 2.8 mg formulation is needed.

Funding Sources

Nutrition International (Ottawa, Ontario).

The Inclusion of Folic Acid in Weekly Iron-Folic Acid Supplements Confers no Additional Benefit on Anemia Reduction in Nonpregnant Women: A Randomized Controlled Trial in Malaysia

BACKGROUND

Weekly iron-folic acid (IFA) supplements are recommended for all menstruating women in countries where anemia prevalence is ≥20%; however, it is unknown whether the inclusion of folic acid in weekly IFA supplements reduces anemia.

OBJECTIVES

We examined whether the inclusion of folic acid in weekly IFA supplements conferred any benefit on hemoglobin (Hb) concentration, anemia reduction, or iron status [ferritin and soluble transferrin receptor (sTfR)], over iron alone.

METHODS

In this secondary analysis of a randomized controlled trial in Malaysia, n = 311 nonpregnant women (18-45 y old) received 60 mg Fe with either 0, 0.4, or 2.8 mg folic acid once-weekly for 16 wk. Fasting blood was collected at baseline and 16 wk. A generalized linear model (normal distribution with identity link) was used to assess Hb concentration at 16 wk (primary outcome).

RESULTS

At baseline, 84% of women had low folate status (plasma folate < 14 nmol/L). At 16 wk, marginal mean (95% CI) Hb was 131 (130, 133), 131 (129, 132), and 132 (130, 133) g/L; ferritin was 58.2 (53.9, 62.5), 56.5 (52.2, 60.9), and 58.0 (53.7, 62.3) μg/L; and sTfR was 5.8 (5.5, 6.1), 5.8 (5.5, 6.1), and 5.9 (5.6, 6.2) mg/L in the 0, 0.4, and 2.8 mg/wk groups, respectively, with no differences between groups (P > 0.05). Baseline plasma folate concentration did not modify the effect of treatment on Hb concentration at 16 wk. Among all women, the risks of anemia [risk ratio (RR): 0.65; 95% CI: 0.45, 0.96; P = 0.03] and iron deficiency based on ferritin (RR: 0.30; 95% CI: 0.20, 0.44; P < 0.001) were lower at 16 wk than at baseline.

CONCLUSIONS

Despite the low folate status among these nonpregnant Malaysian women, the inclusion of folic acid in weekly IFA supplements did not reduce anemia or improve iron status, over iron alone. However, the benefits of folic acid for neural tube defect prevention still warrant its retention in weekly IFA supplements.This trial was registered at www.anzctr.org.au as ACTRN12619000818134.

Weekly iron-folic acid supplements containing 2.8 mg folic acid are associated with a lower risk of neural tube defects than the current practice of 0.4 mg: a randomised controlled trial in Malaysia

Introduction

Weekly iron–folic acid (IFA) supplements are recommended for all menstruating women in countries where anaemia prevalence is >20%. Anaemia caused by folate deficiency is low worldwide, and the need to include folic acid is in question. Including folic acid might reduce the risk of a neural tube defect (NTD) should a woman become pregnant. Most weekly supplements contain 0.4 mg folic acid; however, WHO recommends 2.8 mg because it is seven times the daily dose effective in reducing NTDs. There is a reluctance to switch to supplements containing 2.8 mg of folic acid because of a lack of evidence that this dose would prevent NTDs. Our aim was to investigate the effect of two doses of folic acid, compared with placebo, on red blood cell (RBC) folate, a biomarker of NTD risk.

Methods

We conducted a three-arm double-blind efficacy trial in Malaysia. Non-pregnant women (n=331) were randomised to receive 60 mg iron and either 0, 0.4, or 2.8 mg folic acid once weekly for 16 weeks.

Results

At 16 weeks, women receiving 0.4 mg and 2.8 mg folic acid per week had a higher mean RBC folate than those receiving 0 mg (mean difference (95% CI) 84 (54 to 113) and 355 (316 to 394) nmol/L, respectively). Women receiving 2.8 mg folic acid had a 271 (234 to 309) nmol/L greater mean RBC folate than those receiving 0.4 mg. Moreover, women in the 2.8 mg group were seven times (RR 7.3, 95% CI 3.9 to 13.7; p<0.0001) more likely to achieve an RBC folate >748 nmol/L, a concentration associated with a low risk of NTD, compared with the 0.4 mg group.

Conclusion

Weekly IFA supplements containing 2.8 mg folic acid increases RBC folate more than those containing 0.4 mg. Increased availability and access to the 2.8 mg formulation is needed.

Trail registration number

This trial is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12619000818134).

Temporal Changes in Breast Milk Fatty Acids Contents: A Case Study of Malay Breastfeeding Women

The composition of human breast milk changes in the first two months of life, adapting itself to the evolving needs of the growing new-born. Lipids in milk are a source of energy, essential fatty acids (FA), fat-soluble vitamins, and vital bioactive components. Information on breast milk FA of Malaysian lactating women is scarce. Based on convenience sampling, a total of 20 Malay breastfeeding women who fulfilled the inclusion criteria were recruited. Breast milk was collected three times from each subject at consecutive intervals of 2–3 weeks apart. A total of 60 breast milk samples were collected and classified into “transitional milk” (n = 8), “early milk” (n = 26) and “mature milk” (n = 26). All milk samples were air freighted to University of Groningen, Netherlands for analysis. The dominant breast milk FA were oleic acid, constituting 33% of total fatty acids, followed by palmitic acid (26%). Both these FA and the essential FA, linoleic acid (10%) and alpha-linolenic acid (0.4%), showed no significant changes from transitional to mature milk. Breast milk ratio of n-6:n-3 polyunsaturated fatty acids (PUFA) was comparatively high, exceeding 10 throughout the lactation period, suggesting a healthier balance of PUFA intake is needed in pregnancy and at postpartum.

Association between long-term exposure to ambient air pollution and prevalence of diabetes mellitus among Malaysian adults

Background

Malaysia has the highest rate of diabetes mellitus (DM) in the Southeast Asian region, and has ongoing air pollution and periodic haze exposure.

Methods

Diabetes data were derived from the Malaysian National Health and Morbidity Surveys conducted in 2006, 2011 and 2015. The air pollution data (NO_x, NO₂, SO₂, O₃ and PM₁₀) were obtained from the Department of Environment Malaysia. Using multiple logistic and linear regression models, the association between long-term exposure to these pollutants and prevalence of diabetes among Malaysian adults was evaluated.

Results

The PM₁₀ concentration decreased from 2006 to 2014, followed by an increase in 2015. Levels of NO_x decreased while O₃ increased annually. The air pollutant levels based on individual modelled air pollution exposure as measured by the nearest monitoring station were higher than the annual averages of the five pollutants present in the ambient air. The prevalence of overall diabetes increased from 11.4% in 2006 to 21.2% in 2015. The prevalence of known diabetes, underdiagnosed diabetes, overweight and obesity also increased over these years. There were significant positive effect estimates of known diabetes at 1.125 (95% CI, 1.042, 1.213) for PM₁₀, 1.553 (95% CI, 1.328, 1.816) for O₃, 1.271 (95% CI, 1.088, 1.486) for SO₂, 1.124 (95% CI, 1.048, 1.207) for NO₂, and 1.087 (95% CI, 1.024, 1.153) for NO_x for NHMS 2006. The adjusted annual average levels of PM₁₀ [1.187 (95% CI, 1.088, 1.294)], O₃ [1.701 (95% CI, 1.387, 2.086)], NO₂ [1.120 (95% CI, 1.026, 1.222)] and NO_x [1.110 (95% CI, 1.028, 1.199)] increased significantly from NHMS 2006 to NHMS 2011 for overall diabetes. This was followed by a significant decreasing trend from NHMS 2011 to 2015 [0.911 for NO₂, and 0.910 for NO_x].

Conclusion

The findings of this study suggest that long-term exposure to O₃ is an important associated factor of underdiagnosed DM risk in Malaysia. PM₁₀, NO₂ and NO_x may have mixed effect estimates towards the risk of DM, and their roles should be further investigated with other interaction models. Policy and intervention measures should be taken to reduce air pollution in Malaysia.

Effect of once weekly folic acid supplementation on erythrocyte folate concentrations in women to determine potential to prevent neural tube defects: a randomised controlled dose-finding trial in Malaysia

INTRODUCTION

Folic acid (0.4 mg) taken prior to and during early pregnancy reduces the risk of neural tube defects (NTDs). Because these birth defects occur early in pregnancy, before women may know they are pregnant, many countries have mandated the addition of folic acid to food staples. In countries where fortification is not possible, and weekly iron folic acid programmes exist to reduce anaemia, the WHO recommends that 2.8 mg (7×0.4 mg) folic acid be given instead of the current weekly practice of 0.4 mg. Currently, there is a lack of evidence to support if the 2.8 mg folic acid per week dose is sufficient to raise erythrocyte folate concentrations to a level associated with a reduced risk of a NTD-affected pregnancy. We aim to conduct a three-arm randomised controlled trial to determine the effect of weekly folic acid with iron on erythrocyte folate, a biomarker of NTD risk.

METHODS AND ANALYSIS

We will recruit non-pregnant women (n=300; 18-45 years) from Selangor, Malaysia. Women will be randomised to receive either 2.8, 0.4 or 0.0 (placebo) mg folic acid with 60 mg iron weekly for 16 weeks, followed by a 4-week washout period. The primary outcome will be erythrocyte folate concentration at 16 weeks and the mean concentration will be compared between randomised treatment groups (intention-to-treat) using a linear regression model adjusting for the baseline measure.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of British Columbia (H18-00768) and Universiti Putra Malaysia (JKEUPM-2018-255). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBERS

ACTRN12619000818134 and NMRR-19-119-45736.

Do not neglect the indigenous peoples when reporting health and nutrition issues of the socio-economically disadvantaged populations in Malaysia

The purpose of this correspondence is to express our disappointment with the coverage of the BMC Public Health supplement: Vol 19 (4) titled “Health and Nutritional Issues Among Low Income Population in Malaysia”, which neglected to include the fundamental health and nutrition issues that are adversely affecting the lives and livelihood of the indigenous peoples. The Supplement comprised 21 papers. Two of these papers included indigenous peoples as study subjects. These two papers addressed peripheral, albeit important health issues, namely visual impairment and quality of life, and not the persistent and rising health concerns impacting this population. We will provide evidence from research and reports to justify our critique that the Supplement missed the opportunity to spotlight on the serious extent of the health and nutritional deprivations of the indigenous peoples of Malaysia. As researchers of the indigenous peoples, we ought to lend our voice to the “silenced minority” by highlighting their plight in the media including scientific journals.

Suboptimal Biochemical Riboflavin Status Is Associated with Lower Hemoglobin and Higher Rates of Anemia in a Sample of Canadian and Malaysian Women of Reproductive Age

BACKGROUND

Riboflavin is required for several redox reactions. Clinical riboflavin deficiency occurs mainly in low-income countries, where it is associated with anemia. The functional significance of suboptimal riboflavin status in different populations and its role in anemia is not well understood.

OBJECTIVES

We assessed the biomarker status of riboflavin and its association with hemoglobin concentration and anemia in women living in Vancouver, Canada, and Kuala Lumpur, Malaysia.

METHODS

Healthy nonpregnant, nonbreastfeeding women (19-45 y) were recruited from Canada ( n = 206) and Malaysia (n = 210) via convenience sampling. Fasting blood was collected to assess riboflavin status [erythrocyte glutathione reductase activity coefficient (EGRac)], hematological indicators, soluble transferrin receptor (sTfR), ferritin, vitamin A, folate, and vitamin B-12 concentrations. Linear and logistic regression models were used to assess the association of riboflavin status with hemoglobin concentration and anemia.

RESULTS

EGRac (mean ± SD) values were higher, indicating poorer riboflavin status, in Malaysian compared with Canadian women (1.49 ± 0.17 compared with 1.38 ± 0.11). Likewise, riboflavin biomarker deficiency (EGRac ≥1.40) was significantly more prevalent among Malaysians than Canadians (71% compared with 40%). More Malaysian than Canadian women were anemic (hemoglobin <120 g/L; 18% compared with 7%). With use of linear regression (pooled sample; n = 416), EGRac values were negatively associated with hemoglobin concentration (r = -0.18; P < 0.001). This relation remained significant (P = 0.029) after adjusting for age, parity, ethnicity, vitamin B-12, folate, sTfR, ferritin, and vitamin A. Women with riboflavin deficiency (EGRac ≥1.40) were twice as likely to present with anemia (adjusted OR: 2.38; 95% CI: 1.08, 5.27) compared with women with EGRac <1.40.

CONCLUSIONS

Biochemical riboflavin deficiency was observed in Canadian and Malaysian women, with higher rates of deficiency among Malaysian women. Deficient biomarker status of riboflavin was a weak but significant predictor of hemoglobin and anemia, suggesting that the correction of riboflavin deficiency may potentially play a small protective role in anemia, but this requires further investigation.

Analysis of the Appropriateness and Feasibility of the Reconnaissance Project Interview Questions and Measurements

After the experiences at the individual sites during the Reconnaissance project had been presented in a plenary format, five groups were formed. Four of these groups examined the individual questions on the original questionnaire with specific attention to (1) nutritional status and biological variables, (2) food intake and food security variables, (3) health status assessment variables, and (4) lifestyle, socio-demographic, and social behaviour and practices variables. In this process, the groups identified items on the questionnaire that had been found, at one or another site, to be of doubtful appropriateness or feasibility. The area of concern of the fifth group was the sampling frame and selection procedures for sites and individuals within sites.

Association Between Preconception Care and Birth Outcomes

PURPOSE

To evaluate the association between preconception care and the risk of adverse birth outcomes.

DESIGN

A quasi-experimental study comparing 2 groups: (1) integrated maternal health care (MHC) program (with preconception care) and (2) standard MHC program (without preconception care).

SETTING

Maternal health-care clinics in Alvand and Qazvin cities in Qazvin Province, Iran.

PARTICIPANTS

A total of 152 and 247 Iranian women aged 16 to 35 years were enrolled in the integrated MHC and standard MHC program, respectively.

MEASURES

The birth outcomes measured included low birth weight, preterm birth, maternal and neonatal complications, and mode of delivery (normal vaginal delivery and cesarean delivery).

ANALYSIS

Multiple logistic regression was performed to determine the impact of preconception care and risk of adverse birth outcomes with adjusted odds ratios (ORs) as effect sizes.

RESULTS

One hundred forty-seven women in integrated MHC and 218 women in standard MHC completed this study. Preconception care was associated with reduced risk of preterm birth (OR = 0.298; 95% confidence interval [CI] = 0.120-0.743; P = .009), low birth weight (OR = 0.406; 95% CI = 0.169-0.971; P = .043), maternal complication (OR = 0.399; 95% CI = 0.241-0.663; P < .001), and neonatal complications (OR = 0.460; 95% CI = 0.275-0.771; P = .003).

CONCLUSION

The findings of the present study revealed advantages of preconception care with reduced adverse birth outcomes.

l-5-Methyltetrahydrofolate Supplementation Increases Blood Folate Concentrations to a Greater Extent than Folic Acid Supplementation in Malaysian Women

Background

Folic acid fortification of grains is mandated in many countries to prevent neural tube defects. Concerns regarding excessive intakes of folic acid have been raised. A synthetic analog of the circulating form of folate, l-5-methyltetrahydrofolate (l-5-MTHF), may be a potential alternative.

Objective

The objective of this study was to determine the effects of folic acid or l-5-MTHF supplementation on blood folate concentrations, methyl nutrient metabolites, and DNA methylation in women living in Malaysia, where there is no mandatory fortification policy.

Methods

In a 12-wk, randomized, placebo-controlled intervention trial, healthy Malaysian women (n = 142, aged 20-45 y) were randomly assigned to receive 1 of the following supplements daily: 1 mg (2.27 μmol) folic acid, 1.13 mg (2.27 μmol) l-5-MTHF, or a placebo. The primary outcomes were plasma and RBC folate and vitamin B-12 concentrations. Secondary outcomes included plasma total homocysteine, total cysteine, methionine, betaine, and choline concentrations and monocyte long interspersed nuclear element-1 (LINE-1) methylation.

Results

The folic acid and l-5-MTHF groups had higher (P < 0.001) RBC folate (mean ± SD: 1498 ± 580 and 1951 ± 496 nmol/L, respectively) and plasma folate [median (25th, 75th percentiles): 40.1 nmol/L (24.9, 52.7 nmol/L) and 52.0 nmol/L (42.7, 73.1 nmol/L), respectively] concentrations compared with RBC folate (958 ± 345 nmol/L) and plasma folate [12.6 nmol/L (8.80, 17.0 nmol/L)] concentrations in the placebo group at 12 wk. The l-5-MTHF group had higher RBC folate (1951 ± 496 nmol/L; P = 0.003) and plasma folate [52.0 nmol/L (42.7, 73.1 nmol/L); P = 0.023] at 12 wk than did the folic acid group [RBC folate, 1498 ± 580 nmol/L; plasma folate, 40.1 nmol/L (24.9, 52.7 nmol/L)]. The folic acid and l-5-MTHF groups had 17% and 15%, respectively, lower (P < 0.001) plasma total homocysteine concentrations than did the placebo group at 12 wk; there were no differences between the folic acid and l-5-MTHF groups. No differences in plasma vitamin B-12, total cysteine, methionine, betaine, and choline and monocyte LINE-1 methylation were observed.

Conclusion

These findings suggest differential effects of l-5-MTHF compared with folic acid supplementation on blood folate concentrations but no differences on plasma total homocysteine lowering in Malaysian women. This trial was registered at clinicaltrials.gov as NCT01584050.

Micronutrient Status and Intervention Programs in Malaysia

Approximately 70% of the world's malnourished children live in Asia, giving that region the highest concentration of childhood malnutrition worldwide. Prevalence of stunting and underweight are high especially in south Asia where one in every two preschool children is stunted. Iron-deficiency anemia affects 40%–50% of preschool and primary schoolchildren. Nearly half of all vitamin A deficiency and xerophthalmia in the world occurs in south and southeast Asia. Iodine deficiency disorders have resulted in high goiter rates in India, Pakistan, and parts of Indonesia. Compared with other developing countries in Asia, the nutrition situation in Malaysia is considerably better, owing to rapid economic and socioeconomic development that has occurred since Malaysia gained its independence in 1957. Prevalence of undernutrition and micronutrient deficiency is markedly lower in Malaysian children. Nonetheless, undernutrition in the form of underweight, stunting, and anemia can be found in poor communities throughout the country. A prevalence of 25% underweight and 35% stunting is reported among young children from poor rural households. Anemia and subclinical forms of vitamin A deficiency were reported in children under 5 years old. Typical of a country in nutrition transition, Malaysia faces the dual burden of malnutrition in children, with the persistence of undernutrition problems especially among the poor and the emerging overweight problem especially in urban areas. Since 1996, nutrition programs of the government sector are coordinated under the National Plan of Action for Nutrition. These activities and other nutrition intervention efforts by other agencies are discussed in this paper.

Compliance with WHO IYCF Indicators and Dietary Intake Adequacy in a Sample of Malaysian Infants Aged 6-23 Months

Background: The 2010 World Health Organisation (WHO) Infant and Young Child Feeding (IYCF) indicators are useful for monitoring feeding practices. Methods: A total sample of 300 subjects aged 6 to 23 months was recruited from urban suburbs of Kuala Lumpur and Putrajaya. Compliance with each IYCF indicator was computed according to WHO recommendations. Dietary intake based on two-day weighed food records was obtained from a sub-group (N = 119) of the total sample. The mean adequacy ratio (MAR) value was computed as an overall measure of dietary intake adequacy. Contributions of core IYCF indicators to MAR were determined by multinomial logistic regression. Results: Generally, the subjects showed high compliance for (i) timely introduction of complementary foods at 6 to 8 months (97.9%); (ii) minimum meal frequency among non-breastfed children aged 6 to 23 months (95.2%); (iii) consumption of iron-rich foods at 6 to 23 months (92.3%); and minimum dietary diversity (78.0%). While relatively high proportions achieved the recommended intake levels for protein (87.4%) and iron (71.4%), lower proportions attained the recommendations for calcium (56.3%) and energy (56.3%). The intake of micronutrients was generally poor. The minimum dietary diversity had the greatest contribution to MAR (95% CI: 3.09, 39.87) (p = 0.000) among the core IYCF indicators. Conclusion: Malaysian urban infants and toddlers showed moderate to high compliance with WHO IYCF indicators. The robustness of the analytical approach in this study in quantifying contributions of IYCF indicators to MAR should be further investigated.

Ganglioside Composition in Beef, Chicken, Pork, and Fish Determined Using Liquid Chromatography-High-Resolution Mass Spectrometry

Gangliosides (GA) are found in animal tissues and fluids, such as blood and milk. These sialo-glycosphingolipids have bioactivities in neural development, the gastrointestinal tract, and the immune system. In this study, a high-performance liquid chromatography-mass spectrometry (HPLC-MS) method was validated to characterize and quantitate the GA in beef, chicken, pork, and fish species (turbot, snapper, king salmon, and island mackerel). For the first time, we report the concentration of GM3, the dominant GA in these foods, as ranging from 0.35 to 1.1 mg/100 g and 0.70 to 5.86 mg/100 g of meat and fish, respectively. The minor GAs measured were GD3, GD1a, GD1b, and GT1b. Molecular species distribution revealed that the GA contained long- to very-long-chain acyl fatty acids attached to the ceramide moiety. Fish GA contained only N-acetylneuraminic acid (NeuAc) sialic acid, while beef, chicken, and pork contained GD1a/b species that incorporated both NeuAc and N-glycolylneuraminic acid (NeuGc) and hydroxylated fatty acids.

Intake of added sugar in Malaysia: a review

The term 'added sugars' refers to sugars and syrup added to foods during processing or preparation, and sugars and syrups added at the table. Calls to limit the daily intakes of added sugars and its sources arose from evidence analysed by WHO, the American Heart Association and other organizations. The present review examined the best available evidence regarding levels of added sugar consumption among different age and sex groups in Malaysia and sources of added sugars. Information was extracted from food balance sheets, household expenditure surveys, nutrition surveys and published studies. Varying results emerged, as nationwide information on intake of sugar and foods with added sugar were obtained at different times and used different assessment methods. Data from the 2003 Malaysian Adult Nutrition Survey (MANS) using food frequency questionnaires suggested that on average, Malaysian adults consumed 30 grams of sweetened condensed milk (equivalent to 16 grams sugar) and 21 grams of table sugar per day, which together are below the WHO recommendation of 50 grams sugar for every 2000 kcal/day to reduce risk of chronic disease. Published studies suggested that, for both adults and the elderly, frequently consumed sweetened foods were beverages (tea or coffee) with sweetened condensed milk and added sugar. More accurate data should be obtained by conducting population-wide studies using biomarkers of sugar intake (e.g. 24-hour urinary sucrose and fructose excretion or serum abundance of the stable isotope 13C) to determine intake levels, and multiple 24 hour recalls to identify major food sources of added sugar.

THE RELATIONSHIP BETWEEN METABOLIC SYNDROME AND ITS COMPONENTS WITH SOCIO-ECONOMIC STATUS AMONG ADOLESCENTS IN SHIRAZ, SOUTHERN IRAN

The objective of this study was to investigate the relationship between metabolic syndrome and its individual components with socio-economic factors among 14-18 year-old adolescents in Shiraz, Iran. Using a multistage random sampling, a total of 538 (289 males and 249 females) adolescents consented to the study. Socio-economic status was obtained using a self-administered questionnaire while presence of metabolic syndrome and its individual components was ascertained using NCEP-ATP III criteria. The relationships between the participants' socio-economic status and metabolic syndrome and its components were determined using bivariate and multivariate statistical analyses. Approximately 6% of the adolescents had metabolic syndrome, with significantly more males than females (9.3% vs 2.4%, p < 0.001). The most commonly found abnormality was low high-density lipoprotein cholesterol (42.4%), followed by hypertensive (16.3%). The prevalence rates of elevated triglycerides, abdominal obesity and high fasting plasma glucose were 15.6%, 8.6% and 3.1%, respectively. Metabolic syndrome was significantly more prevalent in obese participants (44.4%) than those with normal body weight (2.0%) or overweight (9.3%). There were positive associations between the components of metabolic syndrome and parental education, school location and household monthly income. Having a family history of obesity was associated with metabolic syndrome after controlling for other variables (OR = 2.1; 95% CI: 0.9-5.2, p = 0.042). Overweight and obese subjects were approximately 8 times and 15 times more likely to develop metabolic syndrome, respectively (overweight: OR = 8.2; 95% CI: 3.6-17.2; obese: OR = 15.4; 95% CI: 4.8-43.7). In conclusion, a positive association exists between socio-economic status and metabolic syndrome and its individual components among the studied participants. An intervention program to prevent metabolic syndrome needs to be developed for this young generation, especially among those who are overweight or obese and those with a family history of obesity. Keywords: adolescents, metabolic syndrome, components of metabolic syndrome, socio-economic status, Iran

Prevalence of overweight among Malaysian adults from rural communities

Assessment of the nutritional status of 4054 households from rural communities in Peninsular Malaysia was undertaken from 1992 to 1995. Body mass index (BMI) and waist-to-hip ratio (WHR) were obtained from a self-selected sample of 1854 men and 2741 women aged >= 18 years. The BMI and WHR results are presented according to gender, age groups and type of community as defined by the main occupation, namely, fishing, rice farming, estate work, rubber and coconut small-holding. The mean BMI for men and women of all age groups are 22.5 kg/m2 and 23.8 kg/m2, respectively. The mean BMI for both genders increases with age between 18.0 and 49.9 years, after which the value declines. The prevalence of pre-obese (BMI >= 25.0-29.9 kg/m2) is 19.8% for men and 28.0% for women. The prevalence of obese men and women (>= 30.0 kg/m2) is 4.2% and 11.1%, respectively. The highest prevalence of pre-obese and obese men is found in the age groups of 30.0-49.9 years, while that for women is in the 40.0-49.9 years age group. The prevalence of pre-obesity and obesity is higher in women than in men for every age group. A similar result was indicated by WHR whereby a higher proportion of women (22.5%) than men (5%) for all ages was found to show central obesity. The prevalence of overweight adults is higher when compared with previous studies on subjects from almost similar rural communities. This study indicated that overweight is on the increase in rural communities, especially among female subjects.

Folate content and availability in Malaysian cooked foods

INTRODUCTION

Data on folate availability of Malaysian cooked foods would be useful for estimation of dietary folate intake; however such information is scarce.

METHODS

A total of 53 samples of frequently consumed foods in Malaysia were selected from the Nutrient Composition of Malaysian Foods. Folate content was determined using HPLC method hyphenated with a stainless steel C18 column and ultraviolet detector (lambda = 280 nm). The index of folate availability was defined as the proportion of folate identified as monoglutamyl derivatives from the total folate content.

RESULTS

Total folate content of different food samples varied from 30-95 microg/100g fresh weight. Among rice-based dishes, the highest and the lowest total folate was in coconut milk rice (nasi lemak) and ghee rice (nasi minyak), respectively. In noodle dishes, fried rice noodle (kuey teow goreng) and curry noodle (mee kari) had the highest folate contents. The highest index of folate availability was in a flat rice noodle dish (kuey teow bandung) (12.13%), while the lowest was in a festival cake (kuih bakul) (0.13%). Folate content was found to be negatively related to its availability.

CONCLUSION

This study determined folate content and folate availability in commonly consumed cooked foods in Malaysia. The uptake of folate from foods with high folate content may not be necessarily high as folate absorption also depends on the capacity of intestinal deconjugation and the presence of high fibre in the foods.

Effectiveness of medical nutrition treatment delivered by dietitians on glycaemic outcomes and lipid profiles of Arab, Omani patients with Type 2 diabetes

AIMS

In this randomized controlled trial we evaluated the effectiveness of medical nutritional therapy on Arab patients with Type 2 diabetes in Oman delivered by a dietitian.

METHODS

Patients with Type 2 diabetes (n = 170) were randomly assigned to a group receiving usual nutritional care (n = 85) or a group receiving practice guidelines nutritional care (n = 85). Anthropometric (weight, height, BMI and waist circumference) and biochemical (fasting blood glucose, HbA1c ) variables were measured at baseline and after each appointment. Patients were given 1-3 appointments with a dietitian over 6 months.

RESULTS

Those in the group receiving practice guidelines nutritional care (n = 85) had significant changes in HbA(1c) (-0.8%, P = 0.001), fasting plasma glucose (-1.3 mmol\l, P = 0.003) and weight (-5.1 kg, P = 0.05), whereas the patients in the usual nutritional care group (n = 85) had no significant improvements in either HbA(1c) (-0.4%, P = 0.248) or fasting plasma glucose (-0.2 mmol/l, P = 0.638) during the same period. We also found a significant difference between the group receiving practice guidelines nutritional care and the usual nutritional care group, respectively, in waist circumference (96.9 ± 7.9 vs. 100.0 ± 8.7 cm, P = 0.019), triglycerides levels (1.42 ± 0.58 vs. 1.98 ± 0.96 mmol\l, P = 0.001), cholesterol levels (5.1 ± 1.0 vs. 5.5 ± 0.9 mmol/l, P = 0.009) and LDL cholesterol levels (3.58 ± 0.98 vs. 3.89 ± 0.98 mmol/l, P = 0.046).

CONCLUSIONS

Medical nutrition therapy provided by dietitians to Arab patients with Type 2 diabetes in Oman resulted in significant improvements in anthropometric and biochemical outcomes in both the usual nutritional care group and the group receiving practice guidelines nutritional care. Subjects with Type 2 diabetes tended to do better with practice guidelines nutritional care than with usual nutritional care. Ongoing medical counselling in nutrition by a trained dietitian is important for better long-term metabolic control.

Micronutrient interventions on cognitive performance of children aged 5-15 years in developing countries

It is estimated that more than 200 million young children worldwide fail to reach their potential in cognitive development owing to undernutrition. Numerous studies have assessed the effects of micronutrient supplementation on growth and cognitive development in infants, toddlers and preschoolers. However, micronutrient interventions on the cognitive performance of older children are limited. This article seeks to provide an update on micronutrient interventions and cognitive outcomes among children aged 5-15 years in developing countries. A total of 13 randomized controlled trials published since 2000 were identified. Majority of these studies assessed the effects of micronutrient-fortified foods on various domains of cognitive function. Among key micronutrients assessed were iron, zinc, iodine and vitamin A. This review found a lack of consistency in the impact of micronutrient supplementation on intelligence, long term mental functions and school examination grades of the children. A beneficial effect of micronutrient supplementation on short term memory was more consistently reported. Overall, the evidence from this review for the impact of micronutrients on cognitive performance in older children remains equivocal. In light of the growing interest on the influence of nutrition on cognition, it is important that culturally-appropriate and sufficiently sensitive assessment tools be used for measuring the desired cognitive outcomes that are most likely to be affected by the nutrients under study.

Physical activity, nutrition, and dyslipidemia in middle-aged women

BACKGROUND

Cardiovascular disease is a major cause of death throughout the world. The aim of this study was to assess the prevalence of overweight/obesity, central obesity, hypertension and dyslipidemia, as well as dietary factors contributing to the development of dyslipidemia among middle-aged women.

METHODS

The research design of the present study was a population-based cross-sectional study; anthropometric measures and blood chemistry were obtained. Physical activity was measured using the original International Physical Activity Questionnaires Long Form while food frequency questionnaire (FFQ) was used in assessing individual's habitual intake. Overall, 809 women, 30-50 years of age from fourteen active urban Primary Healthcare Centers (PHC) in Babol City, northern Iran, were obtained from 1,905 households across operational areas of 14 PHC using systematic random sampling method.

RESULTS

The prevalence rates of women classified as overweight/obese, with central obesity, hypertension and dyslipidemia were 82.8%, 75.5%, 14.6% and 63.4%, respectively. Total physical activity did not correlate with cholesterol ratio. Soybean protein was inversely associated with cholesterol ratio (rho=-0.18, P≤ 0.001). The adjusted OR for dyslipidemia in women with moderate protein intake was significantly higher than in women with high and low intake (OR=2.31; 95% CI= 1.61, 3.30). No significant associations were found between dyslipidemia and carbohydrate, fat intake or physical activity.

CONCLUSION

This study showed very high prevalence of cardiovascular disease risk factors among Iranian middle-aged women. A more detailed study is suggested to develop definitively recommendations for the primary and secondary prevention of cardiovascular disease for the Iranian population.

Sensitivity and specificity of waist circumference as a single screening tool for identification of overweight and obesity among Malaysian adults

Generalised obesity and central obesity are risk factors for Type II diabetes mellitus and cardiovascular diseases. Waist circumference (WC) has been suggested as a single screening tool for identification of overweight or obese subjects in lieu of the body mass index (BMI) for weight management in public health program. Currently, the recommended waist circumference cut-off points of > or = 94cm for men and > or =80cm for women (waist action level 1) and > or = 102cm for men and > or = 88cm for women (waist action level 2) used for identification of overweight and obesity are based on studies in Caucasian populations. The objective of this study was to assess the sensitivity and specificity of the recommended waist action levels, and to determine optimal WC cut-off points for identification of overweight or obesity with central fat distribution based on BMI for Malaysian adults. Data from 32,773 subjects (14,982 men and 17,791 women) aged 18 and above who participated in the Third National Health Morbidity Survey in 2006 were analysed. Sensitivity and specificity of WC at waist action level 1 were 48.3% and 97.5% for men; and 84.2% and 80.6% for women when compared to the cut-off points based on BMI > or = 25kg/m2. At waist action level 2, sensitivity and specificity were 52.4% and 98.0% for men, and 79.2% and 85.4% for women when compared with the cut-off points based on BMI (> or = 30 kg/m2). Receiver operating characteristic analyses showed that the appropriatescreening cut-off points for WC to identify subjects with overweight (> or = 25kg/m2) was 86.0cm (sensitivity=83.6%, specificity=82.5%) for men, and 79.1cm (sensitivity=85.0%, specificity=79.5%) for women. Waist circumference cut-off points to identify obese subjects (BMI > or = 30 kg/m2) was 93.2cm (sensitivity=86.5%, specificity=85.7%) for men and 85.2cm (sensitivity=77.9%, specificity=78.0%) for women. Our findings demonstrated that the current recommended waist circumference cut-off points have low sensitivity for identification of overweight and obesity in men. We suggest that these newly identified cut-off points be considered.

MTHFR C677T polymorphism, homocysteine and B-vitamins status in a sample of Chinese and Malay subjects in Universiti Putra Malaysia

INTRODUCTION

Methylenetetrahydrofolate reductase (MTHFR) C677T is involved in folate and homocysteine metabolism. Disruption in the activity of this enzyme will alter their levels in the body.

METHODOLOGY

This study assessed MTHFR C677T polymorphism and its relationship with serum homocysteine and B-vitamins levels in a sample of Chinese and Malays subjects in UPM, Serdang. One hundred subjects were randomly selected from among the university population. Folate, vitamin B12, B6, and homocysteine levels were determined using MBA, ECLIA, and HPLC, respectively. PCR coupled with HinfI digestion was used for detection of MTHFR C677T polymorphism.

RESULTS

The frequency of T allele was higher in the Chinese subjects (0.40) compared to the Malay (0.14). Folate, vitamin B12 and B6 levels were highest in the wild genotype in both ethnic groups. Subjects with heterozygous and homozygous genotype showed the highest homocysteine levels. The serum folate and homocysteine were mainly affected by homozygous genotype.

CONCLUSION

MTHFR C677T polymorphism plays an important role in influencing the folate and homocysteine metabolism.

Nutritional status of children living with HIV and receiving antiretroviral (ARV) medication in the Klang Valley, Malaysia

INTRODUCTION

Nutrition and HIV are closely related. Any immune impairment as a result of HIV leads to malnutrition, which in turn, can also lead to reduced immunity, thus contributing to a more rapid progression to AIDS.

METHODS

This cross-sectional study determined the nutritional status of children living with HIV and are receiving antiretroviral medication in the Klang Valley. A total of 95 children aged one to eighteen years old were recruited between September 2008 and February 2009. Data collected included socio-economic status, anthropometric measurements, dietary intake, medical history and serum levels of selected micronutrients specific for immunity.

RESULTS

The mean age of the children was 8.4 +/- 3.9 years and the mean duration on antiretroviral medications was 68.3 +/- 38.3 months. Anthropometric assessment found that 9.5% of the children were underweight and 31.6% were overweight. In contrast, 20.8% were stunted and 14.6% severely stunted. Biochemical indicators showed that 10.4% had deficiency in vitamin A while 12.5% had deficiency in selenium. Total cholesterol and HDL-C levels were found to be low in 30.5% and 10.5% of the children respectively.

CONCLUSION

Dietary assessment showed almost all the children did not achieve the recommended energy intake for their age groups and almost half of the children did not achieve the RNI for selenium and vitamin A. This study provides an insight on the nutritional status of children living with HIV.

Type 2 diabetes in the sultanate of Oman

During the past four decades, Oman has undergone a rapid socioe-conomic and epidemiological transition leading to a substantial reduction in the prevalence of various communicable diseases, including vaccine-preventable diseases. Health care planning together with the commitment of policy makers has been a critical factor in this reduction. However, with rapid social and economic growth, lifestyle-related non communicable diseases have emerged as new health challenges to the country. Diabetes and obesity are leading risks posed by the chronic diseases. The burden of diabetes has increased sharply in Oman over the last decade, rising from 8.3% in 1991 to 11.6% in 2000 among adults aged 20 years and older. The World Health Organization (WHO) predicted an increase of 190% in the number of subjects living with diabetes in Oman over the next 20 years, rising from 75,000 in 2000 to 217,000 in 2025. There is a lack of awareness of the major risk factors for diabetes mellitus in the Omani population generally. As education is often the most significant predictor of knowledge regarding risk factors, complications and the prevention of diabetes, health promotion in Oman is deemed critical, along with other prevention and control measures. Suitable prevention strategies for reducing the prevalence of diabetes in Oman are discussed. Recommendations are made for reforms in the current health care system; otherwise, diabetes will constitute a major drain on Oman's human and financial resources, threatening the advances in health and longevity achieved over the past decades.

Maternal, neonatal, and child health in southeast Asia: towards greater regional collaboration

Although maternal and child mortality are on the decline in southeast Asia, there are still major disparities, and greater equity is key to achieve the Millennium Development Goals. We used comparable cross-national data sources to document mortality trends from 1990 to 2008 and to assess major causes of maternal and child deaths. We present inequalities in intervention coverage by two common measures of wealth quintiles and rural or urban status. Case studies of reduction in mortality in Thailand and Indonesia indicate the varying extents of success and point to some factors that accelerate progress. We developed a Lives Saved Tool analysis for the region and for country subgroups to estimate deaths averted by cause and intervention. We identified three major patterns of maternal and child mortality reduction: early, rapid downward trends (Brunei, Singapore, Malaysia, and Thailand); initially high declines (sustained by Vietnam but faltering in the Philippines and Indonesia); and high initial rates with a downward trend (Laos, Cambodia, and Myanmar). Economic development seems to provide an important context that should be coupled with broader health-system interventions. Increasing coverage and consideration of the health-system context is needed, and regional support from the Association of Southeast Asian Nations can provide increased policy support to achieve maternal, neonatal, and child health goals.

The Third National Health and Morbidity Survey

Obesity is an emerging public health threat in the elderly population in developing countries. Hence, the Third National Health and Morbidity Survey has assessed 4746 individuals aged 60 years and older recruited through a household survey to determine the prevalence of adiposity using body mass index and waist circumference. The national’s prevalence of overweight and obesity in men was 29.2% (95% confidence interval [CI] = 27.2-31.3) and 7.4% (95% CI = 6.4-8.6), respectively. However, the prevalence decreased with age. The figures in women were 30.3% (95% CI = 28.5-32.1) and 13.8% (95% CI = 12.5-15.2), respectively. The prevalence of abdominal obesity was 21.4% (95%CI = 20.2-22.6), with 7.7% (95% CI = 6.7-9.0) in men and 33.4% (95% CI = 31.4-35.3) in women. Predictors of adiposity include the following: Malay and Indian ethnicity, higher education level, higher household income, from urban area, and being married. In conclusion, adiposity affects about one third of the Malaysian elderly population, especially those of the younger age group, women, and those with higher socioeconomic status.

Reliability, technical error of measurements and validity of length and weight measurements for children under two years old in Malaysia

The National Health and Morbidity Survey III 2006 wanted to perform anthropometric measurements (length and weight) for children in their survey. However there is limited literature on the reliability, technical error of measurement (TEM) and validity of these two measurements. This study assessed the above properties of length (LT) and weight (WT) measurements in 130 children age below two years, from the Hospital Universiti Kebangsaan Malaysia (HUKM) paediatric outpatient clinics, during the period of December 2005 to January 2006. Two trained nurses measured WT using Tanita digital infant scale model 1583, Japan (0.01kg) and Seca beam scale, Germany (0.01 kg) and LT using Seca measuring mat, Germany (0.1cm) and Sensormedics stadiometer model 2130 (0.1cm). Findings showed high inter and intra-examiner reliability using 'change in the mean' and 'intraclass correlation' (ICC) for WT and LT. However, LT was found to be less reliable using the 'Bland and Altman plot'. This was also true using Relative TEMs, where the TEM value of LT was slightly more than the acceptable limit. The test instruments were highly valid for WT using 'change in the mean' and 'ICC' but was less valid for LT measurement. In spite of this we concluded that, WT and LT measurements in children below two years old using the test instruments were reliable and valid for a community survey such as NHMS III within the limits of their error. We recommend that LT measurements be given special attention to improve its reliability and validity.

Reliability, technical error of measurements and validity of instruments for nutritional status assessment of adults in Malaysia

INTRODUCTION

The Third National Health and Morbidity Survey Malaysia 2006 includes a nutritional status assessment of children. This study aimed to assess the inter- and intra-examiner reliability, the technical error of measurement and the validity of instruments for measuring weight, height and waist circumference.

METHODS

A convenience sample of 130 adults working in a selected office setting was chosen to participate in the study, subject to the inclusion and exclusion study criteria. Two public health nurses, trained to follow a standard protocol, obtained the weight, height and waist circumference measurements. The weight was measured using the Tanita HD-318 digital weighing scale to the nearest 0.1 kg, and Seca Beam Scale to the nearest 0.01 kg. The height was measured using the Seca Bodymeter 206 and Stadiometer, both to the nearest 0.1 cm. The waist circumference was measured using the Seca circumference measuring tape S 201, to the nearest 0.1 cm.

RESULTS

The intra-examiner reliability in descending order was weight and height followed by waist circumference. The height measurement, on average, using the test instrument, reported a recording of 0.4 cm higher than the reference instrument, with the upper and lower limits at 2.5 cm and 1.6 cm, respectively. The technical error of measurement and coefficient of variation of weight and height for both inter-examiner and intra-examiner measurements were all within acceptable limits (below five percent).

CONCLUSION

The findings of this study suggest that weight, height and waist circumference measured in adults aged 18 years and above, using the respective above mentioned instruments, are reliable and valid for use in a community survey. Limiting the number of examiners, especially for waist circumference measurements, would yield a higher degree of reliability and validity.

Obesity among Mongolian Adults from Urban and Rural Areas

Shifts in lifestyles and eating patterns have led to an increasing prevalence of chronic non-communicable diseases in the adult population in Mongolia. This article reports the prevalence of obesity, abdominal obesity and body fat among 408 Mongolian adults aged 25 years and above. The subjects included 61.2% from urban areas and 38.8% from rural areas, reflective of the 60: 40 urban rural ratio in the general population. Anthropometric measurements were taken according to standard methods. Classification of overweight/obesity was based on body mass index of WHO while abdominal obesity was based on WPRO for Asians. Men made up 47.8% (200) and women 52.2% (218) of the sample. The mean age of the subjects was 46.7±12.7 years. About one-third (32.8%) of the subjects were overweight and 10.5% obese. A higher proportion of women (13.3%) than men were obese (7.5%). The age groups of 35-54 years in men and 55-64 years in women showed the highest prevalence of overweight. Prevalence of abdominal obesity was found in 46.5% of the men and in 65.1% of the women. Women aged 55-64 years had the highest proportion (78.4%) of abdominal obesity. In terms of body fat, 20.0 % and 51.5% of the men had high and very high levels of body fat respectively, while among the women, 15.1% and 55.5% respectively had high and very high levels of body fat. Mongolian adults face serious risk of cardiovascular diseases and other aspects of ill-health brought about by obesity. Prevention and control of obesity should be targeted as an urgent public health agenda in Mongolia.

Nutritional Status of Children below Five Years in Malaysia: Anthropometric Analyses from the Third National Health and Morbidity Survey III (NHMS, 2006)

The Third National Health and Morbidity Survey (NHMS III) was conducted in 2006 on a nationally representative sample of population in Malaysia. Over 21,000 children aged 0-17.9 years were measured for body weight and stature according to the protocol of the World Health Organization. This article describes the nutritional status of children aged 0-59.9 months. Mean z score for weightfor-age (WAZ), height-for-age (HAZ) and BMI-for-age were compared with the z-scores tables of the WHO standards. The overall prevalence of underweight and stunting of the children were 12.9% and 17.2% respectively. These levels included 2.4% severe underweight and 6.0% severe stunting. In terms of z scores, the age group of 0-5.9 months showed the best nutritional status with mean WAZ of -0.33 (95%CI: -0.52, 0.15) and -0.40 (-0.57, 0.24) for boys and girls respectively, while mean HAZ was 0.64 (0.38, 0.89) for boys and 0.76 (0.54, 0.98) for girls. Mean HAZ and WAZ status was least satisfactory after about 6 months, suggesting a faltering in growth rate at an age that coincides with dependence on complementary feeding. Prevalence of overweight based on BMI-for-age for the sexes combined was 6.4%, while that based on WAZ was 3.4%. The NHMS III results indicate that Malaysian children have better nutritional status compared to children under 5 years in neighbouring countries. In order to meet the targets set in the National Plan of Nutrition (2006-2015), more effective intervention programmes are needed to accelerate the reduction of underweight and stunting, and to arrest the rise of overweight in young children.

Prevalence of metabolic syndrome among middle aged women in Babol, Iran

Metabolic syndrome is a cluster of interconnected cardiovascular risk factors. This research determined the prevalence of metabolic syndrome by body mass index, sociodemography, and lifestyle habits of women 30-50 years old in Babol Iran. A systematic random sampling was used to select 984 middle aged women from an urban area in Babol, Mazandaran, Iran. Screening was used to select eligible women who fulfilled selection criteria. The Adult Treatment Panel III (ATP III) criteria were used to classify participants as having metabolic syndrome. The overall prevalence of metabolic syndrome was 31.0%. Abdominal obesity was observed in about 76.6% (n = 273) of subjects. The prevalences of hypertension, high fasting blood glucose, high triglycerides and low HDL-cholesterol were 12.1, 12.1, 41.5 and 48.6%, respectively. Older age (OR = 2.07; CI = 1.56-2.75), higher waist circumference (OR = 6.46; 95% CI = 3.48-11.96), higher systolic (OR = 3.84; 95% CI = 2.37-6.22) and diastolic blood pressure (OR = 1.89; 95% CI =1.17-3.05), low education level (OR = 2.780; CI = 1.80-4.31), housekeeping (OR = 3.92; CI = 1.24-12.44) and farming occupation (OR = 20.54; 95% CI = 3.54-119.06) were associated with increased risk for metabolic syndrome. The odds ratio (OR) showed no significant associations between metabolic syndrome and smoking or exposure to smoking. This study showed high prevalence of metabolic syndrome in Iranian middle aged women. A larger area and population study is needed to enable broader recommendations for the prevention of metabolic syndrome.

Perceptions of body image among Malaysian male and female adolescents

INTRODUCTION

Body image concerns are common among adolescents as they undergo rapid physical growth and body shape changes. Having a distorted body image is a risk factor for the development of disordered eating behaviours and eating disorders. This study was undertaken to investigate body image concerns among Malaysian male and female adolescents aged 11-15 years.

METHODS

A total of 2,050 adolescents (1,043 males and 1,007 females) with a mean age of 13.1 +/- 0.8 years from secondary schools in Kedah and Pulau Pinang were included in the study. Questionnaires were used to collect socioeconomic data and body image indicators.

RESULTS

The majority (87 percent) of the adolescents were concerned with their body shape. While the majority of underweight, normal weight and overweight male and female subjects perceived their body weight status correctly according to their body mass index (BMI), a noteworthy proportion in each category misjudged their body weight. About 35.4 percent of the males and 20.5 percent of the females in the underweight category perceived themselves as having a normal weight, while 29.4 percent and 26.7 percent of the overweight males and females respectively also perceived that they had a normal weight. A higher proportion of the females (20 percent) than males (9 percent) with a normal BMI perceived themselves as fat. Most of the male (78-83 percent) and female subjects (69-74 percent) in all the BMI categories desired to be taller than their current height. An appreciable proportion of both the males (41.9 percent) and females (38.2 percent) preferred to remain thin, or even to be thinner (23.7 percent of males and 5.9 percent of females). Females had a significantly higher mean body dissatisfaction score than males, indicating their preference for a slimmer body shape. More males (49.1 percent) preferred a larger body size while more females (58.3 percent) idealised a smaller body size. Compared to normal weight and underweight subjects, overweight males and females expressed lower confidence and acceptance levels, as well as expressed greater preoccupation with and anxiety over their body weight and shape.

CONCLUSION

As having a distorted body image may lead to negative effects such as unhealthy eating habits and disordered eating behaviours, it is recommended that appropriate educational efforts on body image be incorporated into school health activities for adolescents.

Association of major dietary patterns with obesity risk among Mongolian men and women

Mongolia is experiencing changes in its unique nomadic lifestyle and dietary habits in the last two decades with accompanying increase in obesity rate. The dietary pattern approach, which investigates the overall diet in relation to obesity risks, has become appealing in nutrition epidemiology. The aim of this study was to identify major dietary patterns of the Mongolian adults in relation to the risk of having obesity. Dietary intake of a total 418 adults aged ? 25 years was assessed by using a food frequency questionnaire with 68 items. An exploratory factor analysis resulted in three dietary patterns: transitional high in processed meat and potato, traditional rich in whole milk, fats and oils and healthy with greater intake of whole grains, mixed vegetables and fruits. Individuals in the upper quintile of the transitional pattern had significantly greater risk of obesity (BMI > or =25 kg/m2: OR=2.47; 95% CI=1.04-5.86) while subjects in the highest quintile of the healthy dietary pattern were found to have significantly decreased risk of obesity (OR: 0.49; 95% CI=0.25-0.95). Men in the highest quintile of the transitional pattern had greater risk of abdominal obesity WC > or =90 cm: OR= 4.08; 95% CI=1.11-14.97) than those in the lowest quintile. Women in the top quintile of the traditional pattern had a greater odds of having abdominal obesity (WC > or =80 cm: OR=4.59; 95% CI=1.58-13.30) than those in the lowest quintile. The study suggests that public health efforts be targeted at adults in Mongolia to address the undesirable aspects of the transitional and the traditional dietary patterns.

Dietary patterns and the metabolic syndrome in middle aged women, Babol, Iran

It is important to elucidate the dietary factors contributing to the development of metabolic syndrome among middle-aged women to better prevent and manage the syndrome. The objective was to determine the relationship between dietary intake and metabolic syndrome in urban Babolian middle-aged women. Systematic random sampling was used to select 984 women 30-50 years of age from urban area of Babol, Mazandaran, Iran. Dietary patterns were evaluated using a food frequency questionnaire. The ATP III criteria were used to classify study participants as having the metabolic syndrome. Correlations of component foods with indices of the metabolic syndrome were assessed using Spearman's rank correlation coefficient (rho). The adjusted odds ratios (OR) and their 95% confidence intervals were obtained for the nutrient groups. Mean total kilocalories consumed per day were 2965. The study suggests that a good dietary pattern that is rich in fruits, legumes, vegetables, cereals, and fish (component 1), as well as high intake of dairy products and eggs (components 4) decrease the likelihood of having metabolic syndrome. The adjusted OR for the metabolic syndrome in women with low fat intake was higher than in women with high and moderate fat (OR=2.92; 95% CI=1.36, 6.28). It is necessary to emphasize the benefits of lifestyle modification, including losing weight, and consumption of more fruits, legumes, vegetables, cereals, fish, dairy products in reducing the risk of the metabolic syndrome in middle aged women.

Reliability and Technical Error of Calf Circumference and Mid-half Arm Span Measurements for Nutritional Status Assessment of Elderly Persons in Malaysia

This study sought to examine the reliability of two measurements; Calf Circumference (CC) and Mid-half Arm Span (MHAS). A sample of 130 elderly persons aged 60 years and above seen consecutively in the Kuala Lumpur Hospital outpatient clinic during the period of December 2005 to January 2006, upon consent, were recruited to the study. There was a high degree of reliability for both inter- and intra-examiner (r close to 1). For inter-examiner, on average the CC measurements taken by the first examiner were 0.3 cm lower than that of the second examiner. The upper and lower limit of the differences were +0.4 to -0.9 cm respectively. Inter-examiner MHAS measurements on average by the first examiner were 0.2 cm lower than that of the second examiner. The limits were +1.7 to -2.1 cm. By comparison, the inter-examiner CC measurements were more reliable than the MHAS measurements. For intra-examiner, on average the CC measurements at Time 1 were consistent with Time 2 (mean difference=0) with limits of the difference at + 0.5 cm. MHAS measurements at Time 1 were on average 0.1 cm less than at Time 2 with limits at +1.7 and -1.8 cm. The technical error of measurement (TEM) and coefficient of variation of CC and MHAS for both interexaminer and intra-examiner measurements were within acceptable limits with the exception of MHAS TEM. This study suggests that CC and MHAS measured in elderly persons 60 years and above, using Seca Circumference Tape ® 206, Germany (0.05 cm) are reliable and can be used in a community survey.

Abdominal Obesity in Malaysian Adults: National Health and Morbidity Survey III (NHMS III, 2006)

Abdominal obesity (AO) is an independent risk factor for cardiovascular disease, hypertension and diabetes mellitus in adults. There is a lack of data on the magnitude and socio-demographic profile of AO among Malaysian adults at the national level. In the Third National Health and Morbidity Survey (NHMS III) conducted in 2006, AO of adults aged 18 years and above was determined based on the waist circumference as part of the nutritional status assessment. This article reports the prevalence of AO in relation to socio-economic factors and demographic characteristics of adult subjects. Out of a total of 33,465 eligible individuals 18 years and above, waist circumference was measured in 32,900 (98.3%) individuals. The prevalence of AO was assessed using the cut-off points recommended by World Health Organization. The mean waist circumference in men and women was 84.0cm [95% confidence interval (95% CI): 83.8, 84.3] and 80.3cm (95% CI: 80.1, 80.6) respectively. The national prevalence of AO was 17.4% (95% CI: 16.9, 17.9). The identified risks of AO were women (OR: 4.2, 95% CI: 3.8, 4.6), aged 50-59 years (OR: 5.6, 95% CI: 4.0, 7.7), Indians (OR: 3.0, 95% CI: 2.4, 3.8), housewives (OR: 1.4, 95% CI: 1.1, 1.7), subjects with primary education (OR: 1.3, 95% CI: 1.1, 1.5) and ever married (OR: 1.4, 95% CI: 1.2, 1.6). Being the largest population-based study on AO among Malaysians, these findings have important public health implications. There is an urgent need to revise public health policies and programmes aimed at prevention of abdominal obesity especially in the groups at risk.

Development of multi-dimensional body image scale for malaysian female adolescents

The present study was conducted to develop a Multi-dimensional Body Image Scale for Malaysian female adolescents. Data were collected among 328 female adolescents from a secondary school in Kuantan district, state of Pahang, Malaysia by using a self-administered questionnaire and anthropometric measurements. The self-administered questionnaire comprised multiple measures of body image, Eating Attitude Test (EAT-26; Garner & Garfinkel, 1979) and Rosenberg Self-esteem Inventory (Rosenberg, 1965). The 152 items from selected multiple measures of body image were examined through factor analysis and for internal consistency. Correlations between Multi-dimensional Body Image Scale and body mass index (BMI), risk of eating disorders and self-esteem were assessed for construct validity. A seven factor model of a 62-item Multi-dimensional Body Image Scale for Malaysian female adolescents with construct validity and good internal consistency was developed. The scale encompasses 1) preoccupation with thinness and dieting behavior, 2) appearance and body satisfaction, 3) body importance, 4) muscle increasing behavior, 5) extreme dieting behavior, 6) appearance importance, and 7) perception of size and shape dimensions. Besides, a multidimensional body image composite score was proposed to screen negative body image risk in female adolescents. The result found body image was correlated with BMI, risk of eating disorders and self-esteem in female adolescents. In short, the present study supports a multi-dimensional concept for body image and provides a new insight into its multi-dimensionality in Malaysian female adolescents with preliminary validity and reliability of the scale. The Multi-dimensional Body Image Scale can be used to identify female adolescents who are potentially at risk of developing body image disturbance through future intervention programs.

Household food insecurity and coping strategies in a poor rural community in Malaysia

This cross-sectional study assessed household food insecurity among low-income rural communities and examined its association with demographic and socioeconomic factors as well as coping strategies to minimize food insecurity. Demographic, socioeconomic, expenditure and coping strategy data were collected from 200 women of poor households in a rural community in Malaysia. Households were categorized as either food secure (n=84) or food insecure (n=116) using the Radimer/Cornell Hunger and Food Insecurity instrument. T-test, Chi-square and logistic regression were utilized for comparison of factors between food secure and food insecure households and determination of factors associated with household food insecurity, respectively. More of the food insecure households were living below the poverty line, had a larger household size, more children and school-going children and mothers as housewives. As food insecure households had more school-going children, reducing expenditures on the children's education is an important strategy to reduce household expenditures. Borrowing money to buy foods, receiving foods from family members, relatives and neighbors and reducing the number of meals seemed to cushion the food insecure households from experiencing food insufficiency. Most of the food insecure households adopted the strategy on cooking whatever is available at home for their meals. The logistic regression model indicates that food insecure households were likely to have more children (OR=1.71; p<0.05) and non-working mothers (OR=6.15; p<0.05), did not own any land (OR=3.18; p<0.05) and adopted the strategy of food preparation based on whatever is available at their homes (OR=4.33; p<0.05). However, mothers who reported to borrow money to purchase food (OR=0.84; p<0.05) and households with higher incomes of fathers (OR=0.99; p<0.05) were more likely to be food secure. Understanding the factors that contribute to household food insecurity is imperative so that effective strategies could be developed and implemented.

Food-based approaches to combat the double burden among the poor: challenges in the Asian context

Estimates of FAO indicate that 14% of the population worldwide or 864 million in 2002-2004 were undernourished in not having enough food to meet basic daily energy needs. Asia has the highest number of undernourished people, with 163 million in East Asia and 300 million in South Asia. Meanwhile obesity and diet-related non-communicable diseases continue to escalate in the region. The double burden of malnutrition also affects the poor, which is a serious problem in Asia, as it has the largest number of poor subsisting on less than $1/day. As poverty in the region is predominantly rural, agriculture-based strategies are important for improving household food security and nutritional status. These measures include shifting toward production of high-value products for boosting income, enhancing agricultural biodiversity, increasing consumption of indigenous food plants and biofortified crops. Urban poor faces additional nutritional problems being more sensitive to rising costs of living, lack of space for home and school gardening, and trade-offs between convenience and affordability versus poor diet quality and risk of contamination. Time constraints faced by working couples in food preparation and child care are also important considerations. Combating the double burden among the poor requires a comprehensive approach including adequate public health services, and access to education and employment skills, besides nutrition interventions.

Vitamin D status and its association with parathyroid hormone concentrations in women of child-bearing age living in Jakarta and Kuala Lumpur

OBJECTIVE

To describe the vitamin D status of women living in two Asian cities,--Jakarta (6 degrees S) and Kuala-Lumpur (2 degrees N), to examine the association between plasma 25-hydroxyvitamin D and parathyroid hormone (PTH) concentrations, and to determine a threshold for plasma 25-hydroxyvitamin D above which there is no further suppression of PTH. Also, to determine whether dietary calcium intake influences the relationship between PTH and 25-hydroxyvitamin D.

DESIGN

Cross-sectional.

SETTING

Jakarta, Indonesia and Kuala Lumpur, Malaysia.

PARTICIPANTS

A convenience sample of 504 non-pregnant women 18-40 years.

MAIN MEASURES

Plasma 25-hydroxyvitamin D and PTH.

RESULTS

The mean 25-hydroxyvitamin D concentration was 48 nmol/l. Less than 1% of women had a 25-hydroxyvitamin D concentration indicative of vitamin D deficiency (<17.5 nmol/l); whereas, over 60% of women had a 25-hydroxyvitamin D concentration indicative of insufficiency (<50 nmol/l). We estimate that 52 nmol/l was the threshold concentration for plasma 25-hydroxyvitamin D above which no further suppression of PTH occurred. Below and above this concentration the slopes of the regression lines were -0.18 (different from 0; P=0.003) and -0.01 (P=0.775), respectively. The relation between vitamin D status and parathyroid hormone concentration did not differ between women with low, medium or high calcium intakes (P=0.611); however, even in the highest tertile of calcium intake, mean calcium intake was only 657 mg/d.

CONCLUSION

On the basis of maximal suppression of PTH we estimate an optimal 25-hydroxyvitamin D concentration of approximately 50 nmol/l. Many women had a 25-hydroxyvitamin D below this concentration and may benefit from improved vitamin D status.

A national study on the prevalence of obesity among 16,127 Malaysians

A population-based cross-sectional study was conducted in all states of Malaysia with the aim to determine the prevalence of obesity among Malaysians aged fifteen years and above and factors associated. A stratified two-stage cluster sampling design with proportional allocation was used. Trained interviewers using a standardized protocol obtained the weight and height measurements and other relevant information. Subjects with a body mass index >= 30 kg/m2 were labelled as obese. The results show that the overall national prevalence of obesity among Malaysians aged 15 years old and above was 11.7% (95% CI = 11.1 - 12.4%). The prevalence of obesity was significantly higher in females (13.8%) as compared to 9.6% in males (p< 0.0001). Prevalence of obesity was highest amongst the Malays (13.6%) and Indians (13.5%) followed by the indigenous group of "Sarawak Bumiputra" (10.8%) and the Chinese (8.5%). The indigenous group of "Sabah Bumiputra" had the lowest prevalence of 7.3%. These differences are statistically significant (p< 0.0001). Logistic regression analysis results show that there was a significant association between obesity and age, gender, ethnicity urban/rural status and smoking status. The prevalence of obesity amongst those aged >= 18 years old has markedly increased by 280% since the last National Health and Morbidity Survey in 1996.

CONCLUSION

The overall prevalence of obesity in Malaysia is very high as compared to 1996. There is an urgent need for a comprehensive integrated population-based intervention program to ameliorate the growing problem of obesity in Malaysians.