Anis Safura Ramli

JIS Definition Identified More Malaysian Adults with Metabolic Syndrome Compared to the NCEP-ATP III and IDF Criteria

Metabolic syndrome (MetS) is a steering force for the cardiovascular diseases epidemic in Asia. This study aimed to compare the prevalence of MetS in Malaysian adults using NCEP-ATP III, IDF, and JIS definitions, identify the demographic factors associated with MetS, and determine the level of agreement between these definitions. The analytic sample consisted of 8,836 adults aged ≥30 years recruited at baseline in 2007–2011 from the Cardiovascular Risk Prevention Study (CRisPS), an ongoing, prospective cohort study involving 18 urban and 22 rural communities in Malaysia. JIS definition gave the highest overall prevalence (43.4%) compared to NCEP-ATP III (26.5%) and IDF (37.4%), P < 0.001. Indians had significantly higher age-adjusted prevalence compared to other ethnic groups across all MetS definitions (30.1% by NCEP-ATP III, 50.8% by IDF, and 56.5% by JIS). The likelihood of having MetS amongst the rural and urban populations was similar across all definitions. A high level of agreement between the IDF and JIS was observed (Kappa index = 0.867), while there was a lower level of agreement between the IDF and NCEP-ATP III (Kappa index = 0.580). JIS definition identified more Malaysian adults with MetS and therefore should be recommended as the preferred diagnostic criterion.

Bridging the gap in ageing: Translating policies into practice in Malaysian Primary Care

Population ageing is poised to become a major challenge to the health system as Malaysia progresses to becoming a developed nation by 2020. This article aims to review the various ageing policy frameworks available globally; compare aged care policies and health services in Malaysia with Australia; and discuss various issues and challenges in translating these policies into practice in the Malaysian primary care system. Fundamental solutions identified to bridge the gap include restructuring of the health care system, development of comprehensive benefit packages for older people under the national health financing scheme, training of the primary care workforce, effective use of electronic medical records and clinical guidelines; and empowering older people and their caregivers with knowledge, skills and positive attitudes to ageing and self care. Ultimately, family medicine specialists must become the agents for change to lead multidisciplinary teams and work with various agencies to ensure that better coordination, continuity and quality of care are eventually delivered to older patients across time and settings.

An enquiry based on a standardised questionnaire into knowledge, awareness and preferences concerning the care of familial hypercholesterolaemia among primary care physicians in the Asia-Pacific region: the “Ten Countries Study”

Objective To determine physicians’ knowledge, awareness and preferences regarding the care of familial hypercholesterolaemia (FH) in the Asia-Pacific region. Setting A formal questionnaire was anonymously completed by physicians from different countries/regions in the Asia-Pacific. The survey sought responses relating to general familiarity, awareness of management guidelines, identification (clinical characteristics and lipid profile), prevalence and inheritance, extent of elevation in risk of cardiovascular disease (CVD) and practice on screening and treatment. Participants Practising community physicians from Australia, Japan, Malaysia, South Korea, Philippines, Hong Kong, China, Vietnam and Taiwan were recruited to complete the questionnaire, with the UK as the international benchmark. Primary outcome An assessment and comparison of the knowledge, awareness and preferences of FH among physicians in 10 different countries/regions. Results 1078 physicians completed the questionnaire from the Asia-Pacific region; only 34% considered themselves to be familiar with FH. 72% correctly described FH and 65% identified the typical lipid profile, with a higher proportion of physicians from Japan and China selecting the correct FH definition and lipid profile compared with those from Vietnam and Philippines. However, less than half of the physician were aware of national or international management guidelines; this was significantly worse than physicians from the UK (35% vs 61%, p<0.001). Knowledge of prevalence (24%), inheritability (41%) and CVD risk (9%) of FH were also suboptimal. The majority of the physicians considered laboratory interpretative commenting as being useful (81%) and statin therapy as an appropriate cholesterol-lowering therapy (89%) for FH management. Conclusions The study identified important gaps, which are readily addressable, in the awareness and knowledge of FH among physicians in the region. Implementation of country-specific guidelines and extensive work in FH education and awareness programmes are imperative to improve the care of FH in the region.

674 CARDIOVASCULAR RISK FACTORS ASSOCIATED WITH PREHYPERTENSION IN MALAYSIAN ADULTS

Background & Objectives: Malaysia is facing an epidemic of cardiovascular diseases (CVD) withhypertension asa major driver. Given that cardiovascular risk factors (CVRFs) occur in clusters, the aim of the study is to determine the prevalence of CVRFs among Malaysian adults with Prehypertension (PreHT). Methods: This community-based, cross sectional study involving 11,288 adults aged ≥ 30 years was carried out in urban and rural areas in Malaysia between 2007 and 2010. An average of 3 readings of the brachial blood pressures (BP) was recordedwith semi-automated, validated Omron HEM 757 sphygmomanometers. Anthropometric measurements and fasting venous blood for lipid and glucose assays were obtained. Multiple logistic regression analysis was used to determine the factors associated with PreHT. Results: The prevalence of PreHT was 34% (35.4% in males and 33.0% in females). Males (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.43–2.17), rural dwellers (OR 1.29 CI 1.04–1.61), overweight (OR 1.92, CI 1.25–2.95), obesity (OR 2.58, CI 1.60–4.16), increased waist circumference (OR 1.29, CI 1.01–1.65), hypertriglyceridaemia (OR 1.23 CI 1.01–1.49) and family history of hypertension (OR 1.31 CI 1.08–1.58) were more likely to be associatedwith PreHT. Interestingly, waist-hip ratio, total cholesterol, HDL-cholesterol and diabetes mellitus were not associated with PreHT Conclusion: Prevalence of PreHT is overwhelming in Malaysian adults and is associated with multiple CVRFs. Concerted effort must be undertaken aggressively to manage CVRFs in the community and to prevent progression of PreHT to hypertension.

Validity and reliability of the patient assessment on chronic illness care (PACIC) questionnaire: the Malay version

BackgroundMajority of patients with chronic illnesses such as diabetes, receive care at primary care setting. Efforts have been made to restructure diabetes care in the Malaysian primary care setting in accordance with the Chronic Care Model (CCM). The Patient Assessment on Chronic Illness Care (PACIC) is a validated self-report tool to measure the extent to which patients with chronic illness receive care that aligns with the CCM. To date, no validated tool is available to evaluate healthcare delivery based on the CCM in the Malay language. Thus, the study aimed to translate the PACIC into the Malay language and validate the questionnaire among patients with diabetes in the Malaysian public primary care setting.MethodsThe English version of the PACIC questionnaire is a 20-item scale measuring five key components, which are patient activation, decision support, goal setting, problem solving and follow-up care. The PACIC underwent forward - backward translation and cross cultural adaptation process to produce the PACIC-Malay version (PACIC-M). Reliability was tested using internal consistencies and test-retest reliability analyses, while construct validity was tested using the exploratory factor analysis (EFA).ResultsThe content of PACIC-M and the original version were conceptually equivalent. Overall, the internal consistency by Cronbach’s α was .94 and the intra-class correlation coefficient was .93. One item was deleted (item 1) when the factor loading was < 0.4. The factor analyses using promax identified three components (‘Goal Setting/Tailoring and Problem solving/Contextual’, ‘follow-up/coordination’ and ‘patient activation and delivery system design/ decision support’); explaining 61.2% of the variation. The Kaiser-Meyer-Olkin (KMO) was 0.93 and Bartlett’s test of sphericity was p = .000. Therefore, the final version of the PACIC-M consisted of 19 items, framed within three components.ConclusionThe findings demonstrated that the PACIC-M measured different dimensions from the English version of PACIC. It is however; highly reliable and valid to be used in assessing three CCM model subscales. Further confirmatory factor analysis of PACIC-M should be conducted to confirm this new model.

Knowledge, awareness and practice regarding familial hypercholesterolaemia among primary care physicians in Malaysia: The importance of professional training

BACKGROUND AND AIMS This study aimed to determine knowledge, awareness and practice (KAP) regarding familial hypercholesterolaemia (FH) among Malaysian primary care physicians (PCP), and to compare KAP between PCP with postgraduate qualification (PCP-PG-Qual) and PCP without PG qualification (PCP-noPG-Qual). METHODS This was a cross-sectional study involving PCP with ≥1-year working experience in Malaysian primary care settings. An adapted and validated 25-item FH-KAP questionnaire was disseminated during primary care courses. Total score for each domain was calculated by summing-up the correct responses, converted into percentage scores. Normality distribution was examined and comparisons of mean/median percentage scores were made between the two groups of PCP. RESULTS A total of 372 PCP completed the questionnaire. Regarding knowledge, 77.7% correctly defined FH. However, only 8.3% correctly identified coronary artery disease risk in untreated FH. The mean percentage knowledge score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (48.9, SD ± 13.92 vs. 35.2, SD ± 14.13), t(370) = 8.66, p < 0.001. Regarding awareness, 39% were aware of the NICE FH guideline and only 27.2% were aware of FH diagnostic criteria. The median percentage awareness score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (15.4, IqR ± 23.08 vs. 7.7, IqR ± 11.54), p = 0.013. Regarding practice, only 19.1% stratified FH patients as high risk irrespective of other risk factors. The mean percentage practice score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (52.4, SD ± 12.92 vs. 42.7, SD ± 16.63), t(370) = 9.65, p < 0.001. CONCLUSIONS Substantial gaps in FH-KAP among Malaysian PCP were identified, with PCP-PG-Qual having better knowledge, awareness and practice than PCP-noPG-Qual, emphasising the importance of professional training and certification.

Effects of adding tocotrienol-tocopherol mixed fraction and vitamin C supplementation on coronary risk biomarkers in patients with hypercholesterolaemia with moderate coronary risk.

Article history: Received on: 07/01/2016 Revised on: 07/02/2016 Accepted on: 24/03/2016 Available online: 30/04/2016 This study was a prospective clinical trial to investigate the effects of adding combined tocotrienol-tocopherol mixed fraction (TTMF) and vitamin C (TTMF+C) supplementation on coronary biomarkers in non-statin and statin treated patients with hypercholesterolaemia (HC) with moderate coronary risk. A total of 35 patients were randomised at baseline into one of two groups, (G1) TTMF+C (320mg TTMF plus 500mg vitamin C) alone daily and (G2) TTMF+C (320mg TTMF plus 500mg vitamin C) plus atorvastatin 10 mg daily. The entire supplementation were taken for 12 months. Fasting serum samples were taken at baseline, 2weeks, 3months, 6months and 12months post-randomisation and analysed for inflammatory biomarkers; high sensitivity Creactive protein (hsCRP) and interleukin-6 (IL6). Combination of TTMF and vitamin C supplementation leads to neutral effects on lipid profiles and inflammation; with no added benefit in statin-treated HC patients with moderate coronary risk. This neutral effects may be attributed to the tocopherol composition in TTMF which could possibly attenuate any potential beneficial effects of tocotrienols. Clinical studies using pure tocotrienols in the absence of tocopherols would further confirm this.

682 PREVALENCE OF METABOLIC SYNDROME AMONG MALAYSIAN ADULTS AGED ≥ 30 YEARS ACCORDING TO THE NCEP-ATP III, IDF AND JIS DEFINITIONS

Objective: The objective of this study is to compare the prevalence of Metabolic Syndrome (MetS) as defined by the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATP III)1, International Diabetes Federation (IDF) world-wide definition2 and the ‘harmonised’ definition by the Joint Interim Statement (JIS)3. Methods: A community based cross-sectional study involving 11,288 adults aged ≥ 30 years was conducted in urban and rural areas of Malaysia between 2007 and 2010. Demographic data, waist circumference (WC), blood pressure readings; and fasting venous blood for lipid and glucose assays were obtained. Data was analysed using STATA version 11. Results: Out of the11,288 subjects, 8836 had complete data on all the MetS components and were therefore included in the analysis. Mean age was 53.2 years (SD ± 10.6). The table shows the overall and age-adjusted prevalence of MetS according to the NCEP-ATP III, IDF and JIS definitions by location, gender, ethnicity and education attainment. Table. No title available. Conclusions: The JIS definition gave the highest overall prevalence of MetS among Malaysian adults, as well as the age-adjusted prevalence by location, gender, ethnicity and education attainment. The NCEP-ATP III gave the lowest prevalence due to the higher WC cut points. Prevalence was significantly lower in Chinese and Indigenous groups regardless of the criteria used. There was no significant difference in the prevalence between urban and rural population using IDF and JIS definitions. ReferencesNational Cholesterol Education Program (NCEP)Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143–421.Alberti KG, Zimmet P, Shaw J, International Diabetes Federation (IDF) Epidemiology Task Force Consensus Group. The metabolic syndrome: a new world- wide definition. Lancet 2005; 366: 1059–62.Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the metabolic syndrome. A Joint Interim Statement (JIS) of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009; 120: 1640–5.

676 DYSLIPIDAEMIAS IN THE MALAYSIAN POPULATION

Background: Coronary artery disease (CAD) is the leading cause of mortality globally, primarily attributed by atherosclerosis, of which dyslipidaemia is one of the main risk factors. There is limited data in Malaysia on the prevalence and awareness of having dyslipidaemia, and the proportion who are treated. Objectives: To investigate the prevalence of (1)dyslipidaemia; (2)awareness of dyslipidaemia and (3)subjects with dyslipidaemia who are treated. Methodology: This was a cross-sectional study involving 11,525 Malaysian subjects from various rural and urban populations, with representations from the three major ethnic groups (age mean + SD: 52.6 + 11.3years; 6487 females, 5038males). Clinical history and physical examinations were performed and fasting blood samples were collected for the measurement of lipid profiles. Dyslipidaemia was defined by mild, moderate or severe hypercholesterolaemia(HC):TC > 5.2, 6.5 and 7.8mmol/L respectively, or hypertriglyceridaemia (HTG):TG > 1.7 mmol/L, or low HDL-c:females < 1.3, males < 1.0mmol/L. Questionnaires were completed for data on awareness and treatment of dyslipidaemia. Results: Subjects with HC and HTG were 66.9% and 40.9% respectively. Low HDL-c were found in 15.2% and 74.9% in females and males respectively. Among those with HC, 42.6%, 19.3% and 5.0% had mild, moderate and severe HC respectively. Awareness of dyslipidaemia was only found in 13.9% of the population, of whom only 8.0% were on treatment. Conclusion: There is a high prevalence of dyslipidaemias in Malaysia, majority of whom are unaware of having the major risk factor for atherosclerosis-related complications such as CAD. Hence, there is an urgent need for coronary risk identification, prevention and intervention to combat the global epidemic of CAD

220 OVERWEIGHT AND OBESITY IN MALAYSIA: AN EPIDEMIOLOGY SURVEY

Background and Objective: In Malaysia, the prevalence of overweight and obesity (>18 years old) is escalating with 16.6% and 4.4% in 1996, 29.1% and 14.0% in 2006, and 33.6% and 19.5% in 2008 (1-3). This study aim at continue monitoring the prevalence and its associations as it is strongly related to cardiovascular death (4). Design and Method: A community-based cross sectional study, was carried out in Malaysia between 2007 and 2010, using cut-off points body mass index (BMI) of 23 and 27.5 kg/m2 for overweight and obese (5). Data was analysed using STATA version 11. Results: A total of 10,963 subjects with complete BMI readings, out of 11,572 adult (>18 years old) subjects’ (mean age 51.2±11.0) data were analysed. The age-adjusted prevalence of overweight and obese were 38.3% (95% CI: 37.7- 39.1) and 34.0% (95% CI: 33.0-34.8), with female was significantly more obese (36.7%, CI; 35.4-37.8) than male (30.4%, CI; 29.1-31.7) (p<0.001) and urban population was significantly more obese (36.9%, CI; 35.6-38.1) than rural population (30.9%, CI; 29.6-32.1) (p<0.001). Highest prevalence of obesity were in Malays (38.9%, CI; 37.8-39.9), followed by Indians (35.8%, CI; 30.7-41.2) and lowest in Chinese (17.4%, CI; 15.2-19.5). Obese subjects were 1.8 (CI; 1.44-2.33), 1.7 (CI; 1.04-2.81), 2.38 (CI; 1.34-4.23) and 2.4 (CI; 1.91-3.01) more likely to have dyslipidaemia, impaired fasting glucose (IFG), newly diagnosed diabetes and hypertension, when compared to normal BMI, respectively. Conclusion: This study highlights the serious rise in obesity prevalent which deem the health system into action strategy at national level, as suggested by WHO (6) in fighting globesity. References:Khambalia AZ, Seen LS. Trends in overweight and obese adults in Malaysia (1996–2009): a systematic review. Obesity Reviews. 2010;11(6):403-12.Kee CC, Jamaiyah H, Noor Safiza MN, Geeta A, Khor GL, Suzana S, et al. Abdominal obesity in Malaysian adults: National Health and Morbidity Survey III (NHMS III, 2006). Malaysian Journal of Nutrition. 2008;14(2):125-35.Mohamud WN, Musa KI, Khir AS-M, Ismail AA-S, Ismail IS, Kadir KA, et al. Prevalence of overweight and obesity among adult Malaysians: an update. Asia Pacific Journal Of Clinical Nutrition. 2011;20(1):35-41.Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries. Current Problems in Cardiology. 2010;35(2):72-115.MOH. Clinical Practice Guideline on the Management of Obesity 2004. 2004.