Farnaza Ariffin

Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study

BACKGROUND Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability. METHODS We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost. FINDINGS Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040). INTERPRETATION The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables. FUNDING Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

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.

Migrant Workers in Malaysia: Current Implications of Sociodemographic and Environmental Characteristics in the Transmission of Intestinal Parasitic Infections.

A cross-sectional study of intestinal parasitic infections amongst migrant workers in Malaysia was conducted. A total of 388 workers were recruited from five sectors including manufacturing, construction, plantation, domestic and food services. The majority were recruited from Indonesia (n = 167, 43.3%), followed by Nepal (n = 81, 20.9%), Bangladesh (n = 70, 18%), India (n = 47, 12.1%) and Myanmar (n = 23, 5.9.2%). A total of four nematode species (Ascaris lumbricoides, Trichuris trichiura, Enterobius vermicularis and hookworms), one cestode (Hymenolepis nana) and three protozoan species (Entamoeba histolytica/dispar, Giardia sp. and Cryptosporidium spp.) were identified. High prevalence of infections with A. lumbricoides (43.3%) was recorded followed by hookworms (13.1%), E. histolytica/dispar (11.6%), Giardia sp. (10.8%), T. trichura (9.5%), Cryptosporodium spp. (3.1%), H. nana (1.8%) and E. vermicularis (0.5%). Infections were significantly influenced by socio-demographic (nationality), and environmental characteristics (length of working years in the country, employment sector and educational level). Up to 84.0% of migrant workers from Nepal and 83.0% from India were infected with intestinal parasites, with the ascarid nematode A. lumbricoides occurring in 72.8% of the Nepalese and 68.1% of the Indian population. In addition, workers with an employment history of less than a year or newly arrived in Malaysia were most likely to show high levels of infection as prevalence of workers infected with A. lumbricoides was reduced from 58.2% to 35.4% following a year’s residence. These findings suggest that improvement is warranted in public health and should include mandatory medical screening upon entry into the country.

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.

312 RELATIONSHIP BETWEEN MENOPAUSE AND CARDIOVASCULAR RISK FACTORS IN MALAYSIA

Background and Objective: Menopausal women are at an increased risk of developing cardiovascular diseases (CVD). This study is to determine the association between CVD risk factors in women who are menopausal compared to non menopausal Design and methods: Community-based, cross sectional study involving 11,288 adults aged ≥ 30 years was carried out in urban and rural areas of Malaysia between 2007 and 2010. Women who were on anti-hypertensive and anti-cholesterol treatment were excluded. Multivariate logistic regression analysis was used to determine the association between CVD risk factors and menopausal status. Results: Out of the 11,288 adults, 4645 women fulfilled the inclusion criteria of whom 2086 (45%) were menopausal and 2559 (55%) were non menopausal. Mean total cholesterol (p=0.001), low density lipid (p=0.001), triglycerides (p=0.001), high systolic blood pressure (p=0.001) and diastolic blood pressure (p=0.010) were significantly higher in menopausal as compared to non-menopausal women. There was no significant difference in mean high density lipoprotein level between the two groups (p=0.839). Mean body mass index in menopausal was significantly lower as compared to non-menopausal women (p=0.001). Conclusion: Menopausal women in Malaysia have higher CVD risk profile as compared to non-menopausal women. Concerted effort must be undertaken to screen and reduce CVD risk factors in these women.

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.

679 PREVALENCE OF DIABETES MELLITUS AMONG URBAN AND RURAL POPULATION IN MALAYSIA: IS THERE A DIFFERENCE?

Background & Objectives: Diabetes mellitus (DM) is one of the major cardiovascular risk factors. Its prevalence in Malaysia has showed an increased trend in the past three decades. The 3rd Malaysian National Health and Morbidity Survey 2006 reported that 14.9% of adults aged ≥ 30 years had DM. The aim of this study is to determine the prevalence, awareness, treatment and control of DM among the urban and rural population in Malaysia. Methods: This was a cross-sectional community-based study involving 11,288 adults aged ≥ 30 years conducted between 2007 and 2010. Demographic data, anthropometric measurements and venous blood glucose were obtained. Data was analysed using STATA version 11. Results: The prevalence of DM was 15.9 % (CI: 15.2 – 16.5), awareness rate was 76.3% (CI: 74.3 – 78.3), treatment rate was 56.1% (CI: 53.7 – 58.4) and control rate was 57.4% (CI: 55.0 – 59.7). The age, gender and ethnicity adjusted prevalence was significantly higher in the urban than rural population (15.8 % vs 14.5 %, p = 0.002). Similar trend was found for the treatment rate (57.4% vs 45.3%, p = 0.001). However, a reverse trend was seen for the control rate (47.7% vs 53.6%, p = 0.001). There was no significant difference in the adjusted awareness rate observed between urban and rural population (73.8% vs 66.7%, p = 0.356). Conclusions: The prevalence of DM in the urban population is higher in Malaysia. This might reflect the effect of urbanization. However, the control rate was lower for the urban population in spite of having higher treatment rate.

683 PREVALENCE, AWARENESS, TREATMENT AND CONTROL OF HYPERTENSION IN MALAYSIAN URBAN AND RURAL POPULATION: A CROSS SECTIONAL STUDY OF 11 288 SUBJECTS

Background & Objective: Hypertension is the leading cardiovascular risk factor globally as well as in Malaysia. The study aims to determine the prevalence, awareness, treatment and control of hypertension in Malaysian urban and rural populations. 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. An average of 3 blood pressure (BP) measurements using semi-automated, validated Omron HEM 757 sphygmomanometer was taken. Hypertension was defined as mean systolic BP > 140 mmHg and/or diastolic BP > 90 mmHg, or a self-reported diagnosis of hypertension or on anti-hypertensive agents. Data was analysed using STATA version 11. Results: The prevalence of hypertension was 47.9% (CI: 47- 49); awareness rate was 53.2% (CI: 51.5–53.1); treatment rate was 38.2% (CI: 36.8 – 39.5) and control rate was 15.9% (CI 14.9 – 16.9). The age and ethnicity adjusted prevalence of hypertension was significantly higher in rural as compared to urban population (46.1% vs 40.3%, p = 0.001). Significantly more urbansubjects received treatment (36.8% vs 32.5%, p = 0.001) with more urban subjects had their blood pressure controlled (16.9% vs12%, p = 0.001). Conclusion: Prevalence of hypertension is high in both urban andrural populations with higher treatment and control rates in the urban population. Hence, there is an urgent need for a comprehensive and integrated population-based intervention programme to improve outcomes in this population.

685 CARDIOVASCULAR RISK PROFILES OF THE ELDERLY POPULATION IN MALAYSIA

Background & Objective: Cardiovascular disease (CVD) is the 2nd leading cause of death in Malaysian hospitals and the prevalence of CVD risk factors is especially high amongst the elderly. This study aims to determine the cardiovascular risk profiles of the Malaysian elderly population. Methods: This community-based, cross sectional study involving 3113 adults aged ≥ 60 years was conducted in urban and rural areas in Malaysia between 2007 and 2010. Demographic data, anthropometric measurements and venous blood assays were obtained. Data was analyzed using STATA version 11. Results: Among the 3113 elderly subjects, 55% were from the urban areas and 45% were from the rural areas. 52.1% were males and 47.9% were females. Mean age was 67 years (SD ± 5.86). The subjects consisted of 71.7% Malays, 11.3% Chinese, 2% Indians and 15% others including Bumiputra Sabah & Sarawak. In relation to the various CVD risk factors among the elderly, comparing the urban and rural population, it is illustrated in the table below: Table. No title available. Conclusion: The elderly subjects from the urban areas had a higher prevalence of CVD risk factors compared to the rural areas. CVD risk factors assessment should be conducted routinely in the elderly and treated accordingly to reduce CV mortality in this vulnerable group.