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BACKGROUND Although higher diet quality at mid-life has been associated with better cognitive function in late adulthood, it is unclear whether dietary improvement after mid-life may reduce the risk of cognitive impairment. OBJECTIVES We examined associations between changes in diet quality and risk of cognitive impairment in the Singapore Chinese Health Study cohort. METHODS We used data from 14,683 Chinese men and women who were recruited at ages 45 to 74 y from 1993 to 1998 and re-interviewed after 20 y at ages 61 to 96 y during follow-up 3 (2014-2016). Diet quality was measured using the Dietary Approaches to Stop Hypertension (DASH) scores at baseline and follow-up 3 interviews. Cognitive impairment was defined using scores from the Singapore-modified Mini-Mental State Examination at the follow-up 3 interview. Multivariable logistic regression models were used to estimate ORs and 95% CIs for the associations between change in DASH scores and cognitive impairment. RESULTS Higher quintiles in DASH scores at baseline and follow-up 3 interviews were associated with lower odds of cognitive impairment in a dose-dependent manner (both: P-trend

Background: Limited research has been conducted on the effect of quality diet index (QDI), which represents a comprehensive assessment of healthy diet quality and quantity, on pancreatic cancer risk in Asian populations. Methods: Using data from the Singapore Chinese Health Study, a prospective cohort of 63,257 middle-aged or older Chinese men and women, four QDI scores: the Alternative Health Eating Index-2010 (AHEI-2010), the alternate Mediterranean Diet (aMED), the Dietary Approaches to Stop Hypertension (DASH), and the Heathy Diet Indicator (HDI), at baseline were calculated. After 25 years of follow-up, 311 cohort participants developed pancreatic cancer. Cox proportional hazard regression method was used to estimate HR and 95% confidence interval (CI) for pancreatic cancer associated with higher QDI scores. Results: Higher scores of AHEI-2010, aMED, and DASH were significantly associated with lower pancreatic cancer risk (all Ptrend < 0.05). Compared with the lowest quartile, HRs (95% CIs) of pancreatic cancer for the highest quartiles of AHEI-2010, aMED, and DASH scores were 0.65 (0.46–0.90), 0.57 (0.38–0.85), and 0.66 (0.46–0.95), respectively. These associations were more apparent among men. Overall, there was no statistically significant difference in the QDI–pancreatic cancer risk association between subgroups stratified by levels of body mass index, history of diabetes, and smoking status. Conclusions: Higher QDI scores were significantly associated with reduced risk of pancreatic cancer. Impact: The consistent results across multiple QDIs shows that adherence to a healthy diet may lower pancreatic cancer risk, suggesting that dietary modification may be a promising approach for primary prevention of pancreatic cancer.

Background Community-based diabetes prevention programs varied widely in effectiveness, and the intervention strategy consisting of lifestyle interventions, stepwise addition of metformin, and financial incentives has not been studied in real-world clinical practice settings. The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) trial is a pragmatic trial that aims to compare the effectiveness of a community-based stepwise diabetes prevention program with added financial incentives (intervention) versus the standard of care (control) in reducing the risk of type 2 diabetes over 3 years among overweight or obese individuals with pre-diabetes. Methods This is an open-label, 1:1 randomized controlled trial which aims to recruit 846 adult individuals with isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance (IGT), or both IFG and IGT from Singapore. Intervention arm participants attend 12 group-based sessions (2 nutrition workshops, 9 exercise sessions, and a goal-setting workshop) delivered at community sites (weeks 1 to 6), receive weekly physical activity and nutrition recommendations delivered by printed worksheets (weeks 7 to 12), and receive monthly health tips delivered by text messages (months 4 to 36). From month 6 onwards, intervention arm participants who remain at the highest risk of conversion to diabetes are prescribed metformin. Intervention arm participants are also eligible for a payment/rewards program with incentives tied to attendance at the group sessions and achievement of the weight loss target (5% of baseline weight). All participants are assessed at baseline, month 3, month 6, and every 6 months subsequently till month 36. The primary endpoint is the proportion of participants with diabetes at 3 years. Secondary endpoints include the mean change from baseline at 3 years in fasting plasma glucose, 2-hour plasma glucose, HbA1c, body weight, body mass index, physical activity, and dietary intake. Discussion The Pre-DICTED trial will provide evidence of the effectiveness and feasibility of a community-based stepwise diabetes prevention program with added financial incentives for individuals with pre-diabetes in Singapore. The study will provide data for a future cost-effectiveness analysis, which will be used to inform policymakers of the value of a nationwide implementation of the diabetes prevention program. Trial registration ClinicalTrials.govNCT03503942. Retrospectively registered on April 20, 2018. Protocol version: 5.0 Date: 1 March 2019

Background The prevalence of obesity is increasing in many Asian countries. However, longitudinal data on the impacts of dietary factors on weight gain in Asian populations are sparse. Objectives We evaluated the relationship between changes in intakes of nutrients, foods, and beverages and diet quality and long-term changes in body weight. Methods We used data (n = 3064) from the Singapore Multi-Ethnic Cohort, a prospective cohort including Chinese, Indian, and Malay residents aged 21-65 years. Dietary intakes were assessed using an FFQ, and body weight and waist circumference were measured during health examinations. Diet quality was evaluated using the Dietary Approaches to Stop Hypertension (DASH) and Alternative Healthy Eating Index (AHEI-2010) scores. Data were collected at baseline (2004-2010) and follow-up (2011-2016), with a mean follow-up of 6.0 years. Linear regression was used to assess the associations between dietary changes and weight change, adjusted for socio-demographic and lifestyle variables. Results Improvements in dietary quality scores (DASH, -0.34 kg per 5 points; AHEI-2010, -0.35 kg per 10 points) and replacement of carbohydrates with protein (-0.44 kg per 5% of energy) were significantly associated with less weight gain. Increased intakes of white rice (+0.25 kg per serving/d), soft drinks (+0.69 kg), red meat (+0.58 kg), and poultry with skin (+0.74 kg) were directly associated with weight gain. The replacement of 1 serving per day of white rice with whole grains (-0.68 kg), vegetables (-0.33 kg), poultry without skin (-0.79 kg), and eggs (-0.87 kg) was associated with less weight gain. Similar associations were observed between changes in dietary factors and changes in waist circumference. Conclusions Among Asian adults, increasing dietary quality, reducing soft drink consumption, and replacing white rice with whole grains, vegetables, and selected high-protein foods was associated with less weight gain.

Context The prevalence of type 2 diabetes mellitus (T2DM) and cardiovascular diseases (CVDs) is increasing in Asia and several countries are adopting preventive policies to reduce consumption of sugar-sweetened beverages (SSBs). However, evidence on the relation between SSB consumption and cardiometabolic health in Asian populations has not been summarized. Objective In this systematic review, the associations between consumption of SSBs and cardiometabolic outcomes, including obesity, T2DM, and CVD, are examined in Asian populations. Data sources The PubMed, Scopus, and Web of Science databases, and gray literature were searched up to October, 2020 to identify relevant articles. Data extraction Two investigators independently extracted data from included studies. Data analysis When sufficient studies were available, a random-effects meta-analysis was used to calculate the pooled estimates (expressed as risk ratio [RR] and 95% confidence interval [CI]). Heterogeneity was tested and quantified using the Cochrane Q test and I2 statistic, respectively. Results Of the 17 studies included, 8 provided results about measures of adiposity (3 on weight change, 4 on body mass index (BMI), 2 on percent body fat, and 1 on abdominal obesity), 6 reported results about T2DM, and 3 reported on different CVD outcomes. High SSB consumption was significantly associated with greater weight gain and with a higher risk of selected CVD outcomes as compared with low consumption. In the meta-analysis, high SSB consumption was associated with greater T2DM risk before (RR, 1.51; 95%CI, 1.15–1.98 for highest vs lowest category; I2 = 76%) and after (RR, 1.38; 95%CI, 1.09–1.73; I2 = 56%) adjustment for BMI. Conclusions These findings suggest that high SSB consumption is directly associated with weight gain, risk of T2DM, and, possibly, selected CVD outcomes in Asian populations. Public health strategies to reduce SSB consumption in Asian countries are warranted. Systematic Review Registration PROSPERO registration no. CRD42019129456.Keywords: adiposity. cardiovascular disease, Asia, sugar-sweetened beverages, type 2 diabetes.

Background: Both high energy density and fast eating rates contribute to excess energy intakes. The energy intake rate (EIR; kcal/min) combines both the energy density (kcal/g) and eating rate (g/min) of a food to quantify the typical rate at which calories of different foods are ingested. Objectives: We describe the EIRs of diets in a multi-ethnic Asian population, and examine relationships between the consumption of high-EIR foods and total energy intake, body composition, and cardio-metabolic risk factors. Methods: Diet and lifestyle data from the Singapore Multi-Ethnic Cohort 2 (n = 7011; 21-75 y), were collected through interviewer-administrated questionnaires. The EIR for each of the 269 foods was calculated as the product of its eating rate and energy density. Multivariable models were used to examine associations between the relative consumption of foods with higher and lower EIRs and energy intake, body composition, and cardio-metabolic risks, after adjusting for age, sex, ethnicity, education level, physical activity, smoking status, and alcohol drinking status. Results: Individuals with higher daily energy intakes and with obesity consumed a significantly larger percentage of their energy from high-EIR foods, with a smaller relative intake of lower-EIR foods. Individuals with raised serum cholesterol also consumed a significantly higher proportion of high-EIR foods, whereas those without hypertension consumed a larger percentage of energy intake from low-EIR foods. Individuals classified as having a "very high"dietary EIR had a significantly 1.3 kg higher body weight (95% CI, 0.2-1.5; P = 0.013), 0.4 kg/m2 higher BMI (95% CI, 0.03-0.8; P = 0.037), and 1.2 cm larger waist circumference (95% CI, 0.2-2.2; P = 0.010), and were more likely to have abdominal overweight (OR, 1.3; 95% CI, 1.1-1.5; P < 0.001) than those with a "low"dietary EIR. Conclusions: Comparing foods by their EIRs summarizes the combined impact of energy density and eating rate, and may identify foods and dietary patterns that are associated with obesogenic eating styles and higher diet-related cardiovascular disease risk in an Asian population.

There is limited research on the effect of dietary quality on hepatocellular carcinoma (HCC) risk in populations with relatively high risk of HCC. Using data from Singapore Chinese Health Study, a prospective cohort study, of 63 257 Chinese aged 45 to 74, we assessed four diet-quality index (DQI) scores: the Alternative Health Eating Index-2010 (AHEI-2010), Alternate Mediterranean Diet (aMED), Dietary Approaches to Stop Hypertension (DASH) and Heathy Diet Indicator (HDI). We identified 561 incident HCC cases among the cohort participants after a mean of 17.6 years of follow-up. Cox proportional hazard regression model was used to estimate hazard ratio (HR) and 95% confidence interval (CI) for HCC in relation to these DQI scores. Unconditional logistic regression method was used to evaluate the associations between DQIs and HCC risk among a subset of individuals who tested negative for hepatitis B surface antigen (HBsAg). High scores of AHEI-2010, aMED and DASH, representing higher dietary quality, were associated with lower risk of HCC (all Ptrend

Minimally invasive testing for early detection of lung cancer to improve patient survival is a major unmet clinical need. This study aimed to develop and validate a serum multi-microRNA (multimiR) panel as a minimally invasive test for early detection of nonsmall cell lung cancer (NSCLC) regardless of smoking status, gender, and ethnicity. Our study included 744 NSCLC cases and 944 matched controls, including smokers and nonsmokers, male and female, with Asian and Caucasian subjects. Using RT-qPCR and a tightly controlled workflow, we quantified the absolute expression of 520 circulating microRNAs (miRNAs) in a Chinese cohort of 180 early stage NSCLC cases and 216 healthy controls (male smokers). Candidate biomarkers were verified in two case-control cohorts of 432 Chinese and 218 Caucasians, respectively (including females and nonsmokers). A multimiR panel for NSCLC detection was developed using a twofold cross-validation and validated in three additional Asian cohorts comprising 642 subjects. We discovered 35 candidate miRNA biomarkers, verified 22 of them, and developed a five-miR panel that detected NSCLC with area under curve (AUC) of 0.936-0.984 in the discovery and verification cohorts. The panel was validated in three independent cohorts with AUCs of 0.973, 0.916, and 0.917. The sensitivity of five-miR test was 81.3% for all stages, 82.9% for stages I and II, and 83.0% for stage I NSCLC, when the specificity is at 90.7%. We developed a minimally invasive five-miR serum test for detecting early stage NSCLC and validated its performance in multiple patient cohorts independent of smoking status, gender, and ethnicity.

Coffee, Caffeine, and Health In many countries, a large majority of adults consume caffeine daily. This review summarizes the evidence about the varied physiological effects of caffeine and coffee ...

Background In observational studies, coffee consumption has been consistently associated with a lower risk of type 2 diabetes mellitus. Trials examining the effect of coffee consumption on glucose metabolism have been limited by the use of surrogate insulin sensitivity indices, small sample sizes, lack of blinding, and short follow-up duration. Objectives We aimed to overcome limitations of previously conducted coffee trials in a randomized placebo-controlled trial of the effect of coffee consumption on insulin sensitivity. Methods We conducted a 24-wk randomized placebo-controlled trial in 126 overweight, non-insulin sensitive (HOMA-IR ≥1.30), Chinese, Malay, and Asian-Indian males and females aged 35-69 y. Participants were randomly assigned to receive 4 cups of instant regular coffee (n = 62) or 4 cups of a coffee-like placebo beverage (n = 64) per day. The primary outcome was the amount of glucose metabolized per kilogram of body weight per minute (Mbw) assessed during steady-state conditions with a hyperinsulinemic euglycemic clamp. Secondary outcomes included other clamp-based insulin sensitivity measures, biological mediators of insulin sensitivity, and measures of fasting glucose metabolism. Results Coffee consumption did not significantly change insulin sensitivity compared with placebo (percentage mean difference in Mbw = 4.0%; 95% CI: -8.3, 18.0%; P = 0.53). Furthermore, no significant differences in fasting plasma glucose (2.9%; 95% CI: -0.4, 6.3%; P = 0.09) or biological mediators of insulin resistance, such as plasma adiponectin (2.3%; 95% CI: -1.4, 6.2%; P = 0.22), were observed between coffee and placebo groups over 24 wk of intervention. Participants in the coffee arm experienced a loss of fat mass (FM) (-3.7%; 95% CI: -6.3, -1.1%; P = 0.006) and reduction in urinary creatinine concentrations (-21.2%; 95% CI: -31.4, -9.5%; P = 0.001) compared with participants in the placebo arm over 24 wk of intervention. Conclusions Consuming 4 cups/d of caffeinated coffee for 24 wk had no significant effect on insulin sensitivity or biological mediators of insulin resistance but was associated with a modest loss of FM and reduction in urinary creatinine concentrations.This trial was registered at clinicaltrials.gov as NCT01738399. Registered on November 28, 2012. Trial sponsor: Nestle Research, Lausanne, Switzerland. Trial site: National University of Singapore.

Background Both fresh and processed foods are available in the modern food environment where taste can signal presence of nutrients. However, whether these taste–nutrient relationships are maintained across different degrees of food processing is not well understood, and less is known about the relative contribution of different taste qualities to population energy intakes. Objectives To investigate the association between perceived intensity of 6 taste modalities and a food's nutrient content in the context of food processing and to further examine the relative contribution of different taste clusters to total energy intakes, stratified by weight status. Methods Diet and lifestyle data from the Singapore Multi-Ethnic Cohort Phase 2 (N = 7011; aged 21–75 y) were collected through interviewer-administrated questionnaires. Taste and nutrient profiles for each of the 269 Singaporean foods were derived using a published taste database and food composition table. Each food was then categorized into the NOVA food-processing classification (unprocessed, processed, ultra-processed) to compare the strength of taste–nutrient relationships. Multivariable-adjusted models were used to examine associations between relative consumption of foods from different taste clusters and processing categories, energy intake, and BMI (in kg/m2) within a population cohort. Results Sweet taste and mono- and disaccharide content of foods were significantly associated across all processing categories, although this association was weaker among ultra-processed foods (UPFs) (r = 0.42) than among unprocessed foods (r = 0.72). In contrast, associations between fat sensation and fat content (r = 0.74), as well as salt taste and sodium content (r = 0.84), were stronger for UPFs. Individuals who had higher energy intakes or were overweight (BMI >23) derived significantly greater percentage of energy from processed foods rather than UPFs, and this energy was higher from “savory–fatty” and lower from “neutral” tasting foods than those with lower energy intakes and normal weight (all P

Identifying when most weight gain occurs throughout the life course can inform targeted public health interventions. We evaluated the association of childbirth, marriage, and employment changes with weight changes in a multi-ethnic Asian cohort. Singapore Multi-Ethnic Cohort participants ≥21 years (n = 9655) who identified as ethnic Chinese, Malay, or Indian were weighed and interviewed about marital status, employment, and number of children at baseline and after about four years. We used multivariable regression to evaluate life transitions in relation to weight change and major gain (≥5 kg), and adjusted for socio-demographic covariates. Weight gain was 3.55 kg (95% CI 3.17, 3.94) higher in young adults (21–30 years) compared with participants older than 60 years at baseline. Getting married was associated with weight gain in women, but not men (p interaction &lt, 0.01). Women who got married gained 1.63 kg (95% CI 0.88, 2.38) more weight and were more likely to gain ≥5 kg (OR 1.99, 95% CI 1.35, 2.93) than those remaining unmarried. Having children was not associated with weight gain. Only among ethnic Indians, remaining a homemaker was associated with less weight gain than remaining employed. In this multi-ethnic Asian population, obesity prevention efforts should target young adulthood and, in women, the transition into marriage.

Aims/hypothesisWe aimed to evaluate metabolic biomarkers in relation to incident type 2 diabetes (T2D) representing three major ethnic groups in Asia (Chinese, Malay, and Indian) and a European population. MethodsWe used data from male and female adult participants of multiple cohorts, including two cohorts from Singapore (n = 6,393 Asians) consisting of ethnic Chinese, Malays, and Indians, and three cohorts of European-origin participants from Finland (n = 14,558). We used nuclear magnetic resonance to quantify 154 metabolic biomarkers in plasma collected at baseline and performed multivariable logistic regression to assess associations between the metabolic measures and risk of T2D with adjustments for age, sex, BMI and either fasting glucose or glycated haemoglobin (HbA1c). ResultsOf 154 metabolic biomarkers, 59 were associated with higher risk of T2D in both Asians and Europeans (P < 0.0003; Bonferroni-corrected). These included branched-chain and aromatic amino acids and alanine, the inflammatory marker glycoprotein acetyls, total fatty acids, the proportion of monounsaturated fatty acids, apolipoprotein B, larger very low-density lipoprotein particle sizes, and triglycerides. A further 13 metabolic biomarkers were associated with lower T2D risk in both populations including proportion of omega-6 polyunsaturated fatty acids and larger high-density lipoprotein particle sizes. Associations were consistent within the Asian ethnic groups (Phet [≥] 0.05 for all 154 metabolic biomarkers) and largely consistent with the European population (Phet [≥] 0.05 for 128 of 154 metabolic biomarkers). Conclusions/interpretationMetabolic biomarkers across a variety of biological pathways were consistently associated with T2D risk in three Asian ethnic groups and a European population. Research in contextO_ST_ABSWhat is already known about this subject?C_ST_ABS- Previous metabolomics studies have uncovered metabolites that were consistently associated with risk of type 2 diabetes (T2D) - However, these studies were mostly conducted in populations of predominantly European ancestry, and it remains unclear if these findings can be generalized to different Asian ethnic groups What is the key question?- Are associations between metabolic biomarkers and T2D risk consistent between major Asian ethnic groups and a European population? What are the new findings?- Of 154 metabolic biomarkers, 59 including branched-chain and aromatic amino acids, glycoprotein acetyls, total fatty acids, the proportion of monounsaturated fatty acids, apolipoprotein B, larger very low-density lipoprotein particle sizes, and triglycerides were associated with higher T2D risk and a further 13 were associated with lower risk in both populations including proportion of omega-6 polyunsaturated fatty acids and larger high-density lipoprotein particle sizes - Associations were consistent within the Asian ethnic groups (Phet [≥] 0.05 for all 154 metabolic biomarkers) and largely consistent with the European population (Phet [≥] 0.05 for 128 of 154 metabolic biomarkers). How might this impact on clinical practice in the foreseeable future?- Metabolic aberrations were similarly associated with T2D risk in major Asian ethnic groups and Europeans despite environmental, lifestyle, and physiological differences. - These metabolic biomarkers are modifiable and may inform individualized interventions for the prevention of T2D

Preventive policies to improve diet and physical activity are urgently needed to stem the rising global burden of type 2 diabetes (1). In randomized trials, both high-carbohydrate diets (low in saturated fat and high in fiber), combined with physical activity and caloric restriction, and moderate-fat Mediterranean diets reduced diabetes risk (2). These findings suggest that diets with variable carbohydrate intakes are compatible with diabetes-prevention lifestyles but do not identify the optimal amount and type of dietary carbohydrates. Furthermore, the impact of high carbohydrate intakes in other parts of the world beyond the range studied in Western populations remains unclear. Rice provides ∼20% of the world's calorie intake (3). Of the 10 countries with the largest number of diabetes cases, 6 countries in Asia and South America have rice as the main staple food (4). Rice is predominantly consumed as white rice, a refined grain resulting from a milling process that removes the bran and germ and leaves the starchy endosperm. As a result, white rice is low in fiber, polyphenols, and micronutrients such as magnesium that may benefit glucose metabolism (5–7). White rice also has a high glycemic index (GI) and glycemic load (GL), reflecting high postprandial blood glucose levels (5). In several (8–10) but not all (9–11) prospective cohort studies in Asian countries, higher white rice consumption was associated with a higher risk of type 2 diabetes. Therefore, it is crucial to determine whether white rice consumption contributes to the development of type 2 diabetes, particularly in populations with high intake levels. Bhavadharini et al. (12) evaluated the association between …

BACKGROUND: Combinations of circulating fatty acids may affect the risk of type 2 diabetes (T2D) and coronary artery disease (CAD). No previous studies have identified a dietary pattern predicting fatty acid profiles using reduced rank regression (RRR) and evaluated its associations with the risk of T2D and CAD. OBJECTIVE: The aim of this study was to derive a dietary pattern to explain variation in plasma fatty acid concentrations using RRR and evaluate these in relation to risk of T2D and CAD. METHODS: We derived a dietary pattern using fatty acid concentrations from 711 controls of a nested case-control study in the Singapore Chinese Health Study using RRR with 36 food and beverages as predictors and 19 fatty acid biomarkers as responses. Dietary pattern scores were then calculated for the full cohort of men and women (mean age: 56 y). We followed up 45,411 and 58,065 participants for incident T2D and CAD mortality, respectively. Multivariable Cox regression models were used to estimate HRs and 95% CIs. RESULTS: We identified a dietary pattern high in soy, vegetables, fruits, tea, tomato products, bread, fish, margarine and dairy, and low in rice, red meat, coffee, alcohol, sugar-sweetened beverages, and eggs. This pattern predicted higher circulating n–3 (ω-3) PUFAs (18:3n–3, 20:3n–3, 20:5n–3), odd-chain fatty acids (15:0, 17:0), 18:2n–6 and 20:1, and lower 20:4n–6 and 16:1. During a mean follow-up of 11 y and 19 y, 5207 T2D and 3016 CAD mortality events, respectively, were identified. Higher dietary pattern scores were associated with a lower risk of T2D [multivariable-adjusted HR comparing extreme quintiles, 0.86 (95% CI: 0.79, 0.95); P-trend

BACKGROUND Prospective studies linking dietary pattern and cognitive function in the elderly are limited in Asian populations. OBJECTIVE We examined the associations between various healthful dietary patterns and risk of cognitive impairment in Chinese adults. METHODS We used data from the Singapore Chinese Health Study of 16,948 men and women who were aged 45-74 y at baseline (1993-1998) and reinterviewed at the third follow-up visit (2014-2016), ∼20 y later. Diet quality at baseline was assessed according to the alternate Mediterranean diet (aMED), the Dietary Approaches to Stop Hypertension (DASH) diet, the alternative Healthy Eating Index (AHEI)-2010, overall plant-based diet index (PDI), and healthful plant-based diet index (hPDI). Cognitive function was evaluated using a Singapore-modified Mini-Mental State Examination during the third follow-up visit when subjects were aged 61-96 y. Multivariable logistic regression models were used to compute ORs and 95% CIs associated with the risk of cognitive impairment defined using education-specific cut-offs. RESULTS Cognitive impairment was present in 2443 (14.4%) participants. The OR (95% CI) for cognitive impairment comparing the highest with the lowest quartile of diet quality scores was 0.67 (0.59, 0.77) for aMED, 0.71 (0.62, 0.81) for DASH, 0.75 (0.66, 0.85) for AHEI-2010, 0.82 (0.71, 0.94) for PDI, and 0.78 (0.68, 0.90) for hPDI (all P values for trend

Findings on the relations of maternal dietary patterns during pregnancy and risk of preterm birth and offspring birth size remain inconclusive. We aimed to systematically review and quantify these associations. We searched MEDLINE, Embase, CENTRAL, and CINAHL up to December 2017. Three authors independently conducted a literature search, study selection, data extraction, and quality assessment. Summary effect sizes were calculated with random effects models and studies were summarized narratively if results could not be pooled. We included 36 studies and pooled results from 25 observational studies (167,507 participants). Two common dietary patterns—“healthy” and “unhealthy”—were identified. Healthy dietary patterns—characterized by high intakes of vegetables, fruits, wholegrains, low-fat dairy, and lean protein foods—were associated with lower risk of preterm birth (OR for top compared with bottom tertile: 0.79; 95% CI: 0.68, 0.91; I2 = 32%) and a weak trend towards a lower risk of small-for-gestational-age (OR: 0.86; 95% CI: 0.73, 1.01; I2 = 34%). Only statistically data-driven healthy dietary patterns, and not dietary index-based patterns, were associated with higher birth weight (mean difference: 67 g; 95% CI: 37, 96 g; I2 = 75%). Unhealthy dietary patterns—characterized by high intakes of refined grains, processed meat, and foods high in saturated fat or sugar—were associated with lower birth weight (mean difference: −40 g; 95% CI: −61, −20 g; I2 = 0%) and a trend towards a higher risk of preterm birth (OR: 1.17; 95% CI: 0.99, 1.39; I2 = 76%). Data from observational studies indicate that greater adherence to healthy dietary patterns during pregnancy is significantly related to lower risk of preterm birth. No consistent associations with birth weight and small- or large-for-gestational-age were observed.

Background Few studies have investigated the association between screen viewing (SV) and sleep duration among young children. This study aims to examine the association between total and device-specific SV and sleep duration among children aged 2 and below. Methods We conducted a cross-sectional study of 714 Singaporean children aged 2 years and below. Parents were recruited during routine well-child clinic visits from two national polyclinics. In Singapore, all parents visit well-child clinics with their children at regular intervals for routine check-ups and vaccinations. Socio-demographic characteristics, duration of total and device-specific SV, and sleep duration were reported by parents via interviewer-administered questionnaires. Multiple linear regression analysis was used to assess associations between various types of SV and sleep duration, adjusted for socio-demographic variables. Due to significant interaction between SV and age, stratified analyses for children aged less than 6 months and those aged 7–24 months were performed. Results The prevalence of daily SV among children was 53.1%; 28.3% in children up to 6 months and 73.8% in children aged 7 to 24 months. TV viewing was reported for 44.3% of all children and mobile device SV for 30.1%. Children’s average sleep duration was 13.9 (SD = 3.5) hours daily and younger children had longer sleep duration than older ones (up to 6 months: mean = 15.6 h, SD = 3.9; 7–24 months: mean = 12.4 h, SD = 2.2; P

BackgroundCancer has become the leading cause of mortality in Singapore and among other Asian populations worldwide. Despite the presence of National Cancer Screening programmes in Singapore, less than half of the population has had timely screening according to guidelines. The underlying factors of poor cancer screening rates and health outcomes among Asian ethnic groups remain poorly understood. We therefore examined cancer screening participation rates and screening behavior in a multi-ethnic Singapore population.MethodsWe collected data from 7,125 respondents of the 2015–2016 Singapore Community Health Study. Factors associated with cervical, breast, and colorectal cancer screening were evaluated using modified Poisson regression. Adjusted prevalence ratios were computed with 95% confidence intervals after adjusting for confounders.ResultsThe mean age of the respondents was 57.7 ± 10.9 years; 58.9% were female and were predominately Chinese (73.0%), followed by Malay (14.2%), and Indian (10.9%). Less than half of the respondents in the recommended age groups had undergone cancer screening (cervical, 43%; breast, 35.1%; colorectal, 27.3%). Malay respondents were significantly less likely to screen as recommended for cervical (aPR = 0.75, CI = 0.65–0.86, p < 0.001), breast (aPR = 0.83, CI = 0.68–0.99, p = 0.045), and colorectal cancer (aPR = 0.55, CI = 0.44–0.68, p < 0.001), as compared to Chinese respondents. Respondents who had obtained lower secondary level education were 42% more likely to screen for cervical cancer (aPR = 1.42, CI = 1.23–1.64, p < 0.001), and 22% more likely to screen for breast cancer (aPR = 1.22, CI = 1.02–1.46, p = 0.032), compared to those with primary level education and below. Respondents with a household income ≥S$10,000/month were 71% more likely to screen for breast cancer (aPR = 1.71, CI = 1.37–2.13, p < 0.001), as compared with ConclusionsEthnicity and socio-economic status were significantly associated with lower uptake of cancer screening tests in Singapore. To improve the screening uptake among disadvantaged groups, a multi-faceted approach is needed that addresses the barriers to screening such as the adequacy of subsidy schemes and ethnic differences.

ObjectivesSeveral studies have linked diabetes mellitus to adverse childhood experiences (ACEs). While a number of studies have examined the association between ACEs and diabetes in Western populations, few have done it in Asian populations. The current study aimed to examine (1) the association between ACEs and diabetes, including the association after age stratification, and (2) the association of comorbid depression, resource use and health-related quality of life (HRQoL) among those with diabetes and ACEs in Singapore.SettingsParticipants were surveyed in their homes or any other preferred venue of their choice.Participants6126 individuals aged 18 years and above were randomly selected among Singapore residents.DesignCross-sectional nationwide epidemiological study.ResultsExposure to any ACE was not associated with increased odds of diabetes; however, those who had experienced parental separation, death or divorce of a parent had higher odds of diabetes. In addition, we observed significant interaction between age and ACEs in relation to odds of diabetes. ACEs were significantly associated with higher odds of diabetes mainly in the younger age group. The prevalence of major depressive disorder was significantly higher among those with diabetes and ACEs than those with diabetes alone (3.7% and 0.3% respectively).ConclusionsEfforts to promote regular exercise and healthy lifestyles both in the population and among those with diabetes must continue for the prevention and management of diabetes. The findings emphasise the need to create more awareness of both the prevalence and impact of ACEs among those treating chronic diseases.

Background: Hypertriglyceridemia has emerged as a critical coronary artery disease (CAD) risk factor. Rare loss-of function (LoF) variants in apolipoprotein C-III have been reported to reduce triglycerides (TG) and are cardioprotective in American Indians and Europeans. However, there is a lack of data in other Europeans and non-Europeans. Also, whether genetically increased plasma TG due to ApoC-III is causally associated with increased CAD risk is still unclear and inconsistent. The objectives of this study were to verify the cardioprotective role of earlier reported six LoF variants of APOC3 in South Asians and other multi-ethnic cohorts and to evaluate the causal association of TG raising common variants for increasing CAD risk. Methods: We performed gene-centric and Mendelian randomization analyses and evaluated the role of genetic variation encompassing APOC3 for affecting circulating TG and the risk for developing CAD. Results: One rare LoF variant (rs138326449) with a 37% reduction in TG was associated with lowered risk for CAD in Europeans (p = 0.007), but we could not confirm this association in Asian Indians (p = 0.641). Our data could not validate the cardioprotective role of other five LoF variants analysed. A common variant rs5128 in the APOC3 was strongly associated with elevated TG levels showing a p-value 2.8 × 10− 424. Measures of plasma ApoC-III in a small subset of Sikhs revealed a 37% increase in ApoC-III concentrations among homozygous mutant carriers than the wild-type carriers of rs5128. A genetically instrumented per 1SD increment of plasma TG level of 15 mg/dL would cause a mild increase (3%) in the risk for CAD (p = 0.042). Conclusions: Our results highlight the challenges of inclusion of rare variant information in clinical risk assessment and the generalizability of implementation of ApoC-III inhibition for treating atherosclerotic disease. More studies would be needed to confirm whether genetically raised TG and ApoC-III concentrations would increase CAD risk. Ministry of Health (MOH) National Medical Research Council (NMRC) Published version AIDHS/SDS: The Sikh Diabetes Study/ Asian Indian Diabetic Heart Study was supported by NIH grants-R01DK082766; R01DK118427 (NIDDK) and NOT-HG11-009 (NHGRI) and grants from Presbyterian Health Foundation and Harald Hamm Diabetes Center of Oklahoma. Sequencing services were provided through the RS&G Service by the Northwest Genomics Center at the University of Washington, Department of Genome Sciences, under US Federal Government contract number HHSN268201100037C from the National Heart, Lung, and Blood Institute of the NIH. LOLIPOP: The LOLIPOP study is supported by the National Institute for Health Research (NIHR) Comprehensive Biomedical Research Centre Imperial College Healthcare NHS. Trust, the British Heart Foundation (S.P./04/002), the Medical Research Council (G0601966, G0700931), the Wellcome Trust (084723/Z/08/Z, 090532 & 098381) the NIHR (RP-PG-0407-10371), the NIHR Official Development Assistance (ODA, award 16/136/68), the European Union FP7 (EpiMigrant, 279143) and H2020 programs (iHealth-T2D, 643774). We acknowledge the support of the MRC-PHE Centre for Environment and Health, and the NIHR Health Protection Research Unit on Health Impact of Environmental Hazards. The work was carried out in part at the NIHR/Wellcome Trust Imperial Clinical Research Facility. The views expressed are those of the author(s) and not necessarily those of the Imperial College Healthcare NHS. Trust, the NHS, the NIHR, or the Department of Health. We thank the participants and research staff who made the study possible. JC is supported by the Singapore Ministry of Health’s National Medical Research Council under its Singapore Translational Research Investigator (STaR) Award (NMRC/ STaR/0028/2017). SAMAFS: SAMAFS is supported in part by National Institutes of Health (NIH) grants P01 HL045522, R01 DK047482, DK053889, R01 HL113323, R37 MH059490, and T2D-GENES Consortium grants (U01 DK085524, U01 DK085584, U01 DK085501, U01 DK085526, and U01 DK085545). We thank the participants of the San Antonio Family Heart Study and the San Antonio Family Diabetes/Gallbladder Study for their continued cooperation and participation in our research programs. MISS-OLIVER: The OLIVER and MISS are partly supported by NIH grants -R01DK082766 funded by the National Institute of Health (NIDDK), Presbyterian Health Foundation Grants, the College of Medicine Alumni Association grant, and Leinbach Seed Grant from the University of Oklahoma Health Sciences Center. The authors thank all the participants of MISS-OLIVER participants and are grateful for their contribution to this study. UKBB: YT is supported by a Funai Overseas Scholarship from the Funai Foundation for Information Technology and the Stanford University School of Medicine. MAR is partially supported by Stanford University and a National Institute of Health center for Multi-and Trans-ethnic Mapping of Mendelian and Complex Diseases grant (5 U01 HG009080) and partially supported by the National Human Genome Research Institute (NHGRI) of the National Institutes of Health (NIH) under award R01HG010140.

Background The prevalence of obesity and its related chronic diseases have been increasing especially in Asian countries. Obesity-related genetic variants have been identified, but these explain little of the variation in BMI. Recent studies reported associations between DNA methylation and obesity, mostly in non-Asian populations. Methods We performed an epigenome-wide association study (EWAS) on general adiposity (body mass index, BMI) and abdominal adiposity (waist circumference, WC) in 409 multi-ethnic Asian individuals and replicated BMI and waist-associated DNA methylation CpGs identified in other populations. The cross-lagged panel model and Mendelian randomization were used to assess the temporal relationship between methylation and BMI. The temporal relationship between the identified CpGs and inflammation and metabolic markers was also examined. Results EWAS identified 116 DNA methylation CpGs independently associated with BMI and eight independently associated with WC at false discovery rate PFDR Conclusion Our study provides evidence of an association between obesity and DNA methylation in multi-ethnic Asians and suggests that obesity can drive methylation change. The results also suggested possible causal influence that obesity-related methylation changes might have on inflammation and lipoprotein levels.

Purpose: Variations in specific oral processing behaviours may contribute to differences in glucose, insulin and satiety responses to a standardised test meal. This study tested how natural variations in oral processing between slower and faster eaters contribute to differences in post-prandial glucose (PP glucose), insulin response (PP insulin) and post-meal satiety for a standardised test meal. Methods: Thirty-three participants with higher risk for type 2 diabetes consumed a standardised test-meal while being video recorded to derive specific oral processing behaviours. Plasma glucose, insulin and satiety measures were collected at baseline, during and post meal. Participants were split into slower and faster eaters using median split based on their eating rates and individual bolus properties were analysed at the point of swallow. Results: There were large variations in eating rate (p < 0.001). While there was no significant difference in PP glucose response (p > 0.05), slower eaters showed significantly higher PP insulin between 45 and 60 min (p < 0.001). Slower eaters had longer oro-sensory exposure and increased bolus saliva uptake which was associated with higher PP glucose iAUC. Faster eating rate and larger bolus particle size at swallow correlated with lower PP glucose iAUC. A slower eating rate with greater chews per bite significantly increased insulin iAUC. Faster eaters also consistently rated their hunger and desire to eat higher than slower eaters (p < 0.05). Conclusions: Natural variations in eating rate and the associated oral processing contributed to differences in PP glucose, PP insulin and satiety responses. Encouraging increased chewing and longer oral-exposure time during consumption, may promote early glucose absorption and greater insulin and satiety responses, and help support euglycaemia. Trial Registration: ClinicalTrials.gov identifier: NCT04522063.

The study aimed to investigate the association between leisure time physical activity (LTPA) subtypes and cardiometabolic outcomes in the Singapore Multi-Ethnic Cohort (MEC). Self-reported data on socio-demographics, lifestyle factors , LTPA subtypes, and health screening data on body-mass index (BMI), waist circumference (WC), systolic and diastolic blood pressure (SBP and DBP), triglycerides (TG), and HDL-and LDL cholesterol were collected. Multivariable linear regression analyses were used adjusting for confounders. The mean age of 9768 participants was 45.2 &plusmn, 12.5 years (57.3% female, 47.3% Chinese, 26.0% Malay, and 26.8% Indians). Overall, 65.8% engaged in LTPA, and walking, strength/fitness and running were most common. Higher total LTPA was associated with lower WC, DBP, TG, a trend towards lower BMI, and higher SBP and HDL. Running was beneficially associated with all outcomes except for SBP and LDL. Balance exercises (BMI, SBP and DBP), cycling (BMI, WC and HDL), and strength/fitness (BMI, WC, TG and HDL) were also favorably associated with a number of outcomes, whereas ball games (DBP and TG), dancing (HDL) and other LTPA (DBP) were only favorably associated with selected outcomes. Unfavorable associations were found for total LTPA (SBP), strength/fitness (SBP), golf (DBP) and swimming (BMI and WC). Further research is warranted to inform future health promotion efforts.

BackgroundSocial media influence almost every aspect of our lives by facilitating instant many-to-many communication and self-expression. Recent research suggests strong negative and positive impacts of social media exposure on youth mental health; however, there has been more emphasis on harmful relationships.ObjectiveGiven the limited research on the benefits of social media for mental health, this qualitative study explored the lived experiences of youth to understand how social media use can contribute to positive mental health among youth.MethodsUsing an interpretivist epistemological approach, 25 semistructured interviews and 11 focus group discussions were conducted with male and female youth of different ethnicities (aged 15 to 24 years) residing in Singapore, who were recruited through purposive sampling from the community. We conducted inductive thematic analysis and concept mapping to address the research aims.ResultsWe found that youth engaged in a wide range of activities on social media from connecting with family and friends to participating in global movements, and these served as avenues for building positive mental health. Based on participants’ narratives, our analysis suggested that positive mental health among youth could be influenced by 3 features of social media consumption (connection with friends and their global community, engagement with social media content, and the value of social media as an outlet for expression). Through these, pathways leading to the following 5 positive mental health components were identified: (1) positive relationships and social capital, (2) self-concept, (3) coping, (4) happiness, and (5) other relevant aspects of mental health (for example, positivity and personal growth).ConclusionsThe study results highlight the integral role of social media in the lives of today’s youth and indicate that they can offer opportunities for positive influence, personal expression, and social support, thus contributing to positive mental health among youth. The findings of our research can be applied to optimize engagement with youth through social media and enhance the digital modes of mental health promotion.

This article aims to provide a detailed description of the Singapore Breast Cancer Cohort (SGBCC), an ongoing multi-ethnic cohort established with the overarching goal to identify genetic markers for breast cancer risk, prognosis and treatment response, as well as to understand the ethnic differences in disease risk and outcome in an Asian setting. The cohort comprises of breast cancer patients aged 21 years and above from six public hospitals which diagnose and treat nearly 76% breast cancer cases in Singapore. Self-reported data on sociodemographic and lifestyle, reproductive risk factors, medical history and family history of breast or ovarian cancer is collected using a structured questionnaire. Clinical data on tumour characteristics, and treatment modalities are obtained through medical record. Bio-specimens (blood or saliva) is collected at recruitment. Follow-up on survival information is done through routine linkage with the Registry of Births and Deaths. As of 31 December 2016, 7,768 subjects have been recruited to the study with 76% subjects contributed bio-specimens. The SGBCC provides a valuable platform which offers a unique, large and rich resource for new research ideas on breast cancer related phenotypic risk factors and genetic markers.

IntroductionWe evaluated whether concentrations of serum acylcarnitines and amino acids are associated with risk of type 2 diabetes and can improve predictive diabetes models in an Asian population.Research design and methodsWe used data from 3313 male and female participants from the Singapore Prospective Study Program cohort who were diabetes-free at baseline. The average age at baseline was 48.0 years (SD: 11.9 years), and participants were of Chinese, Malay, and Indian ethnicity. Diabetes cases were identified through self-reported physician diagnosis, fasting glucose and glycated hemoglobin concentrations, and linkage to national disease registries. We measured fasting serum concentrations of 45 acylcarnitines and 14 amino acids. The association between metabolites and incident diabetes was modeled using Cox proportional hazards regression with adjustment for age, sex, ethnicity, height, and parental history of diabetes, and correction for multiple testing. Metabolites were added to the Atherosclerosis Risk in Communities (ARIC) predictive diabetes risk model to assess whether they could increase the area under the receiver operating characteristic curve (AUC).ResultsParticipants were followed up for an average of 8.4 years (SD: 2.1 years), during which time 314 developed diabetes. Branched-chain amino acids (HR: 1.477 per SD; 95% CI 1.325 to 1.647) and the alanine to glycine ratio (HR: 1.572; 95% CI 1.426 to 1.733) were most strongly associated with diabetes risk. Additionally, the acylcarnitines C4 and C16-OH, and the amino acids alanine, combined glutamate/glutamine, ornithine, phenylalanine, proline, and tyrosine were significantly associated with higher diabetes risk, and the acylcarnitine C8-DC and amino acids glycine and serine with lower risk. Adding selected metabolites to the ARIC model resulted in a significant increase in AUC from 0.836 to 0.846.ConclusionsWe identified acylcarnitines and amino acids associated with risk of type 2 diabetes in an Asian population. A subset of these modestly improved the prediction of diabetes when added to an established diabetes risk model.

Novel staple foods are staple foods that are modified with the purpose of improving their nutritional properties. However, consumers' acceptance towards novel staple foods remains to be evaluated, especially in Asian populations where staple foods like white rice are a major source of energy. The objective of this study was to explore consumers' attitudes and perceptions towards novel staple foods in a multi-ethnic Asian population. We conducted 11 focus group discussions, with 37 healthy participants and 22 participants with diabetes recruited through newspaper, email and poster advertisement and in-person recruitment at a clinic. Thematic analysis using the general inductive approach was performed. We found that participants' conceptual understanding of the modification process affected their acceptance towards novel staple foods. Plant-based modifications were considered natural and acceptable while genetic modification and use of chemicals were unnatural and undesirable. Participants expected novel staple foods to be more expensive and less tasty and this was largely due to their perceptions and experiences with healthy eating. Participants with diabetes or family history of diabetes were generally more willing to compromise taste and cost for healthier staple foods, and this appeared to be driven by concerns about diabetes and its related co-morbidities. The appearance of food was an important influence on participants' initial impression of the food, which appeared to be mediated by taste expectations. Participants’ trust of novel staple foods was largely influenced by their trust in food industry, governmental authorities and nutrition science that was mediated through pathways of information and food safety.

Sphingolipids are a diverse class of lipids with various roles in cell functions and subclasses such as ceramides have been associated with cardiovascular diseases (CVD) in previous studies. We aimed to measure molecularly-distinct sphingolipids via a large-scale lipidomic analysis and expand the literature to an Asian population. We performed a lipidomics evaluation of 79 molecularly distinct sphingolipids in the plasma of 2627 ethnically-Chinese Singaporeans. During a mean follow-up of 12.9 years, we documented 152 cases of major CVD (non-fatal myocardial infarction, stroke and cardiovascular death). Total ceramide concentrations were not associated with CVD risk [hazard ratio (HR), 0.99; 95% CI 0.81–1.21], but higher circulating total monohexosylceramides (HR, 1.22; 95% CI 1.03, 1.45), total long-chain sphingolipids (C16–C18) (HR, 1.22; 95% CI 1.02, 1.45) and total 18:1 sphingolipids (HR, 1.21; 95% CI 1.01, 1.46) were associated with higher CVD risk after adjusting for conventional CVD risk factors. Our results do not support the hypothesis that higher ceramide concentrations are linked to higher CVD risk, but suggest that other classes of sphingolipids may affect CVD risk.

Glycaemic traits are used to diagnose and monitor type 2 diabetes, and cardiometabolic health. To date, most genetic studies of glycaemic traits have focused on individuals of European ancestry. Here, we aggregated genome-wide association studies in up to 281,416 individuals without diabetes (30% non-European ancestry) with fasting glucose, 2h-glucose post-challenge, glycated haemoglobin, and fasting insulin data. Trans-ancestry and single-ancestry meta-analyses identified 242 loci (99 novel; P-8), 80% with no significant evidence of between-ancestry heterogeneity. Analyses restricted to European ancestry individuals with equivalent sample size would have led to 24 fewer new loci. Compared to single-ancestry, equivalent sized trans-ancestry fine-mapping reduced the number of estimated variants in 99% credible sets by a median of 37.5%. Genomic feature, gene-expression and gene-set analyses revealed distinct biological signatures for each trait, highlighting different underlying biological pathways. Our results increase understanding of diabetes pathophysiology by use of trans-ancestry studies for improved power and resolution.

Polygenic risk scores (PRS) have been shown to predict breast cancer risk in European women, but their utility in Asian women is unclear. Here we evaluate the best performing PRSs for European-ancestry women using data from 17,262 breast cancer cases and 17,695 controls of Asian ancestry from 13 case-control studies, and 10,255 Chinese women from a prospective cohort (413 incident breast cancers). Compared to women in the middle quintile of the risk distribution, women in the highest 1% of PRS distribution have a ~2.7-fold risk and women in the lowest 1% of PRS distribution has ~0.4-fold risk of developing breast cancer. There is no evidence of heterogeneity in PRS performance in Chinese, Malay and Indian women. A PRS developed for European-ancestry women is also predictive of breast cancer risk in Asian women and can help in developing risk-stratified screening programmes in Asia., Polygenic risk scores predict the likelihood that an individual will develop a certain cancer, however these are often specific for a given population. Here, the authors show that a risk score developed to assess the risk of breast cancer in European women can also predict risk in Asian populations.

To assess contributions of dietary and genetic factors to ethnic differences in AMD prevalence.Population-based analytical study.In the Blue Mountains Eye Study, Australia (European ancestry n = 2826) and Multi-Ethnic Cohort Study, Singapore (Asian ancestry, n = 1900), AMD was assessed from retinal photographs. Patterns of dietary composition and scores of the Alternative Healthy Eating Index were computed using food frequency questionnaire data. Genetic susceptibility to AMD was determined using either single nucleotide polymorphisms (SNPs) of the cAge-standardized prevalence of any (early or late) AMD was higher in the European (16%) compared to Asian samples (9%,Genetic susceptibility to AMD was higher in European compared to Chinese samples and explained more of the AMD risk difference between the two samples than the dietary factors investigated.

IntroductionThis study aims to establish the Knowledge, Attitudes and Practices (KAP) of the general population (people with and without diabetes) towards diabetes. The study will examine (a) recognition and understanding of causes, prevention and treatment strategies of diabetes; (b) identify the knowledge gaps and behavioural patterns that may hamper diabetes prevention and control; (c) stigma towards and stigma perceived by people with diabetes and (d) awareness of anti-diabetes campaigns.Methods and analysisThe study is a nationwide, cross-sectional study of Singapore’s general population aged 18 years and above (n=3000), comprising Chinese, Malay, Indian and other ethnic groups, who can understand English, Chinese, Malay or Tamil language. The sample was derived using a disproportionate stratified sampling using age and ethnicity. The proportion of respondents in each ethnic group (Chinese, Malay and Indian) was set to approximately 30%, while the proportion of respondents in each age group was set around 20% in order to ensure a sufficient sample size. The respondents will be administered questionnaires on diabetes KAP, stigma towards diabetes, lifestyle, diet and awareness of local anti-diabetes campaigns. The analysis will include descriptive statistics and multiple logistic and linear regression analyses to determine the socio-demographic correlates of correct recognition of diabetes, help-seeking preferences, as well as overall knowledge and attitudes among those with and without diabetes. We will consider a p value ≤0.05 as significant.Ethics and disseminationThis study protocol has been reviewed by the Institutional Research Review Committee and the National Healthcare Group Domain Specific Review Board (NHG DSRB Ref 2018/00430). The results of the study will be shared with policymakers and other stakeholders. There will be a local mass media briefing to disseminate the findings online, in print and on television and radio. The results will be published in peer-reviewed journals and presented in scientific meetings.

OBJECTIVES: To assess associations between individual and total circulating n-3 fatty acids (FAs) with self-reported sleep duration and difficulty sleeping in the Fatty Acids and Outcome Research Consortium (FORCE). METHODS: De novo harmonized individual-level analyses were performed and pooled in 10 prospective studies (N = 22,717) with data on sleep duration and 7 studies (N = 9997) with data on difficulty initiating sleeping (DIS). Participant ages ranged from 35 to 96 years from 5 countries (Finland, Iceland, Sweden, Singapore, and the United States). Measured circulating FAs included alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), docosahexaenoic acid (DHA), and the sum of EPA, DPA and DHA. FAs were expressed as a % of total FAs. Self-reported sleep duration was categorized as short (8 hrs). DIS was categorized as yes or no (reference). Cross-sectional associations were assessed by multinomial logistic regression in each study with a standardized protocol including definitions for exposures, outcomes and covariates (demographics, health factors and dietary habits). Cohort-specific odds ratios (OR) per quintile (reference: Q1) of FAs were pooled with inverse-variance weighted meta-analysis. RESULTS: In pooled multivariate analysis, we found that participants with higher circulating n-3 FAs (Q5) had a lower risk of short and long sleep duration. For short sleep ORs (95% confidence intervals, CI) for Q5 were 0.87 (0.78–0.98) for EPA, 0.87 (0.77–0.97) for DPA, 0.83 (0.73–0.93) for DHA and 0.83 (0.74–0.93) for the sum of EPA, DPA and DHA, respectively. For long sleep ORs (95% CI) were 0.79 (0.64–0.97) for DHA, and 0.80 (0.65–0.98) for the sum of EPA, DPA and DHA. The only significant association observed for DIS was for Q3 of DHA, OR = 0.77, 95% CI = 0.63–0.96. CONCLUSIONS: In pooled de novo analyses across multiple cohorts, higher levels of n-3 FAs are associated with lower risk of suboptimal sleep (i.e., too little or too much sleep); These novel findings support the need for additional investigation of the temporal nature and causality of these relationships. FUNDING SOURCES: International Life Sciences Institute, North America.

To examine the associations between dietary patterns in midlife and likelihood of future healthy ageing in Chinese older adults.Prospective population-based study.We included 14,159 participants aged 45-74 years who were free from cancer, cardiovascular disease, or diabetes at baseline (1993-1998) from the Singapore Chinese Health Study.Dietary intakes in midlife were assessed by a validated food frequency questionnaire at baseline. Diet quality was scored according to the alternate Mediterranean diet (aMED), the Dietary Approaches to Stop Hypertension (DASH) diet, the alternative Healthy Eating Index (AHEI)-2010, overall plant-based diet index (PDI), and healthful plant-based diet index (hPDI). Healthy ageing was assessed at the third follow-up visit (2014-2016), which occurred about 20 years after the baseline visit, and was defined as the absence of 10 chronic diseases, no impairment of cognitive function, no limitations in instrumental activities of daily living, no clinical depression at screening, good overall self-perceived health, good physical functioning, and no function-limiting pain among participants who had survival to at least 65 years of age. Multivariable-adjusted logistic regression models were applied to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between each dietary pattern score and healthy ageing.About 20.0% of participants met the healthy ageing criteria. The OR (95% CI) for healthy ageing comparing the highest with the lowest quartile of diet quality scores was 1.52 (1.31-1.77) for aMED, 1.53 (1.35-1.73) for DASH, 1.39 (1.23-1.57) for AHEI-2010, 1.34 (1.18-1.53) for PDI, and 1.45 (1.27-1.65) for hPDI (all P-trend .001). Each standard deviation increment in different diet quality scores was associated with 12% to 18% higher likelihood of healthy ageing.In this Chinese population, adherence to various healthy dietary patterns at midlife is associated with higher likelihood of healthy ageing at later life.

BACKGROUND: Although adherence to healthful dietary patterns has been associated with a lower risk of kidney function decline in Western populations, evidence in Asian populations remains scanty. OBJECTIVES: We examined predefined dietary patterns, namely, the Alternate Healthy Eating Index-2010 (AHEI-2010), the Dietary Approaches to Stop Hypertension (DASH), and the alternate Mediterranean diet (aMED), in relation to risk of end-stage kidney disease (ESKD). METHODS: We included 56,985 Chinese adults (aged 45–74 y) in the Singapore Chinese Health Study who were free of cancer, stroke, coronary artery disease, and ESKD at recruitment (1993–1998). Dietary pattern scores were calculated based on a validated 165-item FFQ. AHEI-2010 and aMED scores were modified by excluding the alcohol intake component because daily drinking has been associated with a higher risk of ESKD in our study population. We identified 1026 ESKD cases over a median follow-up of 17.5 y via linkage with the nationwide Singapore Renal Registry. Multivariable Cox regression models were used to compute HRs and their 95% CIs. RESULTS: Higher scores of all 3 dietary patterns were associated with lower ESKD risk in a dose-dependent manner. Compared with the lowest quintiles, the multivariable-adjusted HRs (95% CIs) of ESKD were 0.75 (0.61, 0.92) for the highest quintile of AHEI-2010, 0.67 (0.54, 0.84) for DASH, and 0.73 (0.59, 0.91) for aMED (all P-trend ≤ 0.004). These inverse associations were stronger with increasing BMI (in kg/m(2)), and the HRs for the diet–ESKD association were lowest in the obese (BMI ≥ 27.5), followed by the overweight (BMI = 25 to

OBJECTIVE SMART-GDM examined whether Habits-GDM, a smartphone application (app) coaching program, can prevent excessive gestational weight gain (EGWG) and improve glycemic control and maternal and neonatal outcomes in gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS In this randomized controlled trial, women diagnosed with GDM between 12 and 30 weeks were randomly assigned to usual care (control) or to additional support from Habits-GDM that integrated dietary, physical activity, weight, and glucose monitoring (intervention). The primary outcome was the proportion of participants with EGWG. Secondary outcomes included absolute gestational weight gain (GWG), glycemic control, and maternal, delivery, and neonatal outcomes. RESULTS In total, 340 women were randomized (170 intervention, 170 control; mean ± SD age 32.0 ± 4.2 years; mean BMI 25.6 ± 5.6 kg/m2). There were no statistically significant differences in the proportions of women with EGWG, absolute GWG, or maternal and delivery outcomes between experimental groups. Average glucose readings were lower in the intervention group (mean difference −0.15 mmol/L [95% CI −0.26; −0.03], P = 0.011) as were the proportions of glucose above targets (premeal: 17.9% vs. 23.3%, odds ratio 0.68 [95% CI 0.53; 0.87], P = 0.003; 2-h postmeal: 19.9% vs. 50%, 0.54 [0.42; 0.70], P < 0.001). When regarded as a composite (although not prespecified), the overall neonatal complications (including birth trauma, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress, neonatal intensive care unit admission, and perinatal death) were significantly lower in the intervention group (38.1% vs. 53.7%, 0.53 [0.34; 0.84], P = 0.006). CONCLUSIONS When added to usual care, Habits-GDM resulted in better maternal glycemic control and composite neonatal outcomes (nonprespecified) but did not reduce EGWG among women with GDM.

Objective: Evidence for effective food environment interventions to improve the quality of out-of-home foods is limited in Asia. The Healthier Dining Programme (HDP) is a voluntary government programme designed to increase the availability and accessibility of healthier foods and beverages at eateries in Singapore, a multi-ethnic, urbanized and developed nation. The objective of our study was to evaluate effects of the HDP on the out-of-home dietary intakes of consumers at an institute of higher learning. Design/Setting: We used a cluster-randomized trial design. Six food centers (two food courts and four canteens) at a large university campus were randomly assigned to the intervention or control arm. Participants were university students or staff aged ≥18 years (n=408) who frequently dined at these six food centers. Relevant data were gathered by interview and a 7-day food diary before and after 10 weeks of the intervention. Generalized estimating equations for logistic and linear regression were used to assess the difference in intake of out-of-home healthier dishes between the two study arms. Results: Participants in the intervention arm were more likely to have at least one healthier out-of-home dish per week as compared to those in the control arm (84% vs. 65%, unadjusted OR: 2.79 95% CI: 1.59, 4.88). This was due mainly to the higher consumption of dishes prepared with healthier oil blends (unadjusted OR: 3.24 95% CI: 1.95, 5.38) and lower-sodium salt (unadjusted OR: 4.36 95% CI: 1.64, 11.58) in the intervention arm. Whilst saturated and polyunsaturated fat intake in the two arms were comparable, participants in the intervention arm had lower total fat (-1.27 g/1000 kcal, 95% CI: -2.48, -0.06) and monounsaturated fat intakes (-0.50 g/1000 kcal, 95% CI: -0.94, -0.06), from out-of-home dishes as compared with the control arm. Conclusions: These findings suggest that environmental interventions at institutes of higher learning to increase healthier food availability and accessibility can improve dietary intake from out-of-home foods.Trial registration: ClinicalTrial.gov, NCT02435264. Registered 5 May 2015 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02435264NUS Institutional Review Board approval number: 11-137

BACKGROUND: Mechanisms linking habitual consumption of coffee and tea to the development of type 2 diabetes and cardiovascular diseases remain unclear. OBJECTIVES: We leveraged dietary, genetic, and biomarker data collected from the UK Biobank to investigate the role of different varieties of coffee and tea in cardiometabolic health. METHODS: We included data from ≤447,794 participants aged 37–73 y in 2006–2010 who provided a blood sample and completed questionnaires regarding sociodemographic factors, medical history, diet, and lifestyle. Multivariable linear regression was used to examine the association between coffee or tea consumption and blood concentrations of glycated hemoglobin, fasting glucose, total cholesterol, HDL cholesterol, LDL cholesterol, fasting triglycerides (TGs), apoA-1, apoB, lipoprotein-a, and C-reactive protein (CRP). Lifestyle and genetic factors affecting caffeine metabolism, responses, or intake were tested for interactions with beverage intake in relation to biomarker concentrations. RESULTS: Compared with coffee nonconsumers, each additional cup of coffee was significantly associated with higher total cholesterol, HDL-cholesterol, and LDL-cholesterol concentrations and lower TG and CRP concentrations in both men and women (P-trend

ObjectiveHemoglobin A1c (HbA1c) accuracy is important for diabetes diagnosis and estimation of overall glycemia. The G6PD-Asahi variant which causes glucose-6-phosphate dehydrogenase (G6PD) deficiency has been shown to lower HbA1c independently of glycemia in African ancestry populations. As different G6PD variants occur in Asian ancestry, we sought to identify Asian-specific G6PD variants associated with HbA1c.Research design and methodsIn eight Asian population-based cohorts, we performed imputation on the X chromosome using the 1000 Genomes reference panel and tested for association with HbA1c (10 005 East Asians and 2051 South Asians). Results were meta-analyzed across studies. We compared the proportion of individuals classified as having diabetes/pre-diabetes by fasting glucose ≥100 mg/dL or HbA1c ≥5.7% units among carriers and non-carriers of HbA1c-associated variants.ResultsThe strongest association was a missense variant (G6PD-Canton, rs72554665, minor allele frequency=2.2%, effect in men=−0.76% unit, 95% CI −0.88 to −0.64, p=1.25×10−27, n=2844). Conditional analyses identified a secondary distinct signal, missense variant (G6PD-Kaiping, rs72554664, minor allele frequency=1.6%, effect in men=−1.12 % unit, 95% CI −1.32 to −0.92, p=3.12×10−15, pconditional_Canton=7.57×10−11). Adjusting for glucose did not attenuate their effects. The proportion of individuals with fasting glucose ≥100 mg/dL did not differ by carrier status of G6PD-Canton (p=0.21). Whereas the proportion of individuals with HbA1c ≥5.7% units was lower in carriers (5%) compared with non-carriers of G6PD-Canton (30%, p=0.03).ConclusionsWe identified two G6PD variants in East Asian men associated with non-glycemic lowering of HbA1c. Carriers of these variants are more likely to be underdiagnosed for diabetes or pre-diabetes than non-carriers if screened by HbA1c without confirmation by direct glucose measurements.

Eating faster is associated with greater body mass index (BMI), but less is known about the relationships between eating rate, energy intake, body composition, and cardio-metabolic risk factors in different Asian ethnic groups. Using data from the Singapore Multi-Ethnic Cohort (n = 7011, 21&ndash, 75 y), we investigated associations between self-reported eating rate (SRER), with energy intake, body composition, blood pressure, and blood lipids. SRER and lifestyle was assessed using interviewer-administered questionnaires. Multivariable models were used to examine the associations of SRER with energy intake, body composition, blood pressure, and blood lipids after adjusting for covariates. General and abdominal overweight were defined as BMI &ge, 23 kg/m2 and waist circumference &gt, 90cm (men) and &gt, 80cm (women), respectively. On average, faster eaters (vs. slower eaters) consumed 105kcal/day more (p = 0.034), had ~5kg higher body weight (p &lt, 0.001), 1.3 kg/m2 higher BMI (p &lt, 0.001), and 3.1cm larger waist-circumference (p &lt, 0.001). Faster eaters had significantly higher blood pressure, circulating triglycerides, and total-to-high-density lipoprotein cholesterol ratio than slower eaters. Faster eaters were twice as likely to develop general (multivariable-OR: 2.2, 95%CI,1.8&ndash, 2.6, p &lt, 0.001), and abdominal (OR:1.8, 95%CI, 1.5&ndash, 2.2, 0.001) overweight than slower eaters. This association was observed across all subgroups by age, sex, and ethnicity. Findings suggest that SRER is a robust behavioral marker for increased risk of higher energy intake, obesity, and poor cardio-metabolic health, and a modifiable behavioral risk-factor for obesity prevention.

Background: Biomarker levels of very long-chain saturated fatty acids (VLCSFAs) have been found to be favorably associated with cardiovascular risk factors including lower risk of diabetes and reduced triglycerides. Few studies have examined the association between VLCSFAs and coronary heart disease (CHD). Aims: To assess the association of circulating arachidic acid (20:0), behenic acid (22:0), and lignoceric acid (24:0) with incident total, fatal, and nonfatal CHD. Methods: We used data from the Fatty Acids and Outcomes Research Consortium consisting of 15 prospective cohorts worldwide which included adults (age≥18 years) who were free of cardiovascular disease and had blood measurements of 20:0, 22:0, and 24:0 at baseline. A study protocol with standardized definitions of exposures, disease outcomes, and covariates was developed, for which each cohort conducted individual participant-level analysis. Cohort-specific associations were pooled using inverse variance-weighted meta-analysis to calculate the overall relative risk (RR) per interquintile range (difference between the 90 th and 10 th percentiles) and 95% confidence interval (CI). Results: Among 33,083 participants, 6,165 cases of total CHD were ascertained. The overall pooled RR and 95% CI were 0.96 (0.89, 1.02) for 20:0, 1.01 (0.92, 1.11) for 22:0, 0.94 (0.86, 1.02) for 24:0, and 0.96 (0.89, 1.04) for 20:0 + 22:0 + 24:0 ( Figure 1 ). However, we noted heterogeneity by lipid compartments, with significant inverse associations for higher 22:0 [0.77 (0.62, 0.96)], 24:0 [0.61 (0.49, 0.77)], and 20:0 + 22:0 + 24:0 [0.73 (0.60, 0.89)] in the total plasma/serum compartment but not in the phospholipid compartment. Similar associations were observed for fatal and nonfatal CHD and when using a random-effects model. Conclusion: Higher circulating VLCSFAs were not associated with total CHD in a global consortium of prospective studies. The finding of an inverse association with total CHD for VLCSFAs in the total plasma/serum compartment warrants further research.

The health benefits of objectively measured physical activity volume versus intensity have rarely been studied, particularly in non-western populations. The aim of this study was to investigate the association between cardiometabolic risk factors and stepping activity including, volume (step count), intensity (cadence) or inactivity (zero-steps/minute/day), in a multi-ethnic Asian population. Participants clinical data was collected at baseline and their physical activity was monitored for seven days, using an accelerometer (Actigraph GT3X+) in 2016. Tertiles (low, moderate, high) of the mean daily step count, peak one-minute, 30-minute, 60-minute cadences and time/day spent at zero-steps/minute were calculated. Adjusted linear regressions explored the association between stepping activity tertiles and cardiometabolic risk factors. A total of 635 participants (41% male, 67% Chinese, mean age 48.4 years) were included in the analyses. The mean daily step count was 7605 (median daily step count 7310) and 7.8 hours of awake time per day were spent inactive (zero-steps/minute). A greater number of associations were found for step intensity than volume. Higher step intensity was associated with reduced body mass index (BMI), waist circumference, blood pressures and higher high-density lipoprotein (HDL). Future health promotion initiatives should consider the greater role of step intensity to reduce cardiometabolic risk.

International audience; Epidemiology studies suggested that low birthweight was associated with a higher risk of hypertension in later life. However, little is known about the causality of such associations. In our study, we evaluated the causal association of low birthweight with adulthood hypertension following a standard analytic protocol using the study-level data of 183,433 participants from 60 studies (CHARGE-BIG consortium), as well as that with blood pressure using publicly available summary-level genome-wide association data from EGG consortium of 153,781 participants, ICBP consortium and UK Biobank cohort together of 757,601 participants. We used seven SNPs as the instrumental variable in the study-level analysis and 47 SNPs in the summary-level analysis. In the study-level analyses, decreased birthweight was associated with a higher risk of hypertension in adults (the odds ratio per 1 standard deviation (SD) lower birthweight, 1.22; 95% CI 1.16 to 1.28), while no association was found between genetically instrumented birthweight and hypertension risk (instrumental odds ratio for causal effect per 1 SD lower birthweight, 0.97; 95% CI 0.68 to 1.41). Such results were consistent with that from the summary-level analyses, where the genetically determined low birthweight was not associated with blood pressure measurements either. One SD lower genetically determined birthweight was not associated with systolic blood pressure (β = − 0.76, 95% CI − 2.45 to 1.08 mmHg), 0.06 mmHg lower diastolic blood pressure (β = − 0.06, 95% CI − 0.93 to 0.87 mmHg), or pulse pressure (β = − 0.65, 95% CI − 1.38 to 0.69 mmHg, all p > 0.05). Our findings suggest that the inverse association of birthweight with hypertension risk from observational studies was not supported by large Mendelian randomization analyses.

We aimed to test whether predefined dietary patterns that are inversely related to risk of type 2 diabetes (T2D) in Western populations were similarly associated with lower T2D risk in an Asian population. We included 45,411 middle-aged and older participants (ages 45–74 years) in the Singapore Chinese Health Study who were free of diabetes, cancer, and cardiovascular disease at baseline (1993–1998). Participants were followed up for T2D diagnosis through 2010. Dietary information was collected using a validated food frequency questionnaire. Dietary pattern scores were calculated for the alternate Mediterranean diet (aMED), Alternate Healthy Eating Index 2010 (AHEI-2010), the Dietary Approaches to Stop Hypertension (DASH) diet, an overall plant-based diet index, and a healthful plant-based diet index. During a median of 11.1 years of follow-up, 5,207 incident cases of T2D occurred. After adjustment for multiple potential confounders, the 5 dietary pattern scores were significantly associated with 16% (for aMED) to 29% (for DASH) lower risks of T2D when comparing the highest score quintiles with the lowest (all P-for-trend values < 0.001). These associations did not vary substantially by baseline age, sex, body mass index, or hypertension status but were limited to nonsmokers (aMED: P for interaction < 0.001; AHEI-2010: P for interaction = 0.03). Adherence to a high-quality diet, as reflected by several predefined diet quality indices derived in Western populations, was significantly associated with lower T2D risk in an Asian population.

Background Healthful dietary patterns are associated with cardiovascular disease risk factors in Western populations. However, a consistent healthful dietary pattern across major Asian ethnic groups has yet to be identified. Objective We aimed to identify a posteriori dietary patterns for Chinese, Malay, and Indian ethnic groups in an urban Asian setting, compare these with a priori dietary patterns, and ascertain associations with cardiovascular disease risk factors including hypertension, obesity, and abnormal blood lipid concentrations. Methods We used cross-sectional data from 8433 Singapore residents (aged 21-94 y) from the Multi-Ethnic Cohort study of Chinese, Malay, and Indian ethnicity. Food consumption was assessed using a validated 169-item food-frequency questionnaire. With the use of 28 food groups, dietary patterns were derived by principal component analysis, and their association with cardiovascular disease risk factors was assessed using multiple linear regression. Associations between derived patterns and a priori patterns (aHEI-2010-Alternative Healthy Eating Index-2010, aMED-alternate Mediterranean Diet, and DASH-Dietary Approaches to Stop Hypertension) were assessed, and the magnitude of associations with risk factors compared. Results We identified a "healthy" dietary pattern, similar across ethnic groups, and characterized by high intakes of whole grains, fruit, dairy, vegetables, and unsaturated cooking oil and low intakes of Western fast foods, sugar-sweetened beverages, poultry, processed meat, and flavored rice. This "healthy" pattern was inversely associated with body mass index (BMI; in kg/m2) (-0.26 per 1 SD of the pattern score; 95% CI: -0.36, -0.16), waist circumference (-0.57 cm; 95% CI: -0.82, -0.32), total cholesterol (-0.070 mmol/L; 95% CI: -0.091, -0.048), LDL cholesterol (-0.054 mmol/L; 95% CI: -0.074, -0.035), and fasting triglycerides (-0.22 mmol/L; 95% CI: -0.04, -0.004) and directly associated with HDL cholesterol (0.013 mmol/L; 95% CI: 0.006, 0.021). Generally, "healthy" pattern associations were at least as strong as a priori pattern associations with cardiovascular disease risk factors. Conclusion A healthful dietary pattern that correlated well with a priori patterns and was associated with lower BMI, serum LDL cholesterol, total cholesterol, and fasting triglyceride concentrations was identified across 3 major Asian ethnic groups.

Background Accelerometer measured physical activity (PA) studies particularly in non-western populations are lacking. Therefore, this study investigated stepping activity in a multi-ethnic urban Asian population. Methods Adult participants from the Singapore Health Study 2 consented to accelerometer activity monitoring for 7-consecutive days. Mean daily step count, peak stepping intensity (i.e. cadence) over 1-min, 30-min and 60-min and time spent in each cadence band: 0 (non-movement), 1–19, 20–39, 40–59, 60–79, 80–99 and ≥ 100 steps/minute (moderate to vigorous PA) were calculated. Results A total of 713 participants (42% male, mean age 47.8 years) were included. Overall, the mean daily step count was 7549. Mean daily step count was significantly lower in Indians (7083 adjusted p = 0.02) but not Malays 7140 (adjusted p = 0.052) compared to Chinese (7745 steps). The proportion of Malays, Indians, and Chinese achieving

Several previous prospective studies suggest that consumption of green leafy and cruciferous vegetables may lower the risk of type 2 diabetes (T2D). We investigated the association between consumption of different types of vegetables in relation to T2D risk in an Asian Population. We included 45 411 participants (age range: 45–74 years) of the Singapore Chinese Health Study (SCHS) free of diabetes, cancer or CVD at baseline (1993–1998). Dietary information was collected using a validated FFQ. Physician-diagnosed incident diabetes was reported at follow-up I (1999–2004) and II (2006–2010) interviews. Cox proportional hazards regression was used to estimate hazard ratio (HR) and 95 % CI of T2D risk. An updated meta-analysis was also conducted to summarise results for green leafy and cruciferous vegetables. During 494 741 person-years of follow-up, 5207 incident T2D occurred. After adjustment for potential confounders, neither total vegetables (top v. bottom quintile HR=1·08; 95 % CI 0·98, 1·18, Ptrend=0·66) nor specific vegetables including dark green leafy vegetables (HR=1·05; 95 % CI 0·96, 1·15, Ptrend=0·21) and cruciferous vegetables (HR=0·97; 95 % CI 0·88, 1·06, Ptrend=0·29) were substantially associated with risk of T2D. A meta-analysis (eleven studies with 754 729 participants and 58 297 cases) including the SCHS and all previous prospective studies suggested borderline significant inverse associations between green leafy (summary relative risk (RR)=0·91; 95 % CI 0·84, 1·00) and cruciferous vegetable consumption (RR=0·87; 95 % CI 0·76, 1·00) and T2D risk, with moderate-to-high heterogeneity. In conclusion, green leafy or cruciferous vegetable consumption was not substantially associated with risk of T2D in an Asian population. Meta-analysis of available cohort data indicated that evidence for a beneficial effect of green leafy or cruciferous vegetable consumption on T2D risk is not convincing.

Health literacy is a key determinant of the public health and health climate of the nation. This study examined the functional health literacy of the nation, factors associated with health literacy, and its relationship with diabetes recognition. This cross-sectional survey recruited participants (N = 2895) who were 18 years and above from a population registry through disproportionate stratified sampling. The Brief Health Literacy Screen and other questionnaires were administered through face-to-face interviews, in one of the four national languages (English, Chinese, Malay or Tamil). The majority (80.5%) had adequate functional health literacy and were able to recognise symptoms of diabetes correctly (83.5% overall, 83.7% and 82.2% in those with adequate and inadequate health literacy, respectively). Those with inadequate health literacy had a higher incidence of chronic conditions (p &lt, 0.001) compared to those with adequate health literacy in bivariate analysis. The majority of the sample had sufficient levels of physical activity (83.3%), and more than half reported an unhealthy lifestyle (57.4%). Older age, Chinese ethnicity, those who were employed, with lower education (secondary or below), and were married had significantly higher odds of inadequate health literacy. Health literacy was not associated with lifestyle, physical activity, chronic conditions and diabetes recognition. Health literacy interventions should focus on the disadvantaged social groups for improving their health literacy.