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1. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data

Author

Marjan W Attaei, MA, Rasha Khatib, PhD, Prof Martin McKee, DSc, Prof Scott Lear, PhD, Prof Gilles Dagenais, MD, Ehimario U Igumbor, PhD, Khalid F AlHabib, MD, Prof Manmeet Kaur, PhD, Lanthe Kruger, PhD, Prof Koon Teo, PhD, Fernando Lanas, MD, Khalid Yusoff, MD, Aytekin Oguz, MD, Prof Rajeev Gupta, PhD, Afzalhussein M Yusufali, MD, Ahmad Bahonar, MD, Prof Raman Kutty, MD, Prof Annika Rosengren, MD, Prof Viswanathan Mohan, DSc, Prof Alvaro Avezum, PhD, Prof Rita Yusuf, PhD, Prof Andrzej Szuba, PhD, Sumathy Rangarajan, MSc, Clara Chow, PhD, Prof Salim Yusuf, DPhil, S Yusuf, S Rangarajan, K K Teo, C K Chow, M O'Donnell, A Mente, D Leong, A Smyth, P Joseph, S Islam, M Zhang, W Hu, C Ramasundarahettige, G Wong, L Dayal, A Casanova, M Dehghan, G Lewis, A Aliberti, A Reyes, A Zaki, B Lewis, B Zhang, D Agapay, D Hari, E Milazzo, E Ramezani, F Hussain, F Shifaly, I Kay, J Rimac, J Swallow, L Heldman, M(a) Mushtaha, M(o) Mushtaha, M Trottier, N Aoucheva, N Kandy, P Mackie, R Solano, S Chin, S Ramacham, S Shahrook, S Trottier, T Tongana, W ElSheikh, J Lindeman, M McQueen, K Hall, J Keys, X Wang, J Keneth, A Devanath, R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, J Dejesus, W Elsheikh, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, JiaXuan, Hu Bo, Sun Yi, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Deng Qing, Cheng Xiaoru, He Xinye, Li Jian, Li Juan, Liu Xu, Ren Bing, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, BianRongwen, TianXiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gómez-Arbeláez, JF Arguello, R Dueñas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar, AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, A Dans, HU Co, JT Sanchez, L Pudol, C Zamora-Pudol, LAM Palileo-Villanueva, MR Aquino, C Abaquin, SL Pudol, ML Cabral, W Zatonski, A Szuba, K Zatonska, R Ilow#, M Ferus, B Regulska-Ilow, D Różańska, M Wolyniec, KF AlHabib, A Hersi, T Kashour, H Alfaleh, M Alshamiri, HB Altaradi, O Alnobani, A Bafart, N Alkamel, M Ali, M Abdulrahman, R Nouri, A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Boström, U Lindblad, P Langkilde, A Gustavsson, M Andreasson, M Snällman, L Wirdemann, K Pettersson, E Moberg, K Yeates, J Sleeth, K Kilonzo, A Oguz, AAK Akalin, KBT Calik, N Imeryuz, A Temizhan, E Alphan, E Gunes, H Sur, K Karsidag, S Gulec, Y Altuntas, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, and R Mapanga

Subjects
Public aspects of medicine, RA1-1270
Abstract

Background: Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. Methods: We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level. Findings: The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59–3·12); p

Published
2017
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2. Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study

Author

Andrew Mente, Mahshid Dehghan, Sumathy Rangarajan, Matthew McQueen, Gilles Dagenais, Andreas Wielgosz, Scott Lear, Wei Li, Hui Chen, Sun Yi, Yang Wang, Rafael Diaz, Alvaro Avezum, Patricio Lopez-Jaramillo, Pamela Seron, Rajesh Kumar, Rajeev Gupta, Viswanathan Mohan, Sumathi Swaminathan, Raman Kutty, Katarzyna Zatonska, Romaina Iqbal, Rita Yusuf, Noushin Mohammadifard, Rasha Khatib, Nafiza Mat Nasir, Noorhassim Ismail, Aytekin Oguz, Annika Rosengren, Afzalhussein Yusufali, Edelweiss Wentzel-Viljoen, Thandi Puoane, Jephat Chifamba, Koon Teo, Sonia S Anand, Salim Yusuf, S Yusuf, S Rangarajan, K K Teo, C K Chow, M O'Donnell, A Mente, D Leong, A Smyth, P Joseph, A Merchant, S Islam, M Zhang, W Hu, C Ramasundarahettige, G Wong, S Bangdiwala, L Dyal, A Casanova, M Dehghan, G Lewis, A Aliberti, A Arshad, A Reyes, A Zaki, B Lewis, B Zhang, D Agapay, D Hari, E Milazzo, E Ramezani, F Hussain, F Shifaly, G McAlpine, I Kay, J Lindeman, J Rimac, J Swallow, L Heldman, M(a) Mushtaha, M(o) Mushtaha, M Trottier, M Riggi, N Aoucheva, N Kandy, P Mackie, R Solano, S Chin, S Ramacham, S Shahrook, S Trottier, T Tongana, W ElSheikh, Y Iyengar, M McQueen, K Hall, J Keys, X Wang, J Keneth, A Devanath, R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, J Dejesus, W Elsheikh, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, Jia Xuan, Hu Bo, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Deng Qing, Cheng Xiaoru, He Xinye, Li Jian, Li Juan, Liu Xu, Ren Bing, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, Bian Rongwen, Tian Xiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gómez-Arbeláez, JF Arguello, R Dueñas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, A Dans, HU Co, JT Sanchez, L Pudol, C Zamora-Pudol, LAM Palileo-Villanueva, MR Aquino, C Abaquin, SL Pudol, ML Cabral, W Zatonski, A Szuba, K Zatonska, R Ilow, M Ferus, B Regulska-Ilow, D Rózanska, M Wolyniec, KF AlHabib, A Hersi, T Kashour, H Alfaleh, M Alshamiri, HB Altaradi, O Alnobani, A Bafart, N Alkamel, M Ali, M Abdulrahman, R Nouri, A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Boström, A Gustavsson, M Andreasson, M Snällman, L Wirdemann, K Yeates, J Sleeth, K Kilonzo, A Oguz, N Imeryuz, Y Altuntas, S Gulec, A Temizhan, K Karsidag, KBT Calik, AAK Akalin, OT Caklili, MV Keskinler, AN Erbakan, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, and R Mapanga

Subjects
Male, medicine.medical_specialty, Apolipoprotein B, Endocrinology, Diabetes and Metabolism, Blood lipids, Blood Pressure, 030204 cardiovascular system & hematology, 03 medical and health sciences, chemistry.chemical_compound, 0302 clinical medicine, Endocrinology, High-density lipoprotein, Risk Factors, Diabetes mellitus, Internal medicine, Internal Medicine, medicine, Dietary Carbohydrates, Humans, 030212 general & internal medicine, chemistry.chemical_classification, biology, Cholesterol, business.industry, medicine.disease, Dietary Fats, Lipids, Diet, Cross-Sectional Studies, chemistry, Cardiovascular Diseases, Saturated fatty acid, biology.protein, lipids (amino acids, peptides, and proteins), Apolipoprotein A1, Female, business, Biomarkers, Polyunsaturated fatty acid
Abstract

Summary Background The relation between dietary nutrients and cardiovascular disease risk markers in many regions worldwide is unknown. In this study, we investigated the effect of dietary nutrients on blood lipids and blood pressure, two of the most important risk factors for cardiovascular disease, in low-income, middle-income, and high-income countries. Methods We studied 125 287 participants from 18 countries in North America, South America, Europe, Africa, and Asia in the Prospective Urban Rural Epidemiology (PURE) study. Habitual food intake was measured with validated food frequency questionnaires. We assessed the associations between nutrients (total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol) and cardiovascular disease risk markers using multilevel modelling. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intakes by use of nutrient density models. We did simulation modelling in which we assumed that the effects of saturated fatty acids on cardiovascular disease events was solely related to their association through an individual risk marker, and then compared these simulated risk marker-based estimates with directly observed associations of saturated fatty acids with cardiovascular disease events. Findings Participants were enrolled into the study from Jan 1, 2003, to March 31, 2013. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, but also with higher HDL cholesterol and apolipoprotein A1 (ApoA1), and lower triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ratio of apolipoprotein B (ApoB) to ApoA1 (all p trend trend trend =0·0014]). Higher intakes of total fat, saturated fatty acids, and carbohydrates were associated with higher blood pressure, whereas higher protein intake was associated with lower blood pressure. Replacement of saturated fatty acids with carbohydrates was associated with the most adverse effects on lipids, whereas replacement of saturated fatty acids with unsaturated fats improved some risk markers (LDL cholesterol and blood pressure), but seemed to worsen others (HDL cholesterol and triglycerides). The observed associations between saturated fatty acids and cardiovascular disease events were approximated by the simulated associations mediated through the effects on the ApoB-to-ApoA1 ratio, but not with other lipid markers including LDL cholesterol. Interpretation Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk. Funding Full funding sources listed at the end of the paper (see Acknowledgments).

Published
2017

3. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study

Author

Mahshid Dehghan, Andrew Mente, Xiaohe Zhang, Sumathi Swaminathan, Wei Li, Viswanathan Mohan, Romaina Iqbal, Rajesh Kumar, Edelweiss Wentzel-Viljoen, Annika Rosengren, Leela Itty Amma, Alvaro Avezum, Jephat Chifamba, Rafael Diaz, Rasha Khatib, Scott Lear, Patricio Lopez-Jaramillo, Xiaoyun Liu, Rajeev Gupta, Noushin Mohammadifard, Nan Gao, Aytekin Oguz, Anis Safura Ramli, Pamela Seron, Yi Sun, Andrzej Szuba, Lungiswa Tsolekile, Andreas Wielgosz, Rita Yusuf, Afzal Hussein Yusufali, Koon K Teo, Sumathy Rangarajan, Gilles Dagenais, Shrikant I Bangdiwala, Shofiqul Islam, Sonia S Anand, Salim Yusuf, R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, S Yusuf, J Dejesus, D Agapay, T Tongana, R Solano, I Kay, S Trottier, J Rimac, W Elsheikh, L Heldman, E Ramezani, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, Jia Xuan, Hu Bo, Sun Yi, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Deng Qing, Cheng Xiaoru, He Xinye, Li Jian, Li Juan, Liu Xu, Ren Bing, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, Bian Rongwen, Tian Xiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gómez-Arbeláez, JF Arguello, R Dueñas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, W Zatonski, A Szuba, K Zatonska, R Ilow, M Ferus, B Regulska-Ilow, D Rózanska, M Wolyniec, null Alkamel, M Ali, M A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Boström, A Gustavsson, M Andreasson, M Snällman, L Wirdemann, A Oguz, N Imeryuz, Y Altuntas, S Gulec, A Temizhan, K Karsidag, KBT Calik, AAK Akalin, OT Caklili, MV Keskinler, AN Erbakan, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, F Hussain, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, and R Mapanga

Subjects
Adult, Male, medicine.medical_specialty, Internationality, Saturated fat, 030204 cardiovascular system & hematology, Lower risk, Risk Assessment, Cohort Studies, 03 medical and health sciences, 0302 clinical medicine, Diabetes mellitus, Internal medicine, Cause of Death, Epidemiology, medicine, Dietary Carbohydrates, Humans, 030212 general & internal medicine, Myocardial infarction, Prospective Studies, Prospective cohort study, Developing Countries, Cause of death, Aged, business.industry, Developed Countries, General Medicine, Middle Aged, medicine.disease, Dietary Fats, Survival Analysis, Surgery, Diet, Cardiovascular Diseases, Income, Female, business, Energy Metabolism, Cohort study
Abstract

Summary Background The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear. Methods The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35–70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3–9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering. Findings During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12–1·46], p trend =0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67–0·87], p trend trend =0·0088; monounsaturated fat: HR 0·81 [0·71–0·92], p trend trend vs quintile 1, HR 0·79 [95% CI 0·64–0·98], p trend =0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality. Interpretation High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings. Funding Full funding sources listed at the end of the paper (see Acknowledgments).

Published
2017

4. Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study

Author

Victoria Miller, Andrew Mente, Mahshid Dehghan, Sumathy Rangarajan, Xiaohe Zhang, Sumathi Swaminathan, Gilles Dagenais, Rajeev Gupta, Viswanathan Mohan, Scott Lear, Shrikant I Bangdiwala, Aletta E Schutte, Edelweiss Wentzel-Viljoen, Alvaro Avezum, Yuksel Altuntas, Khalid Yusoff, Noorhassim Ismail, Nasheeta Peer, Jephat Chifamba, Rafael Diaz, Omar Rahman, Noushin Mohammadifard, Fernando Lana, Katarzyna Zatonska, Andreas Wielgosz, Afzalhussein Yusufali, Romaina Iqbal, Patricio Lopez-Jaramillo, Rasha Khatib, Annika Rosengren, V Raman Kutty, Wei Li, Jiankang Liu, Xiaoyun Liu, Lu Yin, Koon Teo, Sonia Anand, Salim Yusuf, R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, S Yusuf, J Dejesus, D Agapay, T Tongana, R Solano, I Kay, S Trottier, J Rimac, W Elsheikh, L Heldman, E Ramezani, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, Jia Xuan, Hu Bo, Sun Yi, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Deng Qing, Cheng Xiaoru, He Xinye, Li Jian, Li Juan, Liu Xu, Ren Bing, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, Bian Rongwen, Tian Xiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gómez-Arbeláez, JF Arguello, R Dueñas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, W Zatonski, A Szuba, K Zatonska, R Ilow, M Ferus, B Regulska-Ilow, D Rózanska, M Wolyniec, null Alkamel, M Ali, M A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Boström, A Gustavsson, M Andreasson, M Snällman, L Wirdemann, A Oguz, N Imeryuz, Y Altuntas, S Gulec, A Temizhan, K Karsidag, KBT Calik, AAK Akalin, OT Caklili, MV Keskinler, AN Erbakan, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, F Hussain, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, R Mapanga, 10922180 - Schutte, Aletta Elisabeth, and 10998497 - Wentzel-Viljoen, Edelweiss

Subjects
Gerontology, Adult, Male, medicine.medical_specialty, Internationality, Vegetable, 030204 cardiovascular system & hematology, Lower risk, Cohort Studies, 03 medical and health sciences, 0302 clinical medicine, Cause of Death, Epidemiology, Vegetables, Confidence Intervals, Medicine, Humans, 030212 general & internal medicine, Prospective Studies, Family history, Prospective cohort study, Developing Countries, Cause of death, Aged, Proportional Hazards Models, business.industry, Proportional hazards model, Developed Countries, Hazard ratio, Fabaceae, General Medicine, Feeding Behavior, Middle Aged, Cardiovascular disease, Survival Analysis, Legume, Cardiovascular Diseases, Fruit, Multivariate Analysis, Income, Female, business, Risk Reduction Behavior, Demography, Cohort study
Abstract

13 p., Background The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. Methods We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and highincome countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. Findings Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5–9·3) of followup, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74–1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74–1·31; ptrend=0·2033), stroke (0·92, 0·67–1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53–1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68–1·04; ptrend =0·0038), and total mortality (0·81, 0·68–0·96; ptrend

Published
2017

5. Self-reported bone fracture among Malaysian adults: Baseline findings of PURE Malaysia cohort study.

Author

Zaleha MI, Noor Hassim I, Azmi MT, Hasni MJ, Rosnah I, Abdul-Hamid H, Dasiman R, Zainol Abidin N, Ab Razak NH, and Khairul Hazdi Y

Subjects
Male, Humans, Adult, Female, Self Report, Malaysia epidemiology, Prospective Studies, Cohort Studies, Risk Factors, Fractures, Bone epidemiology, Fractures, Bone etiology
Abstract

Introduction: In Malaysia, studies on self-reported bone fractures are scarce. Due to the fact that bone fractures may serve as an indicator of osteoporosis in the community, this study aimed to identify the factors associated with their occurrence among adults in Malaysia., Materials and Methods: Epidemiological data for selfreported bone fractures were obtained through direct interviews using a validated questionnaire from the Prospective Urban and Rural Epidemiology (PURE) study., Results: Of 15,378 respondents, 6.63% (n=1019) reported bone fractures, with a higher proportion of men (65.8%, n=671) than women (34.2%, n=348). Higher odds of selfreporting bone fractures were seen in males (aOR, 2.12; 95%CI: 1.69, 2.65), those with a history of injury (aOR 5.01; 95%CI: 3.10, 6.32) and those who were obese (aOR: 1.46; 95% CI: 1.13, 1.89), highly active (aOR 1.25; 95%CI: 1.02, 1.53), smokers (aOR 1.35; 95%CI: 1.11, 1.65) and alcohol consumers (aOR 1.67; 95%CI: 1.20,2.32)., Conclusion: Adopting a healthier lifestyle that includes a balanced diet and moderate physical activity is critical for weight loss, increased muscle and bone mass and better stability, which reduces the likelihood of fractures following a fall.

Published
2023

6. Preventable stillbirths and neonatal deaths in Malaysia: An analysis of the under-five mortality surveillance data 2015-2017.

Author

Norain A, Sutan R, Azmi MT, and Rozita AR

Subjects
Infant, Newborn, Pregnancy, Female, Humans, Malaysia epidemiology, Infant Mortality, Mothers, Stillbirth epidemiology, Perinatal Death etiology, Perinatal Death prevention & control
Abstract

Introduction: The under-five mortality (U5M) trend in Malaysia significantly declined from 30.0 per 1000 live births (1980) to 8.0 per 1000 live births (2004), and the trend plateaued over the next two decades. Stillbirths and neonatal deaths were the major contributors to U5M. Scarce literature addressing factors associated with preventable U5M in Malaysia. The objective of this study was to describe preventable stillbirths and neonatal mortality, the associated factors and recommendation for improvement., Materials and Methods: The U5M surveillance data from 2015 to 2017 was retrieved for Malaysian cases of stillbirths and neonatal deaths with multiple pregnancies as exclusion. Stillbirth and neonatal death cases were analysed descriptively for socio-demographic and clinical characteristics. Logistic regressions were performed to identify the associated factors., Results: There were 15,444 cases selected for analysis, of which 55% of stillbirths and 45% of neonatal deaths. There were 21% of preventable deaths (U5M) and the major contributing causes of preventable stillbirths and neonatal deaths were classified as perinatal death (82.5%), infectious and parasitic diseases (4.1%) and congenital malformations (3.5%). The birth weight (aOR 6.03, 95% CI: 4.14-8.79), hypertensive mother (aOR 1.88, 95% CI: 1.66-2.12) and instrumental delivery (aOR 1.64, 95% CI: 1.16-2.31) were significantly associated with preventable stillbirths and neonatal deaths. Higher household income (>RM3000 per month) was noted as a protective factor (aOR 0.79, 95% CI:0.69,0.89). Mothers with ethnicities other thanBumiputera, single mothers and housewives were identified as the group of mothers with higher odds of poor perinatal services. Among the 3242 cases of preventable stillbirths and neonatal deaths with a complete documented level of adequacy and quality of healthcare, the most frequently identified factors were due to insufficient antenatal care (ANC) (20.4%), non-compliance with medical advice (12.3%) and unsuitable place of delivery (8.6%)., Conclusion: Increasing trend of preventable stillbirths and neonatal deaths was noted over 3 years (2015-2017), and one-fifth was related to insufficient ANC service-related factors. Remedial measures in improving the quality of ANC services with an emphasis on the targeted high-risk maternal socio-demographic group (other Bumiputera, older antenatal mothers, nonmarried, poor family income neglected family) and enhancing ANC competency skills among the healthcare provider through adequate training are required to decrease preventable stillbirths and neonatal deaths in Malaysia.

Published
2023

7. Assessment of Implementation of Pre-pregnancy care services in Negeri Sembilan, Malaysia.

Author

Sutan R, Mihat M, and Azmi MT

Subjects
Cross-Sectional Studies, Female, Humans, Malaysia, Pregnancy, Surveys and Questionnaires, Motivation, Prenatal Care
Abstract

Introduction: Pre-pregnancy care (PPC) is an established health care program for women of reproductive age that has been widely implemented globally. The implementation of these services varies between countries based on the guidelines advocated. Thus, a standard level of assessment on measuring the performance of the service was difficult. This study aimed to measure the status of implementation PPC services among health workers using the transtheoretical model framework., Methods: A cross-sectional study was conducted among 445 healthcare workers using a validated questionnaire based on local PPC guideline published by the Ministry of Health Malaysia (MOH)., Results: The results showed that many respondents were in the implementation action stage (57%), followed by the maintenance stage (20%), preparation stage (19%), contemplation stage (4%) and pre-contemplation stage (<1%). Further categorisation showed that only 43% of the respondents are successfully implementing PPC according to the standard of MOH. Clinics lead by the Family Medicine Specialist (Adjusted Odds Ratio, AOR 2.845; 95% Confidence Interval, 95%CI: 1.839, 4.40), daily usage of teleprimary care system (TPC) in the clinic (AOR 1.563; 95%CI: 1.019, 2.397), and attended TPC training (AOR 3.358; 95%CI: 2.221, 5.075) were significantly determining the success of PPC implementation., Conclusion: The emphasis on motivation and rewards among the healthcare workers, provision of good internet connection at health clinics and developing a comprehensive model of PPC training targeting the specific healthcare workers are mandatory to enhance the PPC services implementation.

Published
2021

8. The association between serum prolactin levels and interleukin-6 and systemic lupus erythematosus activity.

Author

Wan Asyraf WA, Mohd Shahrir MS, Asrul W, Norasyikin AW, Hanita O, Kong WY, and Azmi MT

Subjects
Adult, Cross-Sectional Studies, Female, Humans, Male, Hyperprolactinemia blood, Hyperprolactinemia complications, Interleukin-6 blood, Lupus Erythematosus, Systemic blood, Lupus Erythematosus, Systemic complications, Prolactin blood
Abstract

Based on the recent evidence of association between hyperprolactinemia and systemic lupus erythematosus disease activity (SLEDAI), a study was conducted to analyze the association of hyperprolactinemia with lupus nephritis disease activity. In this cross-sectional study, the analysis was conducted on SLE patients who visited the University Kebangsaan Malaysia Medical Centre (UKMMC) Nephrology Clinic from August 2015 till February 2016. The disease activity was measured using the SLEDAI score, with more than 4 indicating active lupus nephritis. Basal resting prolactin level was analyzed in 43 patients with lupus nephritis, in 27.9% of them had raised serum prolactin. The median of serum prolactin level at 0 minutes was 19.91 ng/mL (IQR: 15.95-22.65 ng/ mL) for active lupus nephritis, which was significantly higher compared to the median of serum prolactin level of 14.34 ng/mL (IQR: 11.09-18.70 ng/mL) for patients in remission (p=0.014). The serum prolactin level positively correlated with SLEDAI (rhos: 0.449, p=0.003) and the UPCI level in lupus nephritis patients (rhos: 0.241, p=0.032). The results were reproduced when the serum prolactin was repeated after 30 minutes. However, the serum prolactin levels at 0 minutes were higher than those taken after 30 minutes (p=0.001). An assessment of serum IL-6 levels found that the active lupus nephritis patients had a higher median level of 65.91 pg/ mL (IQR: 21.96-146.14 pg/mL) compared to the in-remission level of 15.84 pg/mL (IQR: 8.38-92.84 pg/mL), (p=0.039). Further correlation analysis revealed that there was no statistical correlation between the interleukin (IL)-6 levels with serum prolactin, SLEDAI and other lupus nephritis parameters. An ROC curve analysis of serum prolactin at 0 minutes and serum prolactin after 30 minutes and IL-6 levels for prediction of SLE disease activity provided the cutoff value of serum prolactin at 0 minutes, which was 14.63 ng/mL with a sensitivity of 91.7% and specificity of 58.1% and AUC of 0.74 (p=0.015). This study concurred with the previous findings that stated that hyperprolactinemia is prevalent in SLE patients and correlated with clinical disease activity and UPCI level. The baseline of the fasting serum prolactin level was found to be a sensitive biomarker for the evaluation of lupus nephritis disease activity.

Published
2018
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9. A tale of two construct validation analysis: Rasch model and exploratory factor analysis approach for Three-Factor Eating Questionnaire (TFEQ-R21) among Malaysian male workers.

Author

Rosnah I, Mohd Zali MN, Noor Hassim I, and Azmi MT

Abstract

Introduction: This study aims for construct validation using two approaches, i.e., exploratory factor analysis and Rasch Model., Methods: A cross sectional of 313 male workers from multiple worksites had completed self-administered Malay translated version of Three-Factor Eating Questionnaire- R21. Data quality was assessed by misfit person criteria, dimensionality, summary statistic, item measure and rating (partial credit) scale followed by exploratory factor analysis and internal consistency reliability assessment., Results: The dual approaches of construct validation analysis were complement to each other. Rasch analysis supported the theoretical constructs of three eating behaviour dimensions among respondents. In contrary to exploratory factor analysis, it did show presence of a newfound factor (∝=0.04) came up from the separation of the cognitive restrain and uncontrolled eating however, the correlation between the two respective sub-factors were fair (r=0.39) and weak (r= -0.08). Both analyses had detected three problematic items but those items were psychometrically fit for used for current study setting. The data had adequate psychometric properties. Cronbach's alpha for cognitive restraint, uncontrolled eating and emotional eating were 0.66, 0.79 and 0.87 respectively. Rating scale quality was conformed to standard criteria., Conclusion: Malay version TFEQ-R21 with promising psychometric properties and valid measures for eating behaviour dimensions among male workers aged between 20 to 60 years old is now available. Further development should focus on the items in relation to Malaysian cultural adaptation before its use for daily practice in future setting.

Published
2015

10. Implications of immunosuppressive agents in cardiovascular risks and carotid intima media thickness among lupus nephritis patients.

Author

Sazliyana S, Mohd Shahrir MS, Kong CT, Tan HJ, Hamidon BB, and Azmi MT

Subjects
Adrenal Cortex Hormones administration & dosage, Adrenal Cortex Hormones adverse effects, Adrenal Cortex Hormones therapeutic use, Adult, Cardiovascular Diseases pathology, Cardiovascular Diseases prevention & control, Carotid Artery Diseases etiology, Carotid Artery Diseases pathology, Carotid Artery Diseases prevention & control, Carotid Intima-Media Thickness, Cohort Studies, Cross-Sectional Studies, Cyclosporine administration & dosage, Cyclosporine adverse effects, Cyclosporine therapeutic use, Female, Humans, Immunosuppressive Agents administration & dosage, Immunosuppressive Agents adverse effects, Lupus Nephritis pathology, Male, Risk Factors, Young Adult, Cardiovascular Diseases etiology, Immunosuppressive Agents therapeutic use, Lupus Nephritis complications, Lupus Nephritis drug therapy
Abstract

Introduction: Patients with systemic lupus erythematosus, particularly with lupus nephritis (LN), are at risk of premature cardiovascular (CV) disease., Objective: To determine the association between immunosuppressive medications, traditional CV risk factors and carotid intima media thickness (CIMT) among patients with LN., Methodology: This was a cross-sectional study in which consecutive LN patients attending the Nephrology/SLE Clinic were evaluated for traditional CV risk factors. Detailed information on their treatment was obtained from their medical records. CIMT, an excellent marker of subclinical atherosclerosis, was measured by B Mode carotid ultrasound., Results: A total of 82 patients with LN with a mean age of 33.9 ± 9.8( )years were recruited. More than half had hypertension (n = 55, 67.1%) and dyslipidemia (n = 43, 52.4%) as traditional CV risks. Longer history and higher cumulative dose of corticosteroids were associated with hypertension, but use of intravenous methylprednisolone was associated with lower systolic and diastolic blood pressure and lower serum total cholesterol and triglyceride levels (p < 0.05 each). Hydroxychloroquine use was associated with lower total serum cholesterol and serum low-density lipoprotein levels (p < 0.05). Although the use of cyclosporine A (CyA) was associated with hypertension (p < 0.05), those who received a lower cumulative dose of CyA had thicker CIMT (r (s) = -0.33, p =0.01) and CyA use remained an independent predictor of CIMT during linear regression analysis. There were no associations between CIMT and cumulative dose and duration of steroids, hydroxychloroquine, azathioprine, mycophenolic acid and cyclophosphamide., Conclusion: Aggressive treatment of severe LN and the use of CyA as a steroid-sparing agent may have protective effects against premature atherosclerosis.

Published
2011
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11. Thickened carotid intima media thickness and carotid atherosclerosis among lupus nephritis patients: the role of traditional and lupus-specific factors.

Author

Sazliyana S, Mohd Shahrir MS, Kong NC, Tan HJ, Hamidon BB, and Azmi MT

Subjects
Adult, Atherosclerosis blood, Atherosclerosis epidemiology, C-Reactive Protein analysis, Carotid Artery Diseases blood, Carotid Artery Diseases epidemiology, Comorbidity, Complement C4 analysis, Cross-Sectional Studies, Female, Humans, Lupus Nephritis blood, Lupus Nephritis epidemiology, Malaysia epidemiology, Male, Risk Factors, Atherosclerosis diagnosis, Carotid Artery Diseases diagnosis, Carotid Intima-Media Thickness, Lupus Nephritis pathology
Abstract

Aim: The objectives of this study were to investigate the frequency of thickened carotid intima media thickness (CIMT) and atherosclerosis among lupus nephritis (LN) patients and to study their associated risk factors., Method: In this cross-sectional study, carotid ultrasonography was performed on consecutive LN patients to determine CIMT and presence of carotid plaques. CIMT was considered to be abnormally thickened if it was more than the 75th percentile matched for age and sex from the 'Carotid Atherosclerosis Progression Study'. The association between thickened CIMT with traditional cardiovascular risk factors and lupus characteristics were examined. A total of 83 patients with the mean age of 33.6 ± 10 years were recruited., Results: Fourteen patients (16.9%) had thickened CIMT and three (3.6%) had carotid plaques. On univariate analysis, traditional risk factors significantly associated with thickened CIMT (P < 0.05) were patient's current age, diabetes mellitus and waist circumference. Meanwhile, a lower serum C4 levels and higher serum C-reactive protein levels were the lupus-specific factors associated with thickened CIMT (P < 0.05, P < 0.05 and P < 0.01, respectively). In logistic regression analysis, the independent predictors of thickened CIMT were age of diagnosis, lower serum C4 levels and waist circumference (P < 0.05)., Conclusion: More lupus specific factors were independently associated with thickened CIMT, suggesting that a multi-targeted approach of treatment addressing both the lupus and traditional cardiovascular risks are very important. Larger prospective studies of these special risk factors are indicated., (© 2011 The Authors. International Journal of Rheumatic Diseases © 2011 Asia Pacific League of Associations for Rheumatology and Blackwell Publishing Asia Pty Ltd.)

Published
2011
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12. Effects of background noise on recording of portable transient-evoked otoacoustic emission in newborn hearing screening.

Author

Salina H, Abdullah A, Mukari SZ, and Azmi MT

Subjects
Evoked Potentials, Auditory, Brain Stem physiology, Female, Humans, Infant, Newborn, Male, Prevalence, Prospective Studies, Acoustic Stimulation, Cochlea physiology, Hearing Disorders diagnosis, Hearing Disorders epidemiology, Neonatal Screening, Noise, Otoacoustic Emissions, Spontaneous physiology
Abstract

Transient-evoked otoacoustic emission (TEOAE) is a well-established screening tool for universal newborn hearing screening. The aims of this study are to measure the effects of background noise on recording of TEOAE and the duration required to complete the test at various noise levels. This study is a prospective study from June 2006 until May 2007. The study population were newborns from postnatal wards who were delivered at term pregnancy. Newborns who were more than 8-h old and passed a hearing screening testing using screening auditory brainstem response (SABRe) were further tested with TEOAE in four different test environments [isolation room in the ward during non-peak hour (E1), isolation room in the ward during peak hour (E2), maternal bedside in the ward during non-peak hour (E3) and maternal bedside in the ward during peak hour (E4)]. This study showed that test environment significantly influenced the time required to complete testing in both ears with F [534.23] = 0.945; P < 0.001 on the right ear and F [636.54] = 0.954; P < 0.001 on the left. Our study revealed that TEOAE testing was efficient in defining the presence of normal hearing in our postnatal wards at maternal bedside during non-peak hour with a specificity of 96.8%. Our study concludes that background noise levels for acceptable and accurate TEOAE recording in newborns should not exceed 65 dB A. In addition, when using TEOAE assessment in noisy environments, the time taken to obtain accurate results will greatly increase.

Published
2010
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13. The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school.

Author

Reddy JP, Tan SM, Azmi MT, Shaharom MH, Rosdinom R, Maniam T, Ruzanna ZZ, and Minas IH

Subjects
Female, Humans, Male, Attitude of Health Personnel, Education, Medical, Undergraduate, Mental Disorders psychology, Psychiatry education, Students, Medical psychology
Abstract

Introduction: The stigma attached to mental illness and the mentally ill is a universal phenomenon and a major barrier to the provision of mental health services. Stigmatising attitudes among doctors themselves can result in compromised patient care. The aim of this research project is to study the impact of a clinical posting in psychiatry on the attitudes of medical students to mental illness and to psychiatry. This paper reports the results of the first phase of a longitudinal study., Materials and Methods: A total of 122 year 4 medical students responded to this study. The Attitudes Towards Mental Illness (AMI) and Attitudes Towards Psychiatry (ATP) questionnaires were administered before and after an 8-week attachment in psychiatry., Results: We found that students had somewhat favourable attitudes towards psychiatry and mental illness at the start of their attachment, with a mean score of 108.34 on ATP (neutral score, 90) and 68.24 on AMI (neutral score, 60). There was a significant increase in the mean scores of both scales following the psychiatric attachment for female students (ATP: P = 0.003; AMI: P <0.0005), but not male students (ATP: P = 0.435; AMI: P = 0.283)., Conclusions: An 8-week clinical posting of fourth-year medical students in psychiatry was associated with an increase in positive attitudes to mental illness and to psychiatry among female students but not among male students.

Published
2005

14. Does clinical exposure to patients in medical school affect trainee doctors' attitudes towards mental disorders and patients?--A pilot study.

Author

Tan SM, Azmi MT, Reddy JP, Shaharom MH, Rosdinom R, Maniam T, Ruzanna ZZ, and Minas IH

Subjects
Adult, Female, Humans, Male, Pilot Projects, Attitude of Health Personnel, Education, Medical methods, Mental Disorders, Psychiatry education, Students, Medical psychology
Abstract

Stigmatising attitudes towards mental illness may improve with clinical exposure during medical school training. Attitudes of 48 fourth year medical students in Universiti Kebangsaan Malaysia were assessed before and after their compulsory attachment in Psychiatry, using the Attitude Towards Psychiatry-30 (ATP) and the Attitude towards Mental Illness (AMI) questionnaires. ATP scores improved significantly with training (104.8 and 114.4, pre- and post-attachment respectively) as did AMI scores (63.4 and 68.1 respectively). Both improvements were statistically significant. (ATP: z = 4.55, p < 0.0005) (AMI: z = 3.75, p < 0.0005). Attitudes towards mental illness appeared to have become more favourable with clinical training in psychiatry.

Published
2005

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