Demographic, lifestyle, social, and psychological factors associated with worry-related sleep problems among school-going adolescents in Timor-Leste.

OBJECTIVE: Adolescent sleep problems are a worldwide public health issue. The present study examines factors associated with worry-related sleep problems among school-going adolescents. The country of interest is Timor-Leste, a low-income country, where studies pertaining to adolescent sleep problems are lacking. DESIGN AND MEASURES: Data were analysed from the Global School-Based Student Health Survey Timor-Leste (n = 3455). An ordered probit model was used to assess the effects of demographic, lifestyle, social, and psychological factors on different levels of worry-related sleep problems (i.e., no, mild and severe sleep problems). RESULTS: School-going adolescents were more likely to face mild or severe worry-related sleep problems if they were older, passive smokers, alcohol drinkers and moderately active. School-going adolescents who sometimes or always went hungry were more likely to experience worry-related sleep problems than those who did not. Involvement in physical fights, being bullied, and loneliness were positively associated with the probability of having modest or severe worry-related sleep problems. CONCLUSION: Age, exposure to second-hand smoke, alcohol consumption, physical activity, going hungry, physical fights, being bullied and loneliness are the important determining factors of adolescent worry-related sleep problems. Policymakers should pay special attention to these factors when formulating intervention measures.

Does Awareness of Malaysian Healthy Plate Associate with Adequate Fruit and Vegetable Intake among Malaysian Adults with Non-Communicable Diseases?

The healthy eating plate concept has been introduced in many countries, including Malaysia, as a visual guide for the public to eat healthily. The relationship between Malaysian Healthy Plate (MHP) and adequate fruit and vegetable (FV) intake among morbid Malaysian adults is unknown. Hence, we investigated the relationship between awareness of the MHP and FV intake among morbid Malaysian adults. National survey data on 9760 morbid Malaysian adults aged 18 years and above were analyzed. The relationship between awareness of MHP and FV intake among Malaysian adults with obesity, diabetes mellitus, hypertension, and hypercholesterolemia were determined using multivariable logistic regression controlling for sociodemographic characteristics and lifestyle risk factors. Our data demonstrated that MHP awareness is associated with adequate FV intake among the Malaysian adults with abdominal obesity (adjusted odds ratio (aOR): 1.86, 95% confidence interval (CI): 1.05-3.29), diabetes mellitus (aOR: 4.88, 95% CI: 2.13-22.18), hypertension (aOR: 4.39, 95% CI: 1.96-9.83), and hypercholesterolemia (aOR: 4.16, 95% CI: 1.48-11.72). Our findings indicated the necessity for ongoing efforts by policymakers, healthcare professionals, and nutrition educators to promote the concept of MHP and ensure that morbid Malaysian adults consume a sufficient intake of FV or adopt a healthy eating pattern to achieve and maintain optimal health.

Body mass index and waist circumference trajectories across the life course and birth cohorts, 1996-2015 Malaysia: sex and ethnicity matter.

OBJECTIVE: The global obesity epidemic remains a significant threat to public health and the economy. Age-period-cohort (APC) analysis is one method to model the trajectory of obesity. However, there is scarce published evidence of such analyses among the South East Asian population. This study aims to explore the sex and ethnic variations of BMI and waist circumference trajectories over time among non-institutionalized Malaysian adults aged 18 to 80 years. METHODS: Data from four population-based National Health and Morbidity Surveys conducted in 1996, 2006, 2010, and 2015 were pooled. Hierarchical Age-Period-Cohort (HAPC) analysis explored the trajectories of BMI and waist circumference across the life course and birth cohorts by sex and ethnicity. These models assumed no period effect. RESULTS: Generally, BMI and waist circumference trajectories increased across age and birth cohorts. These trajectories varied by sex and ethnicity. Females have more profound increasing BMI and waist circumference trajectories than their male counterparts as they age and as cohort recency increases. Chinese have less profound BMI and waist circumference increases across the life course and birth cohorts than other ethnic groups. CONCLUSIONS: The profound increasing cohort trajectories of obesity, regardless of sex and ethnicity, are alarming. Future studies should focus on identifying factors associated with the less profound cohort effect among the Chinese to reduce the magnitude of trajectories in obesity, particularly among future generations.

Social Support among Older Persons and Its Association with Smoking: Findings from the National Health and Morbidity Survey 2018.

BACKGROUND: Globally, the average age of the world's population of older people continues to rise and having a good social support network becomes increasingly relevant with the aging populace. Overall, in Malaysia, social support prevalence was low among older persons. This study was conducted to determine the association between social support and smoking status among the older Malaysian population. METHODS: Data were obtained from the National Health and Morbidity (NHMS) 2018 survey on the health of older Malaysian adults and analyzed. This cross-sectional population-based study used a two-stage stratified random sampling design. Sociodemographic characteristics, smoking status, and social support data were collected from respondents aged 60 years and more. A validated Malay language interviewer-administered questionnaire of 11-items, the Duke Social Support Index, was utilized to assess the social support status. A multivariable logistic regression analysis was used to assess the association of social support and smoking status among the respondents. RESULTS: The prevalence of good social support was significantly higher among the 60-69 years old (73.1%) compared to the ≥80 years old respondents (50%). Multivariate logistic regression analysis showed that respondents aged ≥80 years old were 1.7 times more likely to have poor social support compared to those aged 60-69 years. Respondents with no formal education were 1.93 times more likely to have poor social support compared to respondents who had tertiary education. Respondents with an income of MYR 3000. Former smokers had good social support compared to current smokers (73.6% vs. 78.7%). For current smokers, they had poor social support, which is almost 1.42 times higher than that for non-smokers. CONCLUSION: There was poor social support among older people who were current smokers, had an increased age, had no formal education and had a low income. The findings obtained from this study could assist policymakers to develop relevant strategies at the national level to enhance the social support status among older smokers and aid in their smoking cessation efforts.

Can the association between hypertension and physical activity be moderated by age?

Objectives: Physical inactivity, hypertension and non-communicable diseases are major public concerns across the globe. To our knowledge, there is a lack of research that has investigated the moderating effect of age on the relationship between hypertension and physical activity in developing countries. This study had two objectives: (1) investigating hypertension and sociodemographic factors associated with physical activity and (2) investigating whether age moderates the relationship between hypertension and physical activity. Methods: Nationally representative data of Malaysia were used to generate cross-sectional evidence. The sample size was 2156 respondents. An ordered probit regression was utilized to assess factors associated with the practice of physical activity. Results: Respondents aged 40-49 years with hypertension were 7.3% less likely to participate in high-level physical activity when compared to those without hypertension. The probability of having a low level of physical activity was 12.3% higher among hypertensive patients aged ≥60. Males, married individuals, less-educated adults, low-income earners, and individuals who were aware of their BMI, had a higher tendency to indulge in a highly active lifestyle than others. Conclusion: The effect of hypertension on physical activity was moderated by age. Factors influencing physical activity levels among adults were income, gender, marital status, education, employment status, and BMI awareness.

Obesity and Its Association with Undiagnosed Diabetes Mellitus, High Blood Pressure and Hypercholesterolemia in the Malaysian Adult Population: A National Cross-Sectional Study Using NHMS Data.

This study aimed to report the prevalence of obesity, classified using Asian cut-off, and its relationships with undiagnosed diabetes mellitus, high blood pressure, and hypercholesteremia. We analyzed the nationally representative data from 14,025 Malaysian adults who participated in the NHMS 2015. The relationship between obesity and undiagnosed diabetes mellitus, high blood pressure, and hypercholesteremia was determined using multivariable logistic regressions, and lifestyle risk factors and sociodemographic characteristics were adjusted. The undiagnosed high blood pressure group showed the highest proportionate of overweight/obese (80.0%, 95% CI: 78.1-81.8) and central obesity (61.8%, 95% CI: 59.3-64.2). Inverse association was observed between underweight with undiagnosed high blood pressure (aOR: 0.40, 95% CI: 0.26-0.61) and hypercholesterolemia (aOR: 0.75, 95% CI: 0.59-0.95) groups. In contrast, positive relationships were shown between overweight/obese and risk of undiagnosed diabetes mellitus (aOR: 1.65, 95% CI: 1.31-2.07), high blood pressure (aOR: 3.08, 95% CI: 2.60-3.63), and hypercholesterolemia (aOR: 1.37, 95% CI: 1.22-1.53). Likewise, central obesity was positively associated with a risk of undiagnosed diabetes mellitus (aOR: 1.40, 95% CI: 1.17-1.67), high blood pressure (aOR: 2.83, 95% CI: 2.45-3.26), and hypercholesterolemia (aOR: 1.26, 95% CI: 1.12-1.42). Our findings indicated the importance of periodical health examinations to assess the risk of non-communicable diseases among the general and abdominal obese Malaysian adults.

Lifestyles and Sexual Behaviour Among School-Going Adolescents: A Mediational Role of Mental Health.

Sexual behaviour and mental health among adolescents are major public health issues. This study examines how lifestyles affect sexual behaviour among school-going adolescents in Malaysia, and the potential mediational role of mental health. It is the first to our knowledge to explore the mediating effect of mental health on sexual behaviour with a focus on a fast-growing developing country. Data were obtained from the National Health and Morbidity Survey 2017 (n = 27,497). Structural equation modelling was utilized to examine depression and anxiety as mediators of the relationships between sexual behaviour and smoking, alcohol drinking and illicit drug use, controlling for sociodemographic factors. Results showed that adolescents who smoked, consumed alcohol, used illicit drugs, and had depression and anxiety were more likely to engage in sexual behaviour than others. Depression and anxiety partially mediated the relationships between sexual behaviour and smoking, and illicit drug use. The association between alcohol drinking and sexual behaviour was fully mediated by depression and anxiety. In conclusion, lifestyles may affect sexual behaviour through mediation of mental health. Therefore, policymakers should take mental health factors into consideration when designing adolescent sexual behaviour preventative interventions.

Agreement between the Fagerström test for nicotine dependence (FTND) and the heaviness of smoking index (HSI) for assessing the intensity of nicotine dependence among daily smokers.

INTRODUCTION: Measuring the level of nicotine addiction among smokers is an integral part of enhancing smoking cessation as nicotine dependence is one of the barriers to smoking cessation. In this study, we compared the level of agreement between FTND and HSI in detecting high nicotine dependence among daily smokers. METHODS: We collected data from participants of a public smoking cessation clinic in Selangor. A trained pharmacist conducted face-to-face interviews with 152 daily smokers using a structured validated questionnaire. Respondents were classified as having high nicotine dependence using both the HSI (score ≥4) and the FTND (score ≥6), and concordance between the two measures, kappa statistics and sensitivity, specificity of the HSI were then determined with the FTND classification as the reference standard. RESULTS: The HSI had a substantial agreement with the FTND (Cohen's kappa=0.72) in measuring high levels of nicotine addiction, with good sensitivity (83.3%) and specificity (89.4%). CONCLUSIONS: The findings suggest that the HSI can be used instead of the FTND in clinical-based investigations to screen for high nicotine dependence among daily smokers in the clinical setting.

Validation of the Malay Version of the Decisional Balance Inventory (MDBI) among secondary school-going adolescents.

INTRODUCTION: The Decisional Balance Inventory is a tool used to measure propensity to maintain or change a habit which takes into consideration the perceived advantages and disadvantages. This study aimed to establish the validity and reliability of a Malay language version of the DBI for assessing inclination for change in smoking behavior among secondary school-going adolescents in Malaysia. METHODS: We administered the MDBI to 669 secondary school students selected through multistage sampling. The sample consisted of 60.1% male (n=398) and 39.9% (n=264) female students, more than two-thirds (69.9%, n=463) of which were from rural areas. The majority of the respondents were aged 13-14 years [13 years, 36.4% (n=241), 14 years, 40.0% (n=265), 16 years, 23.6% (n=156)]. The construct validity of the MDBI was assessed using explanatory (EFA) and confirmatory factor analysis (CFA), and the reliability of the MDBI via Cronbach's alpha. RESULTS: EFA and parallel analysis extracted three factors in the MDBI that accounted for 65.4% of the observed variance, and this was supported by CFA. Internal consistency of the three factors ranged from 0.734 to 0.867, indicating acceptable reliability. CONCLUSIONS: The MDBI has good psychometric properties and is suitable for measuring smoking intention among Malaysian secondary school-going adolescents. However, it should continue to be tested to expand its usefulness and applicability among adolescents in other sociodemographic settings.

Association between Adequate Fruit and Vegetable Intake and CVDs-Associated Risk Factors among the Malaysian Adults: Findings from a Nationally Representative Cross-Sectional Study.

This study aimed to investigate the relationship between adequate fruit and vegetable intake, and cardiovascular diseases (CVDs)-associated risk factors (i.e., diabetes, hypertension and hypercholesterolemia) among Malaysian adults without history of chronic diseases. We analyzed the data from 11,172 Malaysian adults (i.e., 5554 male and 5618 female), who participated in the population-based National Health and Morbidity Survey 2015. Multiple logistic regression was employed to determine the relationship between adequate daily intake of fruit and vegetables (i.e., ≥5 servings per day) and undiagnosed diabetes, undiagnosed hypertension, and undiagnosed hypercholesterolemia, after adjustment for sociodemographic characteristics and lifestyle risk factors. The mean age (±SE) of these participants was 40.79 (±0.17) years old. Our data demonstrated an adequate daily intake of fruit and vegetables was inversely associated with undiagnosed hypercholesterolemia (adjusted OR: 0.71; 95% CI: 0.51-0.98). Further analyses demonstrated an inverse association between the adequate daily intake of vegetables alone and undiagnosed hypertension (adjusted OR: 0.71; 95% CI: 0.51-0.98). The findings from this study suggest the need for a holistic public health approach to reinforce public awareness about diet-related diseases, which will eventually aid in the prevention of CVDs among Malaysian adults in the long run.

Awareness of body mass index and its associated factors: A cross-sectional study.

This study explores the correlates of sociodemographic factors, smoking, and caloric knowledge to body mass index awareness with a focus on Malaysia. Logistic regressions were estimated to examine sociodemographic factors associated with body mass index awareness. More than half of respondents were unaware of their body mass index (54.8%). Age was negatively associated with body mass index awareness. Adults without formal education were less likely to know their body mass index than those with tertiary-level education. Adults were less likely to be aware of their body mass index if they engaged in smoking. Adults with knowledge of the definition of calories were more aware of their body mass index than others. The findings emphasize the urgent need for a forthcoming sociodemographic factors-specific policy directed toward improving body mass index awareness to lower the prevalence of obesity in Malaysia.

Correlates of dual/poly tobacco use among school-going adolescents in Malaysia: Findings from a nationwide school-based study.

INTRODUCTION: Dual/poly tobacco use is common among youths globally. However, in Malaysia information on dual/poly tobacco use is scarce, thus the present study examines the prevalence and factors associated with dual/poly tobacco users among school-going adolescents in Malaysia. METHODS: We derived data on tobacco and e-cigarette use among Malaysian adolescents from a nationwide school-based study conducted in 2016. A total of 13135 adolescents responded in the cross-sectional survey which used multi-stage sampling to select a representative sample of school-going adolescents aged 11-19 years. A standard validated questionnaire was used to obtain the data and multiple logistic regression was conducted to assess factors associated with dual/ poly tobacco use. RESULTS: The prevalence of dual/poly tobacco use was 6.5%, more than half of which were both conventional and e-cigarette users. Multivariable logistic regression revealed that the likelihood of dual tobacco use was significantly higher among males (AOR=14.73; 95% CI: 9.11-23.81), secondary school students, those aged 16-19 years (AOR=5.99; 95% CI: 4.04-8.87), natives of Sabah (AOR=7.41; 95% CI: 3.48-15.79), and those never been taught on the health hazards of tobacco at school, exposed to secondhand smoke (SHS) at home, school or other public areas, and had a positive perception of e-cigarettes and lower perception of the harms of tobacco smoking. CONCLUSIONS: Although the prevalence of dual/poly users was still low among Malaysian school-going adolescents, proactive measures should be taken to reduce dual tobacco use among youth in Malaysia with focus on the factors identified in this study.

Assessment of association between smoking and all-cause mortality among Malaysian adult population: Findings from a retrospective cohort study.

INTRODUCTION: Smoking is a known risk factor for many chronic diseases. Illness and death due to smoking are a significant public health burden in many countries. This study aims to address the information gap in smoking-related mortality in Malaysia by estimating the risk of cardiovascular disease and all-cause mortalities due to smoking among Malaysian adults. METHODS: We analyzed data on 2525 respondents, aged 24-64 years, of the Malaysian Non-Communicable Disease Surveillance survey conducted September 2005 to February 2006. Mortality records from the Malaysian National Registration Department were linked to the MYNCDS-1 data to determine respondents' mortality status over 12 years from 2006 to 2018. Associations between smoking and all-cause mortalities were assessed using Cox proportional hazards regression with adjustments for non-communicable disease and sociodemographic and lifestyle factors. RESULTS: The prevalence of daily smoking was 21.2% (95% CI: 19.0-23.7). During the 31668 person-years follow-up, 213 deaths from all causes occurred, where 68 deaths were among smokers (13.2%), and 452 were among non-smokers (6.3%). Smoking was associated with a significantly increased risk of all-cause mortality (adjusted hazard ration, AHR=1.79; 95% CI: 1.12- 2.97). These associations remained significant after excluding mortalities in the first two years of follow-up. CONCLUSIONS: Daily smoking is associated with a significantly higher risk of all-cause death. Behavioral and pharmacological smoking cessation interventions should be intensified among smokers to reduce the risk of mortality.

Assessing the Spatiotemporal Spread Pattern of the COVID-19 Pandemic in Malaysia.

Introduction: The unprecedented COVID-19 pandemic has greatly affected human health and socioeconomic backgrounds. This study examined the spatiotemporal spread pattern of the COVID-19 pandemic in Malaysia from the index case to 291,774 cases in 13 months, emphasizing on the spatial autocorrelation of the high-risk cluster events and the spatial scan clustering pattern of transmission. Methodology: We obtained the confirmed cases and deaths of COVID-19 in Malaysia from the official GitHub repository of Malaysia's Ministry of Health from January 25, 2020 to February 24, 2021, 1 day before the national vaccination program was initiated. All analyses were based on the daily cumulated cases, which are derived from the sum of retrospective 7 days and the current day for smoothing purposes. We examined the daily global, local spatial autocorrelation and scan statistics of COVID-19 cases at district level using Moran's I and SaTScan™. Results: At the initial stage of the outbreak, Moran's I index > 0.5 (p < 0.05) was observed. Local Moran's I depicted the high-high cluster risk expanded from west to east of Malaysia. The cases surged exponentially after September 2020, with the high-high cluster in Sabah, from Kinabatangan on September 1 (cumulative cases = 9,354; Moran's I = 0.34; p < 0.05), to 11 districts on October 19 (cumulative cases = 21,363, Moran's I = 0.52, p < 0.05). The most likely cluster identified from space-time scanning was centered in Jasin, Melaka (RR = 11.93; p < 0.001) which encompassed 36 districts with a radius of 178.8 km, from November 24, 2020 to February 24, 2021, followed by the Sabah cluster. Discussion and Conclusion: Both analyses complemented each other in depicting underlying spatiotemporal clustering risk, giving detailed space-time spread information at district level. This daily analysis could be valuable insight into real-time reporting of transmission intensity, and alert for the public to avoid visiting the high-risk areas during the pandemic. The spatiotemporal transmission risk pattern could be used to monitor the spread of the pandemic.

Sociodemographic correlates of knowledge about high sodium-related diseases among adults in Malaysia.

The prevalence of high sodium-related diseases is increasing across the globe. Knowledge plays an important role in disease prevention. The objective of the present study was to examine sociodemographic factors associated with knowledge of high sodium-related diseases. The Malaysian Community Salt Survey (MyCoSS) was used in the present study for secondary analyses. It is a nationwide cross-sectional survey that was conducted in Malaysia. A non-parametric test to evaluate trends and a negative binomial regression were utilised to assess knowledge of high sodium-related diseases. Income, educational level, gender, ethnicity, house locality and hypertension were found to be significantly associated with knowledge of high sodium-related diseases. In particular, higher income earners, well-educated people, women, Malays, urban dwellers and hypertensive adults were more likely to have acquired a lot of knowledge of high sodium-related diseases compared to that acquired by lower income earners, less-educated people, men, individuals of other ethnic groups, rural dwellers and nonhypertensive adults. In conclusion, sociodemographic factors and hypertension play an important role in knowledge acquired about high sodium-related diseases. The findings of the present study could inform a future policy directed towards increasing knowledge about high sodium-related diseases among the population in Malaysia.

Do we need different predictive equations for the acute and late phases of critical illness? A prospective observational study with repeated indirect calorimetry measurements.

BACKGROUND: Predictive equations (PEs) for estimating resting energy expenditure (REE) that have been developed from acute phase data may not be applicable in the late phase and vice versa. This study aimed to assess whether separate PEs are needed for acute and late phases of critical illness and to develop and validate PE(s) based on the results of this assessment. METHODS: Using indirect calorimetry, REE was measured at acute (≤5 days; n = 294) and late (≥6 days; n = 180) phases of intensive care unit admission. PEs were developed by multiple linear regression. A multi-fold cross-validation approach was used to validate the PEs. The best PEs were selected based on the highest coefficient of determination (R2), the lowest root mean square error (RMSE) and the lowest standard error of estimate (SEE). Two PEs developed from paired 168-patient data were compared with measured REE using mean absolute percentage difference. RESULTS: Mean absolute percentage difference between predicted and measured REE was <20%, which is not clinically significant. Thus, a single PE was developed and validated from data of the larger sample size measured in the acute phase. The best PE for REE (kcal/day) was 891.6(Height) + 9.0(Weight) + 39.7(Minute Ventilation)-5.6(Age) - 354, with R2 = 0.442, RMSE = 348.3, SEE = 325.6 and mean absolute percentage difference with measured REE was: 15.1 ± 14.2% [acute], 15.0 ± 13.1% [late]. CONCLUSIONS: Separate PEs for acute and late phases may not be necessary. Thus, we have developed and validated a PE from acute phase data and demonstrated that it can provide optimal estimates of REE for patients in both acute and late phases. TRIAL REGISTRATION: ClinicalTrials.gov NCT03319329.

Mental health and risk behaviors among secondary school students: A study on ethnic minorities.

BACKGROUND: Mental health disorders are highly correlated with risk behaviors. The objective of the present study is to examine the relationship between risk behaviors and mental health among school-going students with a focus on ethnic minorities. METHODS: The National Health and Morbidity Survey (NHMS) 2017 (n = 8230) was used for analyses. It was a nationwide survey conducted in Malaysia. The dependent variables were measured by three risk behaviors (cigarette smoking, alcohol drinking and use of illicit drugs). Probit regressions were utilized to examine the effect of mental health on the probability of smoking, drinking and using illicit drugs. Demographic and lifestyle factors were used as the control variables. Truancy was identified as a mediating variable. RESULTS: Anxiety, depression and suicidal ideation affected cigarette smoking, alcohol drinking and use of illicit drugs through mediation of truancy. After controlling for demographic and lifestyle factors, students with anxiety, depression and suicidal ideation were more likely to smoke, drink and use illicit drugs compared with their peers without any mental health disorders. Furthermore, the likelihood of consuming cigarettes, alcohol and illicit drugs was found to be higher among students who played truant than those who did not. CONCLUSION: Mental health plays an important role in determining participation in risk behaviors among ethnic minority students in Malaysia. Public health administrators and schools have to be aware that students who suffer from mental health disorders are likely to indulge in risk behaviors.