Perceptions, attitudes and beliefs towards soya among healthy Asian women participating in a soya randomised controlled trial.

The soya-breast cancer risk relationship remains controversial in Asia due to limited and inconsistent research findings and is exacerbated by difficulties in recruiting and retaining participants in intervention trials. Understanding public perceptions towards soya is important for designing effective intervention trials. Here, we administered a close-ended, quantitative survey to healthy, peri- and post-menopausal Asian women in the Malaysian Soy and Mammographic Density (MiSo) Study to assess perception towards soya and explore motivators and barriers that affect study adherence using the Capability, Opportunity, Motivation and Belief (COM-B) Model and Theoretical Domains Framework (TDF). Of 118 participants, the majority reported the belief that soya promotes good health (Supplement = 85⋅7 %, Diet = 90⋅0 %, Control = 87⋅9 %). Most participants reported obtaining information about soya from the internet (Supplement = 61⋅0 %, Diet = 55⋅3 %, Control = 35⋅9 %), while health professionals were least reported (Supplement = 9⋅8 %, Diet = 7⋅9 %, Control = 5⋅1 %). Stratified analyses by study completion and adherence status yielded comparable findings. By the end of the study, dietary arm participants reported a strong belief that soya has no impact on their health (Supplement = 7⋅1 % v. Diet = 20⋅0 % v. Control = 0⋅0 %, P = 0⋅012). Motivation and opportunity strongly facilitated soya consumption, while psychological capability was the most common barrier to consumption though less evident among dietary arm participants. While most Asian women have a positive perception towards soya, theory-based intervention trials are warranted to understand the perception-study adherence relationship and to accurately inform the public of the health effects of soya.

A Randomized Controlled Trial of Soy Isoflavone Intake on Mammographic Density among Malaysian Women.

Soy intake is associated with lower breast cancer risk in observational studies concerning Asian women, however, no randomized controlled trials (RCT) have been conducted among Asian women living in Asia. This three-armed RCT assessed the effects of one-year soy isoflavone (ISF) intervention on mammographic density (MD) change among healthy peri- and postmenopausal Malaysian women. This study was registered at ClinicalTrials.gov (NCT03686098). Participants were randomized into the 100 mg/day ISF Supplement, 50 mg/day ISF Diet, or control arm, and assessed for change in absolute and relative dense area from digital mammograms conducted at enrolment and after 12 months, compared over time across study arms using Kruskal-Wallis tests. Out of 118 women enrolled, 91 women completed the intervention, while 27 women (23%) were lost in follow up. The ISF supplement arm participants observed a larger decline in dense area (−1.3 cm2), compared to the ISF diet (−0.5 cm2) and control arm (−0.8 cm2), though it was not statistically significant (p = 0.48). Notably, among women enrolled within 5 years of menopause; dense area declined by 6 cm2 in the ISF supplement arm, compared to <1.0 cm2 in the control arm (p = 0.13). This RCT demonstrates a possible causal association between soy ISF intake and MD, a biomarker of breast cancer risk, among Asian women around the time of menopause, but these findings require confirmation in a larger trial.

The Inclusion of Folic Acid in Weekly Iron-Folic Acid Supplements Confers no Additional Benefit on Anemia Reduction in Nonpregnant Women: A Randomized Controlled Trial in Malaysia.

BACKGROUND: Weekly iron-folic acid (IFA) supplements are recommended for all menstruating women in countries where anemia prevalence is ≥20%; however, it is unknown whether the inclusion of folic acid in weekly IFA supplements reduces anemia. OBJECTIVES: We examined whether the inclusion of folic acid in weekly IFA supplements conferred any benefit on hemoglobin (Hb) concentration, anemia reduction, or iron status [ferritin and soluble transferrin receptor (sTfR)], over iron alone. METHODS: In this secondary analysis of a randomized controlled trial in Malaysia, n = 311 nonpregnant women (18-45 y old) received 60 mg Fe with either 0, 0.4, or 2.8 mg folic acid once-weekly for 16 wk. Fasting blood was collected at baseline and 16 wk. A generalized linear model (normal distribution with identity link) was used to assess Hb concentration at 16 wk (primary outcome). RESULTS: At baseline, 84% of women had low folate status (plasma folate < 14 nmol/L). At 16 wk, marginal mean (95% CI) Hb was 131 (130, 133), 131 (129, 132), and 132 (130, 133) g/L; ferritin was 58.2 (53.9, 62.5), 56.5 (52.2, 60.9), and 58.0 (53.7, 62.3) µg/L; and sTfR was 5.8 (5.5, 6.1), 5.8 (5.5, 6.1), and 5.9 (5.6, 6.2) mg/L in the 0, 0.4, and 2.8 mg/wk groups, respectively, with no differences between groups (P > 0.05). Baseline plasma folate concentration did not modify the effect of treatment on Hb concentration at 16 wk. Among all women, the risks of anemia [risk ratio (RR): 0.65; 95% CI: 0.45, 0.96; P = 0.03] and iron deficiency based on ferritin (RR: 0.30; 95% CI: 0.20, 0.44; P < 0.001) were lower at 16 wk than at baseline. CONCLUSIONS: Despite the low folate status among these nonpregnant Malaysian women, the inclusion of folic acid in weekly IFA supplements did not reduce anemia or improve iron status, over iron alone. However, the benefits of folic acid for neural tube defect prevention still warrant its retention in weekly IFA supplements.This trial was registered at www.anzctr.org.au as ACTRN12619000818134.

Weekly iron-folic acid supplements containing 2.8 mg folic acid are associated with a lower risk of neural tube defects than the current practice of 0.4 mg: a randomised controlled trial in Malaysia.

INTRODUCTION: Weekly iron-folic acid (IFA) supplements are recommended for all menstruating women in countries where anaemia prevalence is >20%. Anaemia caused by folate deficiency is low worldwide, and the need to include folic acid is in question. Including folic acid might reduce the risk of a neural tube defect (NTD) should a woman become pregnant. Most weekly supplements contain 0.4 mg folic acid; however, WHO recommends 2.8 mg because it is seven times the daily dose effective in reducing NTDs. There is a reluctance to switch to supplements containing 2.8 mg of folic acid because of a lack of evidence that this dose would prevent NTDs. Our aim was to investigate the effect of two doses of folic acid, compared with placebo, on red blood cell (RBC) folate, a biomarker of NTD risk. METHODS: We conducted a three-arm double-blind efficacy trial in Malaysia. Non-pregnant women (n=331) were randomised to receive 60 mg iron and either 0, 0.4, or 2.8 mg folic acid once weekly for 16 weeks. RESULTS: At 16 weeks, women receiving 0.4 mg and 2.8 mg folic acid per week had a higher mean RBC folate than those receiving 0 mg (mean difference (95% CI) 84 (54 to 113) and 355 (316 to 394) nmol/L, respectively). Women receiving 2.8 mg folic acid had a 271 (234 to 309) nmol/L greater mean RBC folate than those receiving 0.4 mg. Moreover, women in the 2.8 mg group were seven times (RR 7.3, 95% CI 3.9 to 13.7; p<0.0001) more likely to achieve an RBC folate >748 nmol/L, a concentration associated with a low risk of NTD, compared with the 0.4 mg group. CONCLUSION: Weekly IFA supplements containing 2.8 mg folic acid increases RBC folate more than those containing 0.4 mg. Increased availability and access to the 2.8 mg formulation is needed. TRAIL REGISTRATION NUMBER: This trial is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12619000818134).

Effect of once weekly folic acid supplementation on erythrocyte folate concentrations in women to determine potential to prevent neural tube defects: a randomised controlled dose-finding trial in Malaysia.

INTRODUCTION: Folic acid (0.4 mg) taken prior to and during early pregnancy reduces the risk of neural tube defects (NTDs). Because these birth defects occur early in pregnancy, before women may know they are pregnant, many countries have mandated the addition of folic acid to food staples. In countries where fortification is not possible, and weekly iron folic acid programmes exist to reduce anaemia, the WHO recommends that 2.8 mg (7×0.4 mg) folic acid be given instead of the current weekly practice of 0.4 mg. Currently, there is a lack of evidence to support if the 2.8 mg folic acid per week dose is sufficient to raise erythrocyte folate concentrations to a level associated with a reduced risk of a NTD-affected pregnancy. We aim to conduct a three-arm randomised controlled trial to determine the effect of weekly folic acid with iron on erythrocyte folate, a biomarker of NTD risk. METHODS AND ANALYSIS: We will recruit non-pregnant women (n=300; 18-45 years) from Selangor, Malaysia. Women will be randomised to receive either 2.8, 0.4 or 0.0 (placebo) mg folic acid with 60 mg iron weekly for 16 weeks, followed by a 4-week washout period. The primary outcome will be erythrocyte folate concentration at 16 weeks and the mean concentration will be compared between randomised treatment groups (intention-to-treat) using a linear regression model adjusting for the baseline measure. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of British Columbia (H18-00768) and Universiti Putra Malaysia (JKEUPM-2018-255). The results of this trial will be presented at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBERS: ACTRN12619000818134 and NMRR-19-119-45736.

l-5-Methyltetrahydrofolate Supplementation Increases Blood Folate Concentrations to a Greater Extent than Folic Acid Supplementation in Malaysian Women.

Background: Folic acid fortification of grains is mandated in many countries to prevent neural tube defects. Concerns regarding excessive intakes of folic acid have been raised. A synthetic analog of the circulating form of folate, l-5-methyltetrahydrofolate (l-5-MTHF), may be a potential alternative. Objective: The objective of this study was to determine the effects of folic acid or l-5-MTHF supplementation on blood folate concentrations, methyl nutrient metabolites, and DNA methylation in women living in Malaysia, where there is no mandatory fortification policy. Methods: In a 12-wk, randomized, placebo-controlled intervention trial, healthy Malaysian women (n = 142, aged 20-45 y) were randomly assigned to receive 1 of the following supplements daily: 1 mg (2.27 µmol) folic acid, 1.13 mg (2.27 µmol) l-5-MTHF, or a placebo. The primary outcomes were plasma and RBC folate and vitamin B-12 concentrations. Secondary outcomes included plasma total homocysteine, total cysteine, methionine, betaine, and choline concentrations and monocyte long interspersed nuclear element-1 (LINE-1) methylation. Results: The folic acid and l-5-MTHF groups had higher (P < 0.001) RBC folate (mean ± SD: 1498 ± 580 and 1951 ± 496 nmol/L, respectively) and plasma folate [median (25th, 75th percentiles): 40.1 nmol/L (24.9, 52.7 nmol/L) and 52.0 nmol/L (42.7, 73.1 nmol/L), respectively] concentrations compared with RBC folate (958 ± 345 nmol/L) and plasma folate [12.6 nmol/L (8.80, 17.0 nmol/L)] concentrations in the placebo group at 12 wk. The l-5-MTHF group had higher RBC folate (1951 ± 496 nmol/L; P = 0.003) and plasma folate [52.0 nmol/L (42.7, 73.1 nmol/L); P = 0.023] at 12 wk than did the folic acid group [RBC folate, 1498 ± 580 nmol/L; plasma folate, 40.1 nmol/L (24.9, 52.7 nmol/L)]. The folic acid and l-5-MTHF groups had 17% and 15%, respectively, lower (P < 0.001) plasma total homocysteine concentrations than did the placebo group at 12 wk; there were no differences between the folic acid and l-5-MTHF groups. No differences in plasma vitamin B-12, total cysteine, methionine, betaine, and choline and monocyte LINE-1 methylation were observed. Conclusion: These findings suggest differential effects of l-5-MTHF compared with folic acid supplementation on blood folate concentrations but no differences on plasma total homocysteine lowering in Malaysian women. This trial was registered at clinicaltrials.gov as NCT01584050.

Association between dietary folate intake and blood status of folate and homocysteine in Malaysian adults.

Folate is of prime interest among investigators in nutrition due to its multiple roles in maintaining health, especially in preventing neural tube defects and reducing the risk of cardiovascular diseases. We investigated the effect of dietary folate intake on blood folate, vitamin B(12), vitamin B(6), and homocysteine status. One hundred subjects consisting of Chinese and Malay subjects volunteered to participate in this cross-sectional study. Dietary folate intake was assessed by 24-h dietary recall and a food-frequency questionnaire (FFQ). Serum and red blood cell folate were analyzed using a microbiological assay, while serum vitamin B(12) was determined by electrochemiluminescence immunoassay (ECLIA), and high-performance liquid chromatography (HPLC) was used for the determination of serum vitamin B(6) and homocysteine. The mean folate intake, serum folate, RBC folate, serum vitamin B(12), and B(6), were higher in female subjects, with the exception of serum homocysteine. The Chinese tended to have higher folate intake, serum folate, RBC folate, and vitamin B(12). A positive association was found between folate intake and serum folate while a negative association was found between folate intake and serum homocysteine. Stepwise linear regression of serum folate showed a significant positive coefficient for folate intake whilst a significant negative coefficient was found for serum homocysteine when controlling for age, gender, and ethnicity. In conclusion, high dietary folate intake helps to increase serum folate and to lower the homocysteine levels.

Prevalence of metabolic syndrome among middle aged women in Babol, Iran.

Metabolic syndrome is a cluster of interconnected cardiovascular risk factors. This research determined the prevalence of metabolic syndrome by body mass index, sociodemography, and lifestyle habits of women 30-50 years old in Babol Iran. A systematic random sampling was used to select 984 middle aged women from an urban area in Babol, Mazandaran, Iran. Screening was used to select eligible women who fulfilled selection criteria. The Adult Treatment Panel III (ATP III) criteria were used to classify participants as having metabolic syndrome. The overall prevalence of metabolic syndrome was 31.0%. Abdominal obesity was observed in about 76.6% (n = 273) of subjects. The prevalences of hypertension, high fasting blood glucose, high triglycerides and low HDL-cholesterol were 12.1, 12.1, 41.5 and 48.6%, respectively. Older age (OR = 2.07; CI = 1.56-2.75), higher waist circumference (OR = 6.46; 95% CI = 3.48-11.96), higher systolic (OR = 3.84; 95% CI = 2.37-6.22) and diastolic blood pressure (OR = 1.89; 95% CI =1.17-3.05), low education level (OR = 2.780; CI = 1.80-4.31), housekeeping (OR = 3.92; CI = 1.24-12.44) and farming occupation (OR = 20.54; 95% CI = 3.54-119.06) were associated with increased risk for metabolic syndrome. The odds ratio (OR) showed no significant associations between metabolic syndrome and smoking or exposure to smoking. This study showed high prevalence of metabolic syndrome in Iranian middle aged women. A larger area and population study is needed to enable broader recommendations for the prevention of metabolic syndrome.

A national study on the prevalence of obesity among 16,127 Malaysians.

UNLABELLED: A population-based cross-sectional study was conducted in all states of Malaysia with the aim to determine the prevalence of obesity among Malaysians aged fifteen years and above and factors associated. A stratified two-stage cluster sampling design with proportional allocation was used. Trained interviewers using a standardized protocol obtained the weight and height measurements and other relevant information. Subjects with a body mass index >= 30 kg/m2 were labelled as obese. The results show that the overall national prevalence of obesity among Malaysians aged 15 years old and above was 11.7% (95% CI = 11.1 - 12.4%). The prevalence of obesity was significantly higher in females (13.8%) as compared to 9.6% in males (p< 0.0001). Prevalence of obesity was highest amongst the Malays (13.6%) and Indians (13.5%) followed by the indigenous group of "Sarawak Bumiputra" (10.8%) and the Chinese (8.5%). The indigenous group of "Sabah Bumiputra" had the lowest prevalence of 7.3%. These differences are statistically significant (p< 0.0001). Logistic regression analysis results show that there was a significant association between obesity and age, gender, ethnicity urban/rural status and smoking status. The prevalence of obesity amongst those aged >= 18 years old has markedly increased by 280% since the last National Health and Morbidity Survey in 1996. CONCLUSION: The overall prevalence of obesity in Malaysia is very high as compared to 1996. There is an urgent need for a comprehensive integrated population-based intervention program to ameliorate the growing problem of obesity in Malaysians.

Dietary and blood folate status of Malaysian women of childbearing age.

The protective role of folic acid taken during the periconceptual period in reducing the occurrence of neural tube defects (NTD) has been well documented by epidemiological evidence, randomized controlled trials and intervention studies. Much of the evidence is derived from western populations while similar data on Asian subjects is relatively nascent. Baseline data on folate status of Malaysian women is lacking, while NTD prevalence is estimated as 10 per 10,000 births. This study was conducted with the objective of determining the dietary and blood folate status of Malaysian women of childbearing age. A total of 399 women comprising 140 Malay, 131 Chinese and 128 Indian subjects were recruited from universities and worksites in the suburbs of Kuala Lumpur. Inclusion criteria were that the subjects were not pregnant or breastfeeding, not taking folic acid supplements, not habitual drinkers or smokers. Based on a 24-hour recall, the median intake level for folate was 66 microg (15.7-207.8 microg), which amounts to 16.5% of the Malaysian Recommended Nutrient Intakes level. The median (5-95th percentiles) values for plasma and red cell folate (RBC) concentrations were 11 (4-33) nmol/L and 633 (303-1209) nmol/L respectively. Overall, nearly 15.1% showed plasma folate deficiency (< 6.8 nmol/L), with Indian subjects having the highest prevalence (21.5%). Overall prevalence of RBC folate deficiency (<363 nmol/L) was 9.3%, and an almost similar level prevailed for each ethnic group. Only 15.2% had RBC concentration exceeding 906 nmol/L, which is associated with a very low risk of NTD. The result of this study point to the need for intervention strategies to improve the blood folate status of women of childbearing age, so that they have adequate protection against the occurrence of NTD at birth.

Iron status and dietary iron intake of adolescents from a rural community in Sabah, Malaysia.

Iron deficiency anaemia (IDA) is the most prevalent micronutrient deficiency in the world affecting the general health and wellbeing of millions. In Malaysia, moderately high prevalences of anaemia have been reported amongst infants, young children and women of childbearing age. Data is scant for the adolescents. This study was undertaken to assess the iron status and dietary intake of 165 adolescents, comprising 74 male and 91 female subjects, aged 12 to 19 years, from the rural communities in Tuaran District of Sabah, Malaysia. Convenience sampling was used for the selection of study subjects. Multiple iron status indicators namely, serum ferritin (SF), transferrin saturation (TS), mean corpuscular volume (MCV) and haemoglobin (Hb) were determined for the study. The mean age of the subjects was 15.2 +/-2.1 years. While the majority of the subjects (77.6%) had normal body mass index (BMI) values, 17.6% were underweight and 4.8% overweight. About 35% to 40% of the subjects showed deficient values for haematocrit, serum ferritin, serum iron, mean corpuscular haemoglobin (MCH), mean corpuscular volume (MCV) and transferrin saturation (TS), and 20% were anaemic (Hb <12 g/L). Using the multiple criteria of iron status indicators, the prevalence of iron depletion, iron deficiency and IDA in the male and female adolescents were 5.4% vs. 6.6%, 18.9% vs. 26.4% and 5.4% vs. 26.4%, respectively. Iron deficiency anaemia (85.0%) contributed largely to the prevalence of anaemia. The dietary iron intake of the adolescents was unsatisfactory, with approximately 98% of subjects failing to meet the Malaysian RDA level. Almost all the female subjects (91%) had dietary iron intake below two-thirds of the RDA level compared with a much smaller proportion for the male adolescents (68%). The prevalence of IDA in the present study population, especially in the female adolescents, appears to be a significant public health problem. Priority should therefore be given to the eradication of iron deficiency in adolescents from low-income areas by dietary modification and micronutrient supplementation amongst female adolescents.

Determinants of iron status in Malaysian adolescents from a rural community.

Iron deficiency anaemia is the most common micronutrient deficiency worldwide. The prevalence of anaemia in the developing countries is three to four times higher than that in the developed countries. The iron status was assessed in 199 apparently healthy male and female adolescents aged 12-19 years living in a fishing community in Sabah, Malaysia. Data on socio-economic characteristics, lifestyles, anthropometry measurements, iron status, and dietary intake were gathered. Dietary intake of energy, iron, and most nutrients (with the exception of protein and vitamin C) were below the recommended levels for Malaysian adolescents. Three-quarters of the iron was derived from plant foods. The mean haemoglobin value for the male was 13.9 +/- 1.3 g/dl with 9.5% having less than 12 g/dl, while the respective figures for the female were 12.4 +/- 1.6 g/dl and 28.6%. The mean serum ferritin concentrations for male and female adolescents were 21.5 and 15.4 microg/l, respectively; with 25.7% of the males and 49.5% of the females having deficient levels of ferritin. Dietary intake of total energy and iron, and gender were found to be independent determinants of serum ferritin and haemoglobin levels, accounting for over 40% of the variations for each of these iron indicators. In males, but not in females, the intake of dietary protein and iron, and physical activity were also found to be significant determinants of serum ferritin. The age of subjects and household size were significant determinants of haemoglobin levels for male subjects, but not for female subjects. The findings indicate the importance of adequate intake of energy and dietary iron for improving the iron status of adolescents.