Perceptions, barriers and enablers on salt reduction in the out-of-home sectors in Malaysia (MySaltOH) from the perspective of street food vendors, caterers and consumers.

OBJECTIVE: To explore the perspectives, barriers and enablers on salt reduction in out-of-home sectors in Malaysia among street food vendors, caterers and consumers. DESIGN: A qualitative study involving twenty-two focus group discussions and six in-depth interviews was conducted, recorded and transcribed verbatim. An inductive thematic analysis approach was employed to analyse the data. SETTING: Two in-depth interviews and twenty-two focus group discussions were conducted face-to-face. Four in-depth interviews were conducted online. PARTICIPANTS: Focus group discussions were conducted among twenty-three street food vendors, twenty-one caterers and seventy-six consumers of various eateries. In-depth interviews were conducted among two street food vendors and four caterers, individually. RESULTS: Consumers and food operators perceived a high-salt intake within Malaysia's out-of-home food sectors. Food operators emphasised the necessity for a comprehensive salt reduction policy in the out-of-home sector involving all stakeholders. Consumers faced limited awareness and knowledge, counterproductive practices among food operators and challenges in accessing affordable low-Na food products, whereas food operators faced the lack of standardised guidelines and effective enforcement mechanisms and uncooperative consumer practices. Both groups expressed that food quality and price of salt were also the barriers, and they advocated for awareness promotion, enhanced regulation of manufactured food products and stricter enforcement targeting vendors. Consumers also suggested promoting and recognising health-conscious food premises, whereas food operators suggested on knowledge enhancement tailored to them, strategies for gaining consumers acceptance and maintaining food quality. CONCLUSIONS: These findings provide valuable insights that serve as foundational evidence for developing and implementing salt reduction policies within Malaysia's out-of-home sectors.

Perceptions, barriers and enablers of salt reduction in Malaysian out-of-home sectors (MySaltOH): from the point of view of policy-makers and food industries.

BACKGROUND: High salt intake is a major cause of hypertension and cardiovascular diseases. The out-of-home sectors have been identified as one of the contributors of high salt intake in the population. The National Salt Reduction Policy of Malaysia was initiated in 2015; however, out-of-home sectors are yet to be emphasized and perception by policy-makers and the food industries towards salt reduction are yet unknown. This study aimed to determine the perceptions, barriers and enablers towards salt reduction in the out-of-home sector in Malaysia, as well as among policy-makers and the food industries. METHODS: This is a qualitative study via semi-structured in-depth interviews (IDI) and focus group discussions (FGD) involving several stakeholders consisting of policy-makers from five ministries, five nongovernment organizations (NGOs) and food science/food technology researchers from five regions (West, North, East, and South Peninsular and East Malaysia/Borneo), as well as the food industries. The IDI and FGD sessions were recorded, transcribed verbatim and analysed thematically using Nvivo software version 12. RESULTS: All participants agreed that salt intake in Malaysia is high and leads to hypertension and cardiovascular diseases. Lack of awareness, poor eating culture and behaviour and frequent eating out were among the causes of high salt intake. Awareness campaigns and education, sodium content labelling and product reformulation were strategies that have been implemented by the government; whilst for the food industries, some of them have tried to reduce salt and labelled the sodium content on their food products. However, there were several barriers including perceived poor consumer acceptance, lack of knowledge and resources, and challenges in reformulation, as well as unavailability of guidelines and salt targets. Hence, several enablers have been suggested, which include prioritizing the salt reduction strategy, creating more awareness, collaboration and engagement, research and technology particularly for reformulation and shelf-life stability, incentives and salt tax. CONCLUSIONS: Salt reduction efforts of the out-of-home sector in Malaysia could be achieved through several measures or enablers that can overcome the barriers currently faced by stakeholders, especially policy-makers, food industries and the consumers themselves. This study will benefit the policy-makers to improve the salt reduction policy of out-of-home sectors and highlight the concerns among the food industries on the policy.

Combined associations of family history and self-management with age at diagnosis and cardiometabolic risk in 86,931 patients with type 2 diabetes: Joint Asia Diabetes Evaluation (JADE) Register from 11 countries.

BACKGROUND: Family history (FamH) of type 2 diabetes might indicate shared genotypes, environments, and/or behaviors. We hypothesize that FamH interacts with unhealthy behaviors to increase the risk of early onset of diabetes and poor cardiometabolic control. METHODS: In a cross-sectional analysis of the prospective Joint Asia Diabetes Evaluation Register including patients from 427 clinics in 11 Asian countries/regions in 2007-2021, we defined positive FamH as affected parents/siblings and self-management as (1) healthy lifestyles (balanced diet, non-use of alcohol and tobacco, regular physical activity) and (2) regular self-monitoring of blood glucose (SMBG). RESULTS: Among 86,931 patients with type 2 diabetes (mean±SD age: 56.6±11.6 years; age at diagnosis of diabetes: 49.8±10.5 years), the prevalence of FamH ranged from 39.1% to 85.3% in different areas with FamH affecting mother being most common (32.5%). The FamH group (n=51,705; 59.5%) was diagnosed 4.6 years earlier than the non-FamH group [mean (95% CI): 47.9 (47.8-48.0) vs. 52.5 (52.4-52.6), logrank p<0.001]. In the FamH group, patients with both parents affected had the earliest age at diagnosis [44.6 (44.5-44.8)], followed by affected single parent [47.7 (47.6-47.8)] and affected siblings only [51.5 (51.3-51.7), logrank p<0.001]. The FamH plus ≥2 healthy lifestyle group had similar age at diagnosis [48.2 (48.1-48.3)] as the non-FamH plus <2 healthy lifestyle group [50.1 (49.8-50.5)]. The FamH group with affected parents had higher odds of hyperglycemia, hypertension, and dyslipidemia than the FamH group with affected siblings, with the lowest odds in the non-FamH group. Self-management (healthy lifestyles plus SMBG) was associated with higher odds of attaining HbA1c<7%, blood pressure<130/80mmHg, and LDL-C<2.6 mmol/L especially in the FamH group (FamH×self-management, pinteraction=0.050-0.001). CONCLUSIONS: In Asia, FamH was common and associated with young age of diagnosis which might be delayed by healthy lifestyle while self management  was associated with better control of  cardiometabolic risk factors especially in those with FamH.

The lived experiences of a COVID-19 immunization programme: vaccine hesitancy and vaccine refusal.

BACKGROUND: The COVID-19 pandemic has resulted in a global health emergency and lock-down measures to curb the uncontrolled transmission chain. Vaccination is an effective measure against COVID-19 infections. In Malaysia amidst the national immunisation programme (NIP) which started in February 2021, there were rising concerns regarding the prevalence of vaccine hesitancy and refusal, and therefore, vaccine uptake among Malaysians. Although there are many quantitative studies on COVID-19 vaccination, the subjective experience of individuals was understudied. This study aims to explore the lived experiences of Malaysians regarding vaccine hesitancy and refusal, and facilitating factors that could enhance vaccine acceptance and uptake. METHODS: This qualitative study employed the hermeneutic phenomenological study design. Purposive sampling strategies were used to recruit Malaysians that had direct experiences with friends, family members and their community who were hesitating or refusing to accept the COVID-19 vaccines. A semi-structured interview guide was developed based on the expert knowledge of the investigators and existing literature on the topic. A series of focus group interviews (FGIs) was conducted online facilitated by a multidisciplinary team of experts. The group interviews were transcribed verbatim and analysed. RESULTS: Fifty-nine participants took part in seven FGIs. We found that "incongruence" was the overall thematic meaning that connected all the 3 main themes. These themes comprise firstly, the incongruence between the aims and implementation of the National Immunization Program which highlighted the gap between realities and needs on the ground. Secondly, the incongruence between Trust and Mistrust revealed a trust deficit in the government, COVID-19 news, and younger people's preference to follow the examples of local vaccination "heroes". Thirdly, the incongruence in communication showed the populace's mixed views regarding official media and local social media. CONCLUSIONS: This study provided rich details on the complex picture of the COVID-19 immunization program in Malaysia and its impact on vaccine hesitancy and refusal. The inter-related and incongruent factors explained the operational difficulty and complexity of the NIP and the design of an effective health communication campaign. Identified gaps such as logistical implementation and communication strategies should be noted by policymakers in implementing mitigation plans.

Exosomal microRNAs in the development of essential hypertension and its potential as biomarkers.

MicroRNAs (miRNAs) are small regulatory molecules that are involved in posttranscriptional modifications. These noncoding RNAs are usually ferried by extracellular carriers such as exosomes or other protein and lipid carriers inside a range of body fluids including plasma and urine. Due to their ability to withstand harsh external conditions, exosomal miRNAs possess enormous potential as noninvasive disease biomarkers for, notably hypertension, whereby exosomal miRNAs have been implicated in its pathophysiological processes. More importantly, alterations in the microenvironment as a result of disease progression can induce active and selective loading of miRNAs into exosomes. In this paper, we first review the mechanisms of miRNA loading into exosomes, followed by the roles of exosomal miRNAs in the development of hypertension, and the potentials of exosomal miRNAs as biomarkers in comparison with other free circulating miRNAs. Finally, challenges and future research surrounding exosomal miRNAs will also be discussed. This review will aid in the understanding of noninvasive biomarkers for the early diagnosis of hypertension and for probing therapeutic efficacy.

May Measurement Month 2019: an analysis of blood pressure screening results from Malaysia.

Despite hypertension remaining the leading cause of death worldwide, awareness of hypertension and its control rate is still suboptimal in Malaysia. This study aims to determine the proportion of both diagnosed and undiagnosed hypertension, awareness and its control rate during the yearly May Measurement Month (MMM) campaign that has been coordinated by the International Society of Hypertension. Participants aged ≥18 years were recruited at various screening sites namely universities, health facilities, shopping malls, and other sites. Participant's socio-demographic, environmental, and lifestyle data were captured using a questionnaire. Three blood pressure (BP) readings as well as anthropometric measurements were obtained from all participants. The mean of the second and third BP readings was used in analyses. Hypertension was defined as a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or taking antihypertensive medication. A total of 3062 participants were recruited. The proportion with hypertension in our study was 18.7% (n = 572). The proportion who were aware of their BP status was 63.2%. More than half (57.2%) of the hypertensives were on antihypertensive medication and 70.3% of those treated were controlled. In conclusion, in this BP screening campaign, one in five were hypertensive with almost two thirds aware of their hypertensive status. BP control among those who are taking medications was high at 70% but under 60% of hypertensives were on treatment. Hypertension screening programmes are important to promote awareness and control of hypertension as well as to reduce the devastating complications associated with this disorder.

May Measurement Month 2018: an analysis of blood pressure screening results from Malaysia.

Hypertension continues to be the top global killer, contributing to over 10 million deaths annually. As prevalence and unawareness of hypertension remain high in Malaysia, this study was aimed to screen more individuals to identify those with undiagnosed hypertension. Respondents aged ≥18 years were recruited through opportunistic sampling at various screening sites including health clinics, hospitals, student health centres, universities, community halls, shopping malls, as well as through other health screening campaigns. Each respondent completed a questionnaire on socio-demographic, environmental, and lifestyle data. Anthropometric measurements as well as three blood pressure (BP) measurements were obtained from all participants. Hypertension was defined as a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or taking antihypertensive medication. The total number of participants was 4866. The mean age of the participants was 39.8 (17.6) years with 61.1% female participants. Of the 4866 participants, 1405 (28.9%) had hypertension. The proportion of those aware of their hypertension status was 76.3% (1073/1405). The proportion of those with hypertension on medication was 71% (998/1405). Of those receiving antihypertensive treatment, 62.4% (623/998) had controlled BP. The proportion of hypertension in this study was 28.9%. The awareness rate of 76.3% compares favourably to a previously reported national level of 43.2%. Hence, BP screening programmes may be effective at increasing awareness and should be conducted annually.

FEV1 and total Cardiovascular mortality and morbidity over an 18 years follow-up Population-Based Prospective EPIC-NORFOLK Study.

BACKGROUND: Our study aimed to determine the association between forced expiratory volume in one second (FEV1) and subsequent fatal and non-fatal events in a general population. METHODS: The Norfolk (UK) based European Prospective Investigation into Cancer (EPIC-Norfolk) recruited 25,639 participants between 1993 and 1997. FEV1 measured by portable spirometry, was categorized into sex-specific quintiles. Mortality and morbidity from all causes, cardiovascular disease (CVD) and respiratory disease were collected from 1997 up to 2015. Cox proportional hazard regression analysis was used with adjustment for socio-economic factors, physical activity and co-morbidities. RESULTS: Mean age of the population was 58.7 ± 9.3 years, mean FEV1 for men was 294± 74 cL/s and 214± 52 cL/s for women. The adjusted hazard ratios for all-cause mortality for participants in the highest fifth of the FEV1 category was 0.63 (0.52, 0.76) for men and 0.62 (0.51, 0.76) for women compared to the lowest quintile. Adjusted HRs for every 70 cL/s increase in FEV1 among men and women were 0.77 (p < 0.001) and 0.68 (p < 0.001) for total mortality, 0.85 (p<0.001) and 0.77 (p<0.001) for CVD and 0.52 (p <0.001) and 0.42 (p <0.001) for respiratory disease. CONCLUSIONS: Participants with higher FEV1 levels had a lower risk of CVD and all-cause mortality. Measuring the FEV1 with a portable handheld spirometry measurement may be used as a surrogate marker for cardiovascular risk. Every effort should be made to identify those with poorer lung function even in the absence of cardiovascular disease as they are at greater risk of total and CV mortality.

Knowledge on the action to be taken and recognition of symptoms of stroke in a community: findings from the May Measurement Month 2017 blood pressure screening Programme in Malaysia.

BACKGROUND: Information regarding the knowledge on the action to be taken during stroke and good recognition of stroke symptoms is mandatory in helping to plan out educational strategies to deliver health education to the community. METHODS: This is a cross-sectional study of adults aged 18 and above attending a blood pressure screening program in community in conjunction with May Measurement Month 2017 in Malaysia. A structured self-administered questionnaire was given to the participants who gave verbal consent. Data analysis was done using SPSS v. 23 and multiple logistic regression was used to identify the determinants of knowledge on actions to be taken during stroke and recognition of stroke symptoms. RESULTS: Out of 4096 respondents, 82.9-92.1% of them able to recognise the common stroke symptoms. and 74.2% of the study respondents will go to hospital within 4.5 h of stroke onset. According to binomial logistic regression analyses, adults aged 45 years old and above (OR 1.39 95%CI 1.01-1.92), being Malay (OR 1.74, 95% CI 1.27-2.40), being non-smokers (OR = 2.491, 95% CI: 1.64-3.78), hypertensives (OR: 1.57, 95% CI: 1.02-2.42)and diabetics (OR: 2.54, 95% CI:1.38-4.69) are determinants of right actions to be taken during stroke. Meanwhile, respondents aged 45 years old and older (OR = 1.68, 95% CI: 1.39-2.03), being Malay (OR = 1.49, 95% CI: 1.24-1.79), hypertensive (OR = 1.32, 95% CI: 1.04-1.66) and those who had a previous history of stroke (OR = 2.25, 95% CI: 1.01-5.00) are determinants of good recognition of stroke symptoms. CONCLUSIONS: The overall knowledge of stroke in our study population was good. Older age, being Malay, non-smokers, hypertensives and diabetics are determinants of right actions to be taken during stroke. Meanwhile, older age, being Malay, hypertensive and those who had a previous history of stroke are determinants of good recognition of stroke symptoms.

May Measurement Month 2017 blood pressure screening: findings from Malaysia-South-East Asia and Australasia.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. However there are still many individuals, particularly in many countries in Asia, who have poor BP control. In Malaysia, less than two-fifths have achieved BP control. We participated in BP screening in Malaysia in conjunction with the May Measurement Month 2017 (MMM17), a global initiative by the International Society of Hypertension (ISH) aimed at screening more individuals for earlier detection of hypertension. A nationwide screening of adults aged ≥18 was carried out through health campaigns at clinics, hospitals, during family day events, and charity runs from 1 April 2017 to 31 May 2017 in 42 centres. We used the detailed protocol provided by ISH for data collection. A total of 4116 individuals were screened during MMM17. After multiple imputation, 32.4% (n = 1317/4059) had hypertension. Out of this, 63.9% (842/1317) of those with hypertension were on treatment. Of individuals receiving antihypertensive medication with an imputed BP, 59.5% (n = 496/834) of them had controlled BP. MMM17 was the largest organized BP screening campaign undertaken by health professionals in Malaysia. This study identified that 32.4% of screened individuals had hypertension and 59.5% individuals with treated hypertension had achieved BP control.

Prevalence and risk factors of gestational diabetes mellitus in Asia: a systematic review and meta-analysis.

BACKGROUND: Gestational diabetes mellitus (GDM) is a of the major public health issues in Asia. The present study aimed to determine the prevalence of, and risk factors for GDM in Asia via a systematic review and meta-analysis. METHODS: We systematically searched PubMed, Ovid, Scopus and ScienceDirect for observational studies in Asia from inception to August 2017. We selected cross sectional studies reporting the prevalence and risk factors for GDM. A random effects model was used to estimate the pooled prevalence of GDM and odds ratio (OR) with 95% confidence interval (CI). RESULTS: Eighty-four studies with STROBE score ≥ 14 were included in our analysis. The pooled prevalence of GDM in Asia was 11.5% (95% CI 10.9-12.1). There was considerable heterogeneity (I2 > 95%) in the prevalence of GDM in Asia, which is likely due to differences in diagnostic criteria, screening methods and study setting. Meta-analysis demonstrated that the risk factors of GDM include history of previous GDM (OR 8.42, 95% CI 5.35-13.23); macrosomia (OR 4.41, 95% CI 3.09-6.31); and congenital anomalies (OR 4.25, 95% CI 1.52-11.88). Other risk factors include a BMI ≥25 kg/m2 (OR 3.27, 95% CI 2.81-3.80); pregnancy-induced hypertension (OR 3.20, 95% CI 2.19-4.68); family history of diabetes (OR 2.77, 2.22-3.47); history of stillbirth (OR 2.39, 95% CI 1.68-3.40); polycystic ovary syndrome (OR 2.33, 95% CI1.72-3.17); history of abortion (OR 2.25, 95% CI 1.54-3.29); age ≥ 25 (OR 2.17, 95% CI 1.96-2.41); multiparity ≥2 (OR 1.37, 95% CI 1.24-1.52); and history of preterm delivery (OR 1.93, 95% CI 1.21-3.07). CONCLUSION: We found a high prevalence of GDM among the Asian population. Asian women with common risk factors especially among those with history of previous GDM, congenital anomalies or macrosomia should receive additional attention from physician as high-risk cases for GDM in pregnancy. TRIAL REGISTRATION: PROSPERO (2017: CRD42017070104 ).

Development and validation of the Evidence Based Medicine Questionnaire (EBMQ) to assess doctors' knowledge, practice and barriers regarding the implementation of evidence-based medicine in primary care.

BACKGROUND: Evidence-Based Medicine (EBM) integrates best available evidence from literature and patients' values, which then informs clinical decision making. However, there is a lack of validated instruments to assess the knowledge, practice and barriers of primary care physicians in the implementation of EBM. This study aimed to develop and validate an Evidence-Based Medicine Questionnaire (EBMQ) in Malaysia. METHODS: The EBMQ was developed based on a qualitative study, literature review and an expert panel. Face and content validity was verified by the expert panel and piloted among 10 participants. Primary care physicians with or without EBM training who could understand English were recruited from December 2015 to January 2016. The EBMQ was administered at baseline and two weeks later. A higher score indicates better knowledge, better practice of EBM and less barriers towards the implementation of EBM. We hypothesized that the EBMQ would have three domains: knowledge, practice and barriers. RESULTS: The final version of the EBMQ consists of 80 items: 62 items were measured on a nominal scale, 22 items were measured on a 5 point Likert-scale. Flesch reading ease was 61.2. A total of 343 participants were approached; of whom 320 agreed to participate (response rate = 93.2%). Factor analysis revealed that the EBMQ had eight domains after 13 items were removed: "EBM websites", "evidence-based journals", "types of studies", "terms related to EBM", "practice", "access", "patient preferences" and "support". Cronbach alpha for the overall EBMQ was 0.909, whilst the Cronbach alpha for the individual domain ranged from 0.657-0.940. The EBMQ was able to discriminate between doctors with and without EBM training for 24 out of 42 items. At test-retest, kappa values ranged from 0.155 to 0.620. CONCLUSIONS: The EBMQ was found to be a valid and reliable instrument to assess the knowledge, practice and barriers towards the implementation of EBM among primary care physicians in Malaysia.

The validity and reliability of the English version of the diabetes distress scale for type 2 diabetes patients in Malaysia.

BACKGROUND: Several disease specific instruments have been developed to identify and assess diabetes distress. In Malaysia, the Problem Areas in Diabetes Scale has been validated in Malay, but it does not have specific domains to assess the different areas of diabetes-related distress. Hence, we decided to use the Diabetes Distress Scale instead. To date, only the Malay version of the Diabetes Distress Scale has been validated in Malaysia. However, English is widely spoken by Malaysians, and is an important second language in Malaysia. Therefore, our aim was to determine the validity and reliability of the English version of the Diabetes Distress Scale among patients with type 2 diabetes in Malaysia. METHODS: The Diabetes Distress Scale was administered to 114 patients with type 2 diabetes, who could understand English, at baseline and 4 weeks later, at a primary care clinic in Malaysia. To assess for convergent validity, the Depression Anxiety Stress Scale was administered at baseline. Discriminative validity was assessed by analysing the total diabetes distress scores of participants with poor (HbA1c > 7.0%) and good glycaemic control (HbA1c ≤ 7.0%). RESULTS: The majority of our participants were male 65(57.0%), with a median duration of diabetes of 9.5 years. Exploratory factor analysis showed that the Diabetes Distress Scale had 4 subscales, as per the original Diabetes Distress Scale. The overall Cronbach's α was 0.920 (range = 0.784-0.859 for each subscale). The intraclass correlation ranged from 0.436 to 0.643 for test-retest. The Diabetes Distress Scale subscales were significantly correlated with the different subscales of the Depression Anxiety Stress Scale (spearman's rho range = 0.427-0.509, p < 0.001). Patients with poor glycaemic control had significantly higher diabetes distress score (1.88) compared to those with good glycaemic control (1.50) (p < 0.001). CONCLUSIONS: The English version of the Diabetes Distress Scale was found to be a valid and reliable instrument to evaluate diabetes distress among patients with type 2 diabetes in Malaysia. It can be used in clinical practice to offer a useful indicator of the effect of diabetes-induced distress during clinic visits, especially for patients with poor glycemic control. This would ensure that these patients are provided the care that is required.

Validation of the pooled cohort risk score in an Asian population - a retrospective cohort study.

BACKGROUND: The Pooled Cohort Risk Equation was introduced by the American College of Cardiology (ACC) and American Heart Association (AHA) 2013 in their Blood Cholesterol Guideline to estimate the 10-year atherosclerotic cardiovascular disease (ASCVD) risk. However, absence of Asian ethnicity in the contemporary cohorts and limited studies to examine the use of the risk score limit the applicability of the equation in an Asian population. This study examines the validity of the pooled cohort risk score in a primary care setting and compares the cardiovascular risk using both the pooled cohort risk score and the Framingham General Cardiovascular Disease (CVD) risk score. METHODS: This is a 10-year retrospective cohort study of randomly selected patients aged 40-79 years. Baseline demographic data, co-morbidities and cardiovascular (CV) risk parameters were captured from patient records in 1998. Pooled cohort risk score and Framingham General CVD risk score for each patient were computed. All ASCVD events (nonfatal myocardial infarction, coronary heart disease (CHD) death, fatal and nonfatal stroke) occurring from 1998-2007 were recorded. RESULTS: A total of 922 patients were studied. In 1998, mean age was 57.5 ± 8.8 years with 66.7% female. There were 47% diabetic patients and 59.9% patients receiving anti-hypertensive treatment. More than 98% of patients with pooled cohort risk score ≥7.5% had FRS >10%. A total of 45 CVD events occurred, 22 (7.2%) in males and 23 (3.7%) in females. The median pooled cohort risk score for the population was 10.1 (IQR 4.7-20.6) while the actual ASCVD events that occurred was 4.9% (45/922). Our study showed moderate discrimination with AUC of 0.63. There was good calibration with Hosmer-Lemeshow test χ2 = 12.6, P = 0.12. CONCLUSIONS: The pooled cohort risk score appears to overestimate CV risk but this apparent over-prediction could be a result of treatment. In the absence of a validated score in an untreated population, the pooled cohort risk score appears to be appropriate for use in a primary care setting.

Detection of airflow limitation using a handheld spirometer in a primary care setting.

BACKGROUND AND OBJECTIVE: Early diagnosis of chronic obstructive pulmonary disease (COPD) in primary care settings is difficult to achieve chiefly due to lack of availability of spirometry. This study estimated the prevalence of airflow limitation among chronic smokers using a handheld spirometer in this setting. METHODS: This is a cross-sectional study performed on consecutive patients who were ≥40 years old with ≥10 pack-years smoking history. Face-to-face interviews were carried out to obtain demographic data and relevant information. Handheld spirometry was performed according to a standard protocol using the COPd-6 device (Model 4000, Vitalograph, Ennis, Ireland) in addition to standard spirometry. Airflow limitation was defined as ratio of forced expiratory volume in 1 s (FEV1 )/forced expiratory volume in 6 s <0.75 (COPd-6) or FEV1 /forced vital capacity <0.7. Multiple logistic regression analyses were used to determine predictors of airflow limitation. RESULTS: A total of 416 patients were recruited with mean age of 53 years old. The prevalence of airflow limitation was 10.6% (n = 44) with COPd-6 versus 6% as gauged using standard spirometry. Risk factors for airflow limitation were age >65 years (odds ratio (OR) 3.732 95% confidence interval (CI): 1.100-1.280), a history of 'bad health' (OR 2.524, 95% CI: 1.037-6.142) and low to normal body mass index (OR 2.914, 95% CI: 1.191-7.190). CONCLUSIONS: In a primary care setting, handheld spirometry (COPd-6) found a prevalence of airflow limitation of ∼10% in smokers. Patients were older, not overweight and had an ill-defined history of health problems.

Prevalence and predictors of resistant hypertension in a primary care setting: a cross-sectional study.

BACKGROUND: Patients with resistant hypertension are subjected to a higher risk of getting stroke, myocardial infarction, congestive heart failure and renal failure. However, the exact prevalence of resistant hypertension in treated hypertensive patients in Malaysia is not known. This paper examines the prevalence and determinants of resistant hypertension in a sample of hypertensive patients. METHODS: We examined the control of blood pressure in a randomly selected sample of patients with hypertension in a primary care clinic. Demographic data, blood pressure and anti-hypertensive drug use were captured from patient records at the end of 2007. Resistant hypertension is defined as failure to achieve target blood pressure of < 140/90 mmHg while on full doses of an appropriate three-drug regimen that includes a diuretic. Multivariate logistic regression was used for the analysis. RESULTS: A total of 1217 patients with hypertension were entered into the analysis. Mean age of the patients was 66.8 ± 9.7 years and 64.4% were female. More than half of the subjects (56.9%) had diabetes mellitus. Median BP was 130/80 mmHg. Overall prevalence of resistant hypertension was 8.8% (N = 107/1217). In multivariate logistic regression analysis, presence of chronic kidney disease is more likely to be associated with resistant hypertension (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.56-5.35). On the other hand, increase per year of age is associated with lower odds of resistant hypertension in this population (OR 0.96, 95% CI 0.93-0.99). CONCLUSIONS: Resistant hypertension is present in nearly one in ten hypertensive patients on treatment. Hypertensive patients who have underlying chronic kidney disease are associated with higher odds of having resistant hypertension. Hence, in managing patients with hypertension, primary care physicians should be more alert and identify patients with chronic kidney disease as such patients are more likely to develop resistant hypertension. By doing that, these patients can be treated more aggressively earlier in order to achieve blood pressure target and thus reduce cardiovascular events.

Does use of pooled cohort risk score overestimate the use of statin?: a retrospective cohort study in a primary care setting.

BACKGROUND: Initiation of statin therapy as primary prevention particularly in those with mildly elevated cardiovascular disease risk factors is still being debated. The 2013 ACC/AHA blood cholesterol guideline recommends initiation of statin by estimating the 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the new pooled cohort risk score. This paper examines the use of the pooled cohort risk score and compares it to actual use of statins in daily clinical practice in a primary care setting. METHODS: We examined the use of statins in a randomly selected sample of patients in a primary care clinic. The demographic data and cardiovascular risk parameters were captured from patient records in 1998. The pooled cohort risk score was calculated based on the parameters in 1998. The use of statins in 1998 and 2007, a 10-year interval, was recorded. RESULTS: A total of 847 patients were entered into the analysis. Mean age of the patients was 57.2 ± 8.4 years and 33.1% were male. The use of statins in 1998 was only 10.2% (n = 86) as compared to 67.5% (n = 572) in 2007. For patients with LDL 70-189 mg/dl and estimated 10-year ASCVD risk ≥7.5% (n = 190), 60% (n = 114) of patients were on statin therapy by 2007. There were 124 patients in whom statin therapy was not recommended according to ACC/AHA guideline but were actually receiving statin therapy. CONCLUSIONS: An extra 40% of patients need to be treated with statin if the 2013 ACC/AHA blood cholesterol guideline is used. However the absolute number of patients who needed to be treated based on the ACC/AHA guideline is lower than the number of patients actually receiving it in a daily clinical practice. The pooled cohort risk score does not increase the absolute number of patients who are actually treated with statins. However these findings and the use of the pooled cohort risk score need to be validated further.

Unmet needs of patients with chronic obstructive pulmonary disease (COPD): a qualitative study on patients and doctors.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease with repeated exacerbations resulting in gradual debilitation. The quality of life has been shown to be poor in patients with COPD despite efforts to improve self-management. However, the evidence on the benefit of self-management in COPD is conflicting. Whether this could be due to other unmet needs of patients have not been investigated. Therefore, we aimed to explore unmet needs of patients from both patients and doctors managing COPD. METHODS: We conducted a qualitative study with doctors and patients in Malaysia. We used convenience sampling to recruit patients until data saturation. Eighteen patients and eighteen doctors consented and were interviewed using a semi-structured interview guide. The interviews were audio-recorded, transcribed verbatim and checked by the interviewers. Data were analysed using a thematic approach. RESULTS: The themes were similar for both the patients and doctors. Three main themes emerged: knowledge and awareness of COPD, psychosocial and physical impact of COPD and the utility of self-management. Knowledge about COPD was generally poor. Patients were not familiar with the term chronic obstructive pulmonary disease or COPD. The word 'asthma' was used synonymously with COPD by both patients and doctors. Most patients experienced difficulties in their psychosocial and physical functions such as breathlessness, fear and helplessness. Most patients were not confident in self-managing their illness and prefer a more passive role with doctors directing their care. CONCLUSIONS: In conclusion, our study showed that knowledge of COPD is generally poor. There was mislabelling of COPD as asthma by both patients and physicians. This could have resulted in the lack of understanding of treatment options, outcomes, and prognosis of COPD. The misconception that cough due to COPD was contagious, and breathlessness that resulted from COPD, had important physical and psychosocial impact, and could lead to social isolation. Most patients and physicians did not favour self-management approaches, suggesting innovations based on self-management may be of limited benefit.

Effects of fruit and vegetable intake on memory and attention: a systematic review of randomized controlled trials.

BACKGROUND: Memory and attention are important for daily functioning, and their function deteriorates due to aging. However, fruit and vegetable consumption are one of the protective factors against deterioration in memory and attention. This systematic review of randomized controlled trials (RCTs) aims to identify the effects of fruit and vegetable consumption on memory and attention. METHODS: We conducted a systematic search in EBSCOhost, ProQuest, PubMed, Embase, and Web of Science from inception up to 06/09/2022. The inclusion criteria were peer-reviewed articles, fruit and vegetable intake measured using randomized controlled trials, and the outcome measures that showed the results of memory and attention scores. Two researchers independently extracted articles that met the selection criteria and evaluated the quality of each study. RESULTS: There were 70 articles identified from the databases, of which 13 articles met the inclusion criteria and were included in this systematic review. There were 493 participants in total. The results show that consumption of fruit and vegetable intake improved memory and attention in longitudinal studies (10 to 12 weeks). Children showed improvement in immediate recall after supplementation with blueberries. Older adults required a higher dose of fruit and vegetable intake consumption to achieve significant improvement compared with children and younger adults. Furthermore, the effect of fruits and vegetables on memory showed better immediate memory recall than delayed recall. CONCLUSION: This systematic review showed that there is an improvement in memory and attention with fruit and vegetable intake consumption. Hence, awareness of fruit and vegetable intake consumption is important to maintain cognitive health.

Structural and functional brain correlates of socioeconomic status across the life span: A systematic review.

It is well-established that higher socioeconomic status (SES) is associated with improved brain health. However, the effects of SES across different life stages on brain structure and function is still equivocal. In this systematic review, we aimed to synthesise findings from life course neuroimaging studies that investigated the structural and functional brain correlates of SES across the life span. The results indicated that higher SES across different life stages were independently and cumulatively related to neural outcomes typically reflective of greater brain health (e.g., increased cortical thickness, grey matter volume, fractional anisotropy, and network segregation) in adult individuals. The results also demonstrated that the corticolimbic system was most commonly impacted by socioeconomic disadvantages across the life span. This review highlights the importance of taking into account SES across the life span when studying its effects on brain health. It also provides directions for future research including the need for longitudinal and multimodal research that can inform effective policy interventions tailored to specific life stages.