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Body Composition and Diet of Chinese, Malays and Indians in Singapore: and Their Influence on Cardiovascular Risk Factors

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Body Composition and Diet of Chinese, Malays and Indians in Singapore: and Their Influence on Cardiovascular Risk Factors BODYCOMPOSITIO N AND DIET OFCHINESE ,MALAY S ANDINDIAN S INSINGAPORE : AND THEIR INFLUENCE ON CARDIOVASCULAR RISK FACTORS TKaSdVeuwdwy -1f,*p Promotoren: dr. W.A.va n Staveren Hoogleraar ind eVoedin g van deOuder eMen s dr.J.G.A.J .Hautvas t Hoogleraar ind e Voeding en Gezondheidsleer BODYCOMPOSITIO N ANDDIE TO FCHINESE ,MALAY S AND INDIANS IN SINGAPORE: AND THEIR INFLUENCE ON CARDIOVASCULAR RISK FACTORS 7/ZatfetVetn&ftfetf-'fyat Proefschrift ter verkrijging van degraa dva ndocto r opgeza gva nd e rector magnificus van Wageningen Universiteit dr.ir. L. Speelman inhe topenbaa rt e verdedigen opwoensda g 4 oktober 2000 desnamiddag st e 13.30uu r ind eAul a van Wageningen Universiteit Thisthesi swa sfunde d bya researc h grantfrom th eNationa l Medical Research Grant inSingapor e and a scholarship byth eMinistr y ofHealth , Singapore. Deurenberg-Yap, Mabel Bodycompositio n and diet ofChinese , Malays and Indians inSingapore : and their influence oncardiovascula r risk factors Thesis WageningenUniversit y- Withref . - With summary inDutc h ISBN 90-5808-292-X Printing: Grafisch bedrijf Ponsen &Looije n B.V., Wageningen,Th eNetherland s © Deurenberg-Yap 2000 BIBUOTI-!R;-K LANDBOUWUMIVJ:KSI TK.T WAI;F:W!NC,F;\' Propositions I Indiscriminate use of international' standards will lead to expensive consequences, (thisthesis ) II Anequatio n derived from a least squaresmetho d performs bettertha n anyothe r inth e samplefrom whic h itwa s derived. The accuracy ofa n equation isreduce d when it is applied toothe r samples. Guo SS. 7«:HumanBod y Composition. Eds Roche Ae t al. Human Kinetics, II1996. (thisthesis) . Ill In many publications, inappropriate useo fbod y composition methodology has resulted inquestionabl e conclusions. IV In the assessment of bodycomposition , bioelectrical impedance owes itspopularit y to the ease ofapplicatio n and apparent sophistication ofth e data displayed rather than to the validity ofth e data. It isno tth e food you actually ate, but what you have declared eaten that determines your health risk. VI Periodso fretrea t andreflectio n are as important asperiod so factivit y for total well being and work efficiency. VII To learn without thinking brings about confusion. Tothin k without learning brings about peril. Confucius, Chinese philosopher and sage (c. 551-479 BC) VIII Theessenc e ofknowledg e is,havin g it, to apply it;no t having it,t o confess your ignorance. Confucius, Chinesephilosophe r and sage (c. 551- 479BC ) IX Alltrut h passesthroug h three stages. First, it isridiculed . Second, it is violently opposed. Third, it isaccepte d asbein g self-evident. Arthur Schopenhauer, German philosopher (1788 -1860) Not everything that can becounte d counts,an d not everything that counts canb e counted. Albert Einstein, German/Americanphysicis t (1879 -1955) XI There isnothin g like adrea m to create a future. Victor Hugo,Frenc h author and dramatist. (1802-1885 ) Propositions belong toth ethesi so fMabe l Deurenberg-Yap entitled "Diet and body composition of Chinese, Malays and Indians in Singapore: and their influence on cardiovascular risk". Wageningen University, TheNetherlands , 4' October 2000. (fit Paid. ABSTRACT BODY COMPOSITION AND DIET OF CHINESE, MALAYS AND INDIANS IN SINGAPORE: AND THEIR INFLUENCE ON CARDIOVASCULAR RISK FACTORS PhD thesis by Mabel Deweneberg-Yap, Department of Human Nutrition and Epidemiology, Wageningen University, Wageningen, TheNetherlands. 4th October2000. This thesis describes the studies on body composition and dietary intakes of the three major ethnic groupsresidin g inSingapore , andho wthes e arerelate dt o cardiovascular risk factors in thesegroups . Body composition: Body fat percentage was measured using a four-compartment model described by Baumgartner. When the relationship between body mass index (BMI) and body fat percentagewa s studied, itwa sdiscovere dtha t Singaporeanshav e higher percentageo f body fat compared to Caucasians with the same BMI and that the BMI cut-off value for obesity in Chinese andMalay s is around 27 kg/m2, whiletha t for Indians is around 26 kg/m2 . At levels ofBM I andwaist-to-hi prati o whichar emuc hlowe rtha nth e WHOrecommende d cut-off limits for obesity and abdominal fatness respectively, both the absolute and relative risks of developing cardiovascular risk factors are markedly elevated for all three ethnic groups. Both the excessive fat accumulation and increased risks at low levels of BMI signal a need to re­ examine cut-off values for obesity among Chinese,Malay san dIndians . Diet: Dietary intakeso fenergy ,tota lfat , saturated fat, polyunsaturated fat, monounsaturated fat and cholesterolwer e measured using a food frequency questionnaire specially validated for this purpose. In addition, intakes of fruits, vegetables and grain-based foods were also measured using the same questionnaire. Singaporeans generally have a low intake of fruits, vegetables and whole grain products. The intake of total fat isjus t within the upper recommended limit while that for saturated fat ishighe r thanth erecommende d level. Ona grou p level, it is found that high intakes of fat, saturated fat and low intakes of polyunsaturated fat and vegetables affect serum cholesterol levels adversely. However, on an individual level, due to the rather homogenous intake patterns among the three groups, this cross sectional study was unable to demonstratetha t dietary intakescoul d explainth e differences in serum cholesterol levels among ethnic groups. In summary, the thesis shows that in the light of increased body fat percentage and cardiovascular risksa t lowBMI ,ther e isa nee dt o re-examine the WHO'scut-of f values for the three major ethnic groups in Singapore. Longitudinal studies are also needed for better insight into the effect of dietary intakes and other lifestyle risk factors on cardiovascular risk factors and mortality. CONTENTS Chapter 1 General Introduction 1 Chapter 2 Manifestation ofcardiovascula r risk factors at low 13 levelso fbod y mass index and waist-hip ratio in Singaporean Chinese Chapter 3 Body mass index and percent body fat: amet aanalysi s 31 among different ethnicgroup s Chapter 4 Body fat measurement among Singaporean Chinese, 51 Malaysan d Indians:a comparitivestud yusin g a four- compartment modelan ddifferen t two-compartment models Chapter 5 Theparado x of lowbod y mass indexan d highbod y fat 69 percentage among Chinese,Malay san d Indians in Singapore Chapter 6 Relationshipsbetwee nindice so fobesit y and itsco ­ 87 morbidities among Chinese, Malaysan d Indians in Singapore Chapter 7 Validation ofa semi-quantitative foodfrequency 111 questionnaire for estimation of intakeso fenergy , fats and cholesterol among Singaporeans Chapter 8 Can dietary factors explaindifference s inseru m 131 cholesterol profiles among different ethnic gropus (Chinese,Malay s and Indians) in Singapore? Chapter 9 General Discussion 151 Summary Samenvatting General Introduction Chapter 1 Background Singapore is a an island country state situated at the tip of the Malaya Peninsula, with a land area of 647.8 square kilometres,o fwhic honl y 1.7% isuse d for agriculture. It isa n equatorial country with relatively uniform temperature (25.3°C to 32.TC), high humidity and abundant rainfall. It has a resident population of 3.16 million and is a multi-ethnic, multi-cultural society comprising mainly Chinese (77%), Malays (14%) and Indians (7.6%). The other ethnic groupsmak eu pabou t 1.4% ofth e population1. Over the last four decades, Singapore has experienced a rapid economic growth with a concomitant improvement in health status of her people. The infant mortality rate is among one ofth e lowest inth e world at lesstha n 4 per 1000liv e births while life expectancy at birth hasrise nt o 79.2year s for womenan d 75year sfo r men(Figur e 1). Parallel to these improvements, there has also been a change in the disease patterns among Singaporeans over the last 4 decades. The main causes of deaths moved from those arising frominfectiou s diseases and poor environmental conditions to the so-called lifestyle diseases (Figure 2). Cancers and cardiovascular diseases (mainly coronary heart disease) are the two major causeso fdeaths . The mortality from cardiovascular disease in Singapore is comparable to those of the West and higher than those in other parts of Asia, such as Japan and Hong Kong2. On the other hand obesity prevalence (defined as BMI of 30 kg/m2 or more) is much lower among Singaporean adultsa t approximately 5%a scompare d to Caucasianpopulations 3. From the National Health Survey in Singapore conducted in 19924 and studies by Hughes et al5'6'7, itwa sapparen t that cardiovascular risk factors differ inth e three major ethnic groups in Singapore. Such risk factors include obesity, abdominal adiposity, elevated blood pressure, abnormal blood lipids (elevated total cholesterol and LDL-cholesterol and low HDL- cholesterol levels),elevate d blood glucose and insulin. Introduction Figure 1. Life expectancy at birth*an d infant mortality rate**(IMR , per 1000 live births) in Singapore, 1957- 1998 45 i Life expectancy .. 80 40 70- x 35 § 60 30 \ \ 50 25 | \ 40 20 % \ 30 15 §• V to 20" —"^ 10 10 ^^____ IMR 5 n - 1 r i i 1 i—i 1 1 1 1 1 1 1 1 1 1 1 1 1 0 4> $ # f f N# N# ^ ^ j>f> Source:Population & Planning Unit, Ministryof Health, Singapore Registryof Births andDeaths, Singapore Figure 2. Top ten causes of deaths (% of all deaths) in Singapore, 1957an d 1996 1957 1996 1.Cance r 1.Cance r 9.7I 2.Hear tdisease s 2.Pneumoni a 7.7 1 §11.6 3.Stroke s 3.Hear tdiseas e 7.2 I 110 8 4.Pneumoni a 4.Tuberculosi s 7.0 1 J 5.8 5.Accident s 5 Diarrhoeal disease 5.5 [ • 2.1 6.Diabete s 6.Stroke s 5.5 | ll.l 7.
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