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University of Southampton Research Repository Eprints Soton University of Southampton Research Repository ePrints Soton Copyright © and Moral Rights for this thesis are retained by the author and/or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder/s. The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given e.g. AUTHOR (year of submission) "Full thesis title", University of Southampton, name of the University School or Department, PhD Thesis, pagination http://eprints.soton.ac.uk UNIVERSITY OF SOUTHAMPTON FACULTY OF MEDICINE Department of Primary Care and Population Sciences An Exploration of Dietary Patterns and the Relationship with Obesity in the Malaysian Population by Asma Ali Thesis for the degree of Doctor of Philosophy November 2014 UNIVERSITY OF SOUTHAMPTON ABSTRACT FACULTY OF MEDICINE Public Health Nutrition Thesis for the degree of Doctor of Philosophy AN EXPLORATION OF DIETARY PATTERNS AND THE RELATIONSHIP WITH OBESITY IN THE MALAYSIAN POPULATION Asma Ali Dietary patterns in Malaysia are changing rapidly as a result of the nutrition transition and these changes are potentially leading to an increase of obesity. However, Malaysia lacks studies investigating the association between dietary patterns and obesity using various dietary approaches. This cross- sectional secondary data analysis explored several approaches to characterising the dietary pattern of the Malaysian population and to assess which approach was a better predictor of obesity. Dietary data were collected from a representative sample of 3,063 adults aged between from 18 to 59 years using a validated semi-quantitative Food Frequency Questionnaire (FFQ). Data were analysed using SPSS version 21. Dietary patterns were characterised using three different approaches: The Ultra-Processed Products/Foods (UPP) measure; Principal Component Analysis (PCA); and revised Diet Quality Index (DQI-R). The UPP method groups food consumed into three groups: Group 1 (unprocessed or minimally processed foods) contributed 45.5% of total energy, Group 2 (processed culinary ingredients) providing 19.7% of total energy, Group 1&2 (traditional prepared foods) contributed 5.8%; and Group 3 (ultra-processed products/foods) contributed 29.8% of total energy intake. From the PCA, six dietary patterns were identified: “Traditional”, “Prudent”, “Modern”, “Western”, “Chinese” and “Combination”. The DQI-R, mean score was 64.6 (SD = 8.2) out of a possible 100 points; the lower the score, the less healthy the diet. There was only weak or no association between each approach to assessing dietary pattern and level of BMI and prevalence of obesity. There were consistent associations found between the unhealthiest dietary patterns and consumption of fat, salt and sugar, and low fibre intake. This suggests that those eating more processed foods have a less healthy diet, even though, at present, this is not linked to excess energy intake and obesity. It will be important to monitor closely the changing patterns of diet in the Malaysian population. It is likely that, unless measures are taken, patterns will shift toward the consumption of more processed foods with consequent adverse impact on nutrient and energy intake and, consequently, on BMI. Table of Contents Table of Contents.............................................................................................................. i List of Tables.................................................................................................................... v List of Figures ................................................................................................................. ix DECLARATION OF AUTHORSHIP....................................................................... xiii Acknowledgements........................................................................................................ xv Definitions and Abbreviations .................................................................................... xvii Chapter 1: Introduction ......................................................................................... 1 1.1 General Introduction ........................................................................................... 1 1.2 Significance of the study....................................................................................... 6 1.3 Summary .............................................................................................................. 6 1.4 Research Questions .............................................................................................. 6 1.5 Objectives of the study......................................................................................... 7 1.6 Hypothesis Null ................................................................................................... 7 1.7 Organisation of the Thesis ................................................................................... 8 Chapter 2: Literature Review ................................................................................ 9 2.1 Socio-demographics of the Malaysian population ................................................. 9 2.2 Drivers of nutrition transition ............................................................................ 14 2.2.1 What is changing in nutrition, globally? ................................................ 14 2.2.2 Changes of the global food system ....................................................... 18 2.3 Causal pathway of obesity in Malaysia ................................................................ 20 2.4 Malaysia nutrition transition: from 1965 to 2009 ................................................ 30 2.4.1 Trends over the past four decades of food supply products in Malaysia34 2.4.2 Summary of Malaysian Dietary Patterns ............................................... 39 Chapter 3: Dietary Pattern Approach ................................................................. 43 3.1 Studies on Dietary Patterns in Malaysia .............................................................. 43 3.2 Introduction of dietary pattern ........................................................................... 52 3.3 Types of dietary approaches ............................................................................... 55 3.4 a priori approach ................................................................................................. 57 3.4.1 Indices ................................................................................................. 57 3.4.2 a posteriori approach............................................................................... 68 i 3.4.3 Dietary Pattern and Obesity................................................................. 69 3.5 Conceptual framework of the study ................................................................... 73 3.6 Summary (Research Operational)....................................................................... 75 Chapter 4: Methodology...................................................................................... 77 4.1 Malaysian Adult Nutrition Survey (MANS)........................................................ 77 4.2 Study design....................................................................................................... 81 4.3 Sampling frame .................................................................................................. 81 4.4 Sample size ........................................................................................................ 83 4.5 Study population................................................................................................ 84 4.6 Data collection................................................................................................... 84 4.7 Survey questionnaire .......................................................................................... 84 4.8 Dietary intake .................................................................................................... 89 4.8.1 Converting FFQ to daily energy and other nutrients ............................ 89 4.8.2 Comparing with RNI ........................................................................... 89 4.9 Dietary pattern approaches ................................................................................ 89 4.10 Anthropometric measurement ........................................................................... 89 4.11 Data analysis ...................................................................................................... 90 Chapter 5: General Findings................................................................................ 91 5.1 Dietary intake .................................................................................................... 91 5.1.1 Methodology of Converting FFQ to Energy Intake and Other Nutrients91 5.1.2 Results ................................................................................................. 97 5.1.3 Discussion on findings of dietary intake............................................. 112 5.2 Socio-demographic background......................................................................
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