Comparison of Two Clinical Case Definitions in Detecting Overweight and Obesity Among Registered Nurses in A District Specialist Hospital

Members: Teh Pei Nee1 Chiew Shoen Chuen2 Sheila Gopal Krishnan3 Yap Ee Lee4 Fauziah Yusof5 Rasidah Abdul Manan5 Mathavi Santhrasegaran1 Roszimah bt Ismail6 Hazira Abdul Kadir7

1Staff Nurse, Special Care Nursery, Hospital 2Pharmacist, Clinical Research Centre, Hospital Seri Manjung 3Head of Paediatric Department, Hospital Seri Manjung

4Nursing Sister, Paediatric Ward, Hospital Seri Manjung 5Staff Nurse, Paediatric Ward, Hospital Seri Manjung 6Staff Nurse, Intensive Care Unit, Hospital Seri Manjung

7Staff Nurse, Psychiatric Clinic, Hospital Seri Manjung

NMRR-16-766-28807

1 AREA LAND : 1,168km² POPULATION : 247,603 ( 2015 ) 2  The is a district in the southwestern part of state, .  The district is well known for , a major attraction in MANJUNG Perak and the home of the (TLDM) Lumut Naval Base and dockyard.

Bandar Seri Manjung is the district's principal urban center while smaller towns include Lumut , , , and .

3

HOSPITAL SERI MANJUNG 305 beds NAVI HOSPITAL 1

HOSPITAL DESA PANGKOR 1

PRIVATE HOSPITAL 2

GOVERMENT HEALTH CLINIC 31

PRIVATE HEALTH CLINIC 72

5 Departments Units • Medical • Haemodialysis Unit • Surgical • ICU / CCU • Orthopaedic • Physiotherapy Unit • Ophthalmology • Occupational • Emergency & Traumatology Rehabilitation • Paediatrics • Sterile Equipment Supply • Obstetrics & Gynaecology Unit • Psychiatry & Mental Health • Health Education Unit • Diagnostic & Imaging • Medical Social Work Unit • Pharmacy & Supply • Counselling Psychology • Pathology Department Unit • Dietetics & Catering • Quality Unit / Innovation & CRC(Clinical Research Centre)

6 7 Health burden

8  BMI = weight (kg) height (m2) Overweight and obesity classification

Category IBMI (kg/m2) ABMI (kg/m2 ) Underweight <18.50 <18.50 Normal 18.50-24.99 18.50-22.99 Overweight 25.00-29.99 23.00-27.49 Obese ≥ 30.00 ≥ 27.50

Source: WHO 2004¹, CPG on Management of Obesity 2004².

9 3) There has been some contention whether the generalisation of the IBMI (International Body Mass Index) to the Asian population will underestimate the prevalence of overweight and obesity.

4) In year 2004, WHO was recommended additional BMI cut-off points for Asian populations for public health. (≥23 kg/m2 as increased risk and ≥27.5 kg/m2 as high risk).

10 5) BMI cut-off points have been revised to suit Asian population due to:

(i) high prevalence of Type 2 Diabetes Mellitus among Asian individuals with BMI < 25.0kg/m2, (ii) higher cardiovascular risk factors among Asian individuals at any BMI level, and (iii) population based association between BMI, body fat percentage and distribution.

11 Lamon-Fava S et al, 1996  Prevalence of overweight and obesity is Hossain, 2007 highest in developing countries and is Bhurosy et al , 2014 associated with increase in incidence of cardiovascular disease.

Deuremberg-Yap M et The BMI recommendation for public health was al, 2001 less than IBMI classification. (Singapore) (≥23 kg/m2 as increased risk and ≥27.5 kg/m2 as high risk) Feng R N, et al 2012 The optimal BMI for men and women to predict (China) co-morbidities was less than IBMI classification. ( 24 kg/m2 ) Ren Q, et al 2016 The optimal BMI for men and women to predict (China) Hypertension was less than IBMI classification (23.53kg/m2 and 24.25kg/m2).

Tanu, et al 2014 The optimal BMI to predict Hypertension was (India) ≥24.5kg/m2 (men) and ≥24.9kg/m2( women).

12 Bogossian FE et al, The prevalence of overweight and obesity among 2012 nurses and midwives were higher compared to the general population in Australia, New Zealand and UK.

Miller SK et al, The prevalence of overweight, obesity and 2008 morbidly obesity among American nurses were 30%, 18.7% and 5.2% respectively.

Ogunjimi LO et al, The prevalence of obesity among Nigerian nurses 2010 62.6%.

13 Malaysian National Health Increase of obesity prevalence from and Morbidity Survey 14 % (2006) to 15.1% (2011) (MNHMS) in local population aged above 18 years 2006, 2011 Malaysian National Health IBMI classification and Morbidity Survey, - overweight: 30.0% and obesity : 17.7% 2015 ABMI classification – overweight: 33.4% and obesity: 30.6%.

WHO- Non Communicable • Among obese population, female Malaysians Disease Profile in Malaysia, were more affected than the male 2012 counterparts

Coomarasamy JD et al, The prevalence of overweight and obesity 2014 among female nurses in Malaysia were 33.5% and 17.1% respectively.

14  This study endeavours to answer whether by using IBMI classification among Asian population would lead to a significant proportion of the overweight individuals going below the radar. Hypothesis : Are we missing a significant number of overweight nurses with associated comorbidities by using IBMI criteria?

15 General Objective To compare the prevalence of overweight and obesity based on IBMI and ABMI among female registered nurses. Specific Objectives

1)To compare the prevalence of cardiovascular (CV) related co- morbidities among those who were overweight and obese according to both definitions.

2) To determine the factors associated with overweight and obesity in the study population.

16 Cross-sectional Study

Hospital Seri Manjung Nurses in all departments

September - October 2016

 Sample size : 384 (minimum) - Stratified random sampling (working schedule) - A random number list was generated by using Epical 2000 software. - Proportions were set at 50.6% and precision at 5% (45.6- 55.6%).

MREC approved 17  Inclusion criteria : All female registered nurses in HSM

 Exclusion criteria : Pregnant, on confinement / paid / unpaid leave, refuse to consent

18  Data collection :  Demography, health, work environment, dietary, physical activity were collected via interview by trained researchers by using questionnaire.  Adapted from Canadian National Survey of the Work and Health of Nurses¹², 2005

 Data analysis :  Prevalence of outcome was presented as %  Sensitivity & specificity of both definitions in predicting CV- related co-morbidities were calculated  Associating factors were analysed using multiple logistic regression

MREC approved 19 Consent taking process

Measuring of height and weight as well as BMI calculation

Interviewing the respondent by using questionnaire

20 Nurses who fulfilled the inclusion criteria were given Respondent Information Sheet.

Researchers explained to respondents about the study.

Respondents were given sufficient time to understand, ask questions and consider before deciding on their participation.

All respondents were asked to sign 2 sets of informed consent form.

Figure 2: Information sheet & Consent taking process 21 22 Result

23 Table 1: Characteristics of Respondents* total respondents = 393

Characteristics n (%) Demographic Data Age in years, median (quartiles) 36 (32-41)

Ethnicity Malay 361 (91.9%) Chinese 3 (0.8%) Indian 23 (5.9%) Others 6 (1.5 %)

Marital Status Single 9 (2.3%) Married 378 (96.2%) Divorced 2 (0.5%) 4 (1.0%) Widow Body Mass Index (BMI) BMI in kg/m2, median (quartiles) 26.30 (23.63-30.13)

Weight satisfaction Satisfied 118 (30.0%) Not satisfied 275 (70.0%)

24 IBMI ABMI No. & % of No. & % of Category respondents in CVD Category respondents in CVD each category1 each category1 (n, %)2 (n, %)2

Overweight Overweight 146 (37.2%) 21 (14.4%) 136 (34.6%) 14 (10.3%) (25-29.9kg/m2) (23-27.49kg/m2)

Obese Obese 102 (26.0%) 25 (24.5%) 172 (43.8%) 35 (20.3%) (≥ 30kg/m2) (≥ 27.5kg/m2)

 1: The denominator was total respondents (393)  2: The denominator was respondents in the particular BMI category  CVD = cardiovascular disease

25 Table 3: Sensitivity and specificity of IBMI and ABMI (overweight + obesity) definitions in prediction of CV-related co-morbidities CVD (%)

Sensitivity Specificity PPV NPV

IBMI definition 85.2 40.4 18.5 94.5

ABMI definition 90.7 23.6 15.9 94.1

 In predicting CV-related comorbidities, IBMI was slightly less sensitive [85.2% (95% CI : 72.34; 92.95)] than ABMI [90.7% (95% CI: 78.89; 96.52)] but more specific [40.4% (95% CI: 35.17; 45.85)] than ABMI [23.6% (95% CI: 19.26; 28.56)].

26  The risk of overweight or obese will be double in 10 years time. (OR=1.83; 95%CI: 1.24; 2.70, p=0.002).  Married nurses were 13 times more likely to be overweight or obese (OR=13.11; 95%CI 2.44; 70.63, p=0.003) than single nurses.  Nurses who adhered to food pyramid less than 50% of the time were 2 times more likely to be overweight or obese (OR=2.41, 95%CI: 1.33; 4.35, p=0.004) compared to nurses who were adherent.

27 1a. Prevalence of Overweight & Obesity among Nurses Country % of % of overweight obesity IBMI 1. Ogunjimi LO et al, 2010 Nigeria - 62.6% 2. Kim MJ et al, 2013 Korea 18.6% 7.4% SLIM 3. Miller SK et al , 2007 U.S. 30% 23.9% 4. Coomarasamy JD et al, Malaysia 33.5% 17.1% 2014 Current study , 2016 Malaysia 37.2% 26.0% ABMI 1. Aryee PA et al , 2013 Ghana 18.2 15.5 Current study , 2016 Malaysia 34.6% 43.8%

28 1b. Comparison with GENERAL POPULATION

Subjects % of overweight % of obesity

IBMI 1. NHMS 2015 General 30.0% 17.7% Population 2. Current study , 2016 Nurses 37.2% 26.0%

ABMI 1. NHMS 2015 General 33.4% 30.6% Population 2. Current study , 2016 Nurses 34.6% 43.8%

NHMS: National Health Morbidity Survey⁷ 2015

29  Both ABMI & IBMI definitions had good sensitivity (90.7% vs 85.2%) but IBMI had much higher specificity (40.4%) than ABMI (23.6%).

 However, IBMI is still a good tool to be used and we need a larger scale study to support the utilization of ABMI in Malaysian population.

30 Studies Factors van Drongelen A et al¹⁴, 2011 shift work (Systematic Review)

Kim MJ et al¹³, 2013 shift work

Smith P et al¹⁵, 2013 shift work

increasing age, male, pre- Bogossian FE et al¹º, 2012 menopause as well as menopause

Ogunjimi LO et al⁹, 2010 Eating habit and being married Age, being married & compliance to Current study, 2016 food pyramid

31  The co-morbidities, food pyramid adherence and intensity of physical activities were self-reported.  Less privacy during interview sessions. Conclusion 1. The prevalence of overweight by both classifications was similar but the prevalence of obesity was higher with ABMI. 2. The prevalence of CV related co-morbidities among overweight and obese nurses were similar by using both definitions. 3. Increasing age, being married and the lack of adherence to food pyramid are associated with a higher risk of being overweight and obese.

32 1. Further studies need to be done to evaluate ABMI as a screening tool in the local population.

2. Although maintaining an ideal BMI is in our yearly SKT, this study indicates that it is not being achieved among with increasing age and married. Therefore, we need to look at workplace-based intervention to overcome this.

33  We would like to thank - Hospital Director, Chief Matron (KPJH), Matrons, Sisters, CRC unit staffs, attendants and guards who support this research.

- All the respondents (all categories of female nurses) in Hospital Seri Manjung.

- Pathology & Pharmacy departments’ staffs who involved in answering the questionnaire during pre-test.

- Administrative & CRC unit staffs who involved during interviewer training session.

34 1. WHO expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet, 2004; 157-163.

2. Malaysian Clinical Practice Guidelines (CPG) on Management of Obesity. 2004.

3. Lamon-Fava S, Wilson PW, Schaefer JS. Impact of Body Mass Index on Coronary Heart Disease Risk Factors in Men and Women. Arteriosclerosis, Thrombosis, and Vascular Biology. 1996;16: 1509- 1515doi:10.1161/01.ATV.16.12.1509

4. Hossain P, Kawar B, Nahas EL. Obesity and Diabetes in the Developing World — A Growing Challenge. N Engl J Med. 2007; 356:213-215

5. Bhurosy T, Rajesh Jeewon R. Overweight and Obesity Epidemic in Developing Countries: A Problem with Diet, Physical Activity, or Socioeconomic Status?. The Scientific World Journal. 2014:7

6. National Health and Morbidity Survey. 2011. http://www.moh.gov.my/index.php/file_manager/dl_item/624746305a584e305833426b5a69394f513 05176546. Assessed: 29/01/16

7. National Health and Morbidity Survey . 2015. http://www.iku.gov.my/index.php/research-eng/list-of- research-eng/iku-eng/nhms-eng/nhms-2016. Assessed: 25/4/2016

8. Milier S K, Alpert PT, Cross CL. Overweight And Obesity In Nurses, Advanced Practiced Nurses And Nurses Educators. Journal of The American Academy Of Nurse Practitioners. 2008; 20:259-65

9. Ogunjimi LO, Ikorok MM, Olayinka YO. Prevalence of obesity among Nigeria nurses: The Akwa Ibom state experience. International NGO Journal. 2010; 5:45-49

10. Bogossian FE, et al. A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United Kingdom. Int.J. Nurs Stud. 2012; 49(6):727-38

35 11. Coomarasamy JD, Wint NN, Donna Lou EN,Sukumaran S. Prevalence of Obesity and Daily Lifestyles of the Registered Nurses in Malaysia. International Journal of Innovation and Applied Studies. 2014; 7(3):1202-1208.

12. Canadian National Survey of the Work and Health of Nurses 2005.

13. Kim MJ et al. Association between shift work and obesity among female nurses. Korean Nurses' Survey. BMC Public Health. 2013; 13:1204

14. van Drongelen A, Boot CR, Merkus SL, Smid T, van der Beek AJ. The effects of shift work on body weight change - a systematic review of longitudinal studies. Scand J Work Environ Health. 2011; 13:263–275.

15. Smith P, Fritschi L, Reid A, Mustard C. The Relationship Between Shift Work and Body Mass Index Among Canadian Nurses. Appl Nurs Res. 2013;26:24-31.

16. Tee E-S. Development and promotion of Malaysian Dietary Guidelines. Asia Pac J Clin Nutr 2011;20 (3):455-461 17.WHO | Global recommendations on physical activity for health .2015. http://www.who.int/dietphysicalactivity/physical_activity_intensity/en/. Assessed: 27/4/2016

18. Aryee PA, Helegbe GK, Baah B, Sarfo-Asante RA & Quist-Therson R. Prevalence and Risk Factors for Overweight and Obesity among Nurses in the Tamale Metropolis of Ghana. Journal of Medical and Biomedical Sciences.2013;2(2) : 13-23.

36 37 Appendix A : Respondent Information Sheet & Consent Form Questionnaire of “Comparison of Two Clinical Case Definitions in Detecting Overweight and Obesity among Registered Nurses in a District Specialist Hospital” Introduction We are doing the nursing research regarding Body - Mass Index (BMI) among registered female nurses in in Hospital Seri Manjung (HSM). Information from this survey will help us to compare the prevalence of overweight and obesity based on the 2 clinical case definitions of IBMI and ABMI among the female registered nurses in our hospital. Furthermore to determine the prevalence of comorbidities among those who were overweight according to the ABMI classification and understand the association between demographic data, work environment /status, dietary intake and pattern, physical activity, and overweight/obesity. Number of subjects in this research is 384. This study will be carried over a period of 3 months. You are required to answer a questionnaire. Your height and weight will be measured by the researcher. We do not foresee any risk in this research. Your answers will be kept strictly confidential and used only for statistic purpose. Only the researcher has access to the research data. You may request for the results of the study by the end of the study. While participation in this survey is voluntary, your cooperation is important to ensure that the information collected in this survey is as accurate and as comprehensive as possible. I, ______(name of participant) hereby consent to participate in Comparison of Two Clinical Case Definitions in Detecting Overweight and Obesity among Registered Nurses in a District Specialist Hospital. I understand that: I understand that my participation is voluntary. I can stop participating in this survey at any time. While information gained in this study may be used in a conference presentation, and may also be published in a journal article, I will not be identified. Information concerning me will remain strictly confidential. I may not directly benefit from taking part in this survey. I can ask the researcher, at any time for any additional information.

Participant’s name: ______IC No.: ______Date: ______Participant's signature: ______

Investigator’s name: ______IC No.: ______Date: ______Investigator's signature: ______

Principal Investigator: KUP Teh Pei Nee SCN, Hospital Seri Manjung Tel: 05 – 689 6833, Email: [email protected] 38 Appendix B: Questionnaire

39 Appendix B: Questionnaire

40 Appendix B: Questionnaire

Source: Tee ES, 2011¹⁶

41 AppendixAppendix 1: B : Questionnaire

Reference: WHO | Global recommendations on physical activity for health http://www.who.int/dietphysicalactivity/physical_activity_intensity/en/ 42 43