Validity of dietary questionnaires in Sri Lankan adults and the association of dietary intake with obesity

Traditionally, infectious diseases and under-nutrition have been considered major health problems in Sri Lanka with little attention paid to obesity and associated non-communicable diseases (NCDs). However, the recent Sri Lanka Diabetes and Cardiovascular Study (SLDCS) reported the epidemic level of obesity, diabetes and metabolic syndrome. Moreover, obesity-associated NCDs is the leading cause of death in Sri Lanka and there is an exponential increase in hospitalization due to NCDs adversely affecting the development of the country. Despite Sri Lanka having a very high prevalence of NCDs and associated mortality, little is known about the causative factors for this burden. It is widely believed that the global NCD epidemic is associated with recent lifestyle changes, especially dietary factors. In the absence of sufficient data on dietary habits in Sri Lanka, successful interventions to manage these serious health issues would not be possible. In view of the current situation the dietary survey was undertaken to assess the intakes of energy, macro-nutrients and selected other nutrients with respect to socio demographic characteristics and the nutritional status of Sri Lankan adults especially focusing on obesity. Another aim of this study was to develop and validate a culturally specific food frequency questionnaire (FFQ) to assess dietary risk factors of NCDs in Sri Lankan adults. Data were collected from a subset of the national SLDCS using a multi-stage, stratified, random sampling procedure (n=500). However, data collection in the SLDCS was affected by the prevailing civil war which resulted in no data being collected from Northern and Eastern provinces. To obtain a nationally representative sample, additional subjects (n=100) were later recruited from the two provinces using similar selection criteria. Ethical Approval for this study was obtained from the Ethical Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka and informed consent was obtained from the subjects before data were collected. Dietary data were obtained using the 24-h Dietary Recall (24HDR) method. Subjects were asked to recall all foods and beverages, consumed over the previous 24-hour period. Respondents were probed for the types of foods and food preparation methods. For the FFQ validation study, a 7-day weight diet record (7-d WDR) was used as the reference method. All foods recorded in the 24 HDR were converted into grams and then intake of energy and nutrients were analysed using NutriSurvey 2007 (EBISpro, Germany) which was modified for Sri Lankan food recipes. Socio-demographic details and body weight perception were collected from interviewer-administrated questionnaire. BMI was calculated and overweight (BMI ≥23 kg.m-2), obesity (BMI ≥25 kg.m-2) and abdominal obesity (Men: WC ≥ 90 cm; Women: WC ≥ 80 cm) were categorized according to Asia-pacific anthropometric cut-offs. The SPSS v. 16 for Windows and Minitab v10 were used for statistical analysis purposes. From a total of 600 eligible subjects, 491 (81.8%) participated of whom 34.5% (n=169) were males. Subjects were well distributed among different socio-economic parameters. A total of 312 different food items were recorded and nutritionists grouped similar food items which resulted in a total of 178 items. After performing step-wise multiple regression, 93 foods explained 90% of the variance for total energy intake, carbohydrates, protein, total fat and dietary fibre. Finally, 90 food items and 12 photographs were selected. Seventy-seven subjects completed (response rate = 65%) the FFQ and 7-day WDR. Estimated mean energy intake (SD) from FFQ (1794±398 kcal) and 7DWR (1698±333 kcal, P<0.001) was significantly different due to a significant overestimation of carbohydrate (~10 g/d, P<0.001) and to some extent fat (~5 g/d, NS). Significant positive correlations were found between the FFQ and 7DWR for energy (r = 0.39), carbohydrate (r = 0.47), protein (r = 0.26), fat (r =0.17) and dietary fiber (r = 0.32). Bland-Altman graphs indicated fairly good agreement between methods with no relationship between bias and average intake of each nutrient examined. The findings from the nutrition survey showed on average, Sri Lankan adults consumed over 14 portions of starch/d; moreover, males consumed 5 more portions of cereal than females. Sri Lankan adults consumed on average 3.56 portions of added sugars/d. Moreover, mean daily intake of fruit (0.43) and vegetable (1.73) portions was well below minimum dietary recommendations (fruits 2 portions/d; vegetables 3 portions/d). The total fruit and vegetable intake was 2.16 portions/d. Daily consumption of meat or alternatives was 1.75 portions and the sum of meat and pulses was 2.78 portions/d. Starchy foods were consumed by all participants and over 88% met the minimum daily recommendations. Importantly, nearly 70% of adults exceeded the maximum daily recommendation for starch (11portions/d) and a considerable proportion consumed larger numbers of starch servings daily, particularly men. More than 12% of men consumed over 25 starch servings/d. In contrast to their starch consumption, participants reported very low intakes of other food groups. Only 11.6%, 2.1% and 3.5% of adults consumed the minimum daily recommended servings of vegetables, fruits, and fruits and vegetables combined, respectively. Six out of ten adult Sri Lankans sampled did not consume any fruits. Milk and dairy consumption was extremely low; over a third of the population did not consume any dairy products and less than 1% of adults consumed 2 portions of dairy/d. A quarter of Sri Lankans did not report consumption of meat and pulses. Regarding protein consumption, 36.2% attained the minimum Sri Lankan recommendation for protein; and significantly more men than women achieved the recommendation of ≥3 servings of meat or alternatives daily (men 42.6%, women 32.8%; P<0.05). Over 70% of energy was derived from carbohydrates (Male:72.8±6.4%, Female:73.9±6.7%), followed by fat (Male:19.9±6.1%, Female:18.5±5.7%) and proteins (Male:10.6±2.1%, Female:10.9±5.6%). The average intake of dietary fiber was 21.3 g/day and 16.3 g/day for males and females, respectively. There was a significant difference in nutritional intake related to ethnicities, areas of residence, education levels and BMI categories. Similarly, dietary diversity was significantly associated with several socio-economic parameters among Sri Lankan adults. Adults with BMI ≥25 kg.m-2 and abdominally obese Sri Lankan adults had the highest diet diversity values. Age-adjusted prevalence (95% confidence interval) of overweight, obesity, and abdominal obesity among Sri Lankan adults were 17.1% (13.8-20.7), 28.8% (24.8-33.1), and 30.8% (26.8-35.2), respectively. Men, compared with women, were less overweight, 14.2% (9.4-20.5) versus 18.5% (14.4-23.3), P = 0.03, less obese, 21.0% (14.9-27.7) versus 32.7% (27.6-38.2), P < .05; and less abdominally obese, 11.9% (7.4-17.8) versus 40.6% (35.1-46.2), P < .05. Although, prevalence of obesity has reached to epidemic level body weight misperception was common among Sri Lankan adults. Two-thirds of overweight males and 44.7% of females considered themselves as in "about right weight". Over one third of both male and female obese subjects perceived themselves as "about right weight" or "underweight". Nearly 32% of centrally obese men and women perceived that their waist circumference is about right. People who perceived overweight or very overweight (n = 154) only 63.6% tried to lose their body weight (n = 98), and quarter of adults seek advices from professionals (n = 39). A number of important conclusions can be drawn from this research project. Firstly, the newly developed FFQ is an acceptable tool for assessing the nutrient intake of Sri Lankans and will assist proper categorization of individuals by dietary exposure. Secondly, a substantial proportion of the Sri Lankan population does not consume a varied and balanced diet, which is suggestive of a close association between the nutrition-related NCDs in the country and unhealthy eating habits. Moreover, dietary diversity is positively associated with several socio-demographic characteristics and obesity among Sri Lankan adults. Lastly, although obesity is a major health issue among Sri Lankan adults, body weight misperception was common among underweight, healthy weight, overweight, and obese adults in Sri Lanka. Over 2/3 of overweight and 1/3 of obese Sri Lankan adults believe that they are in "right weight" or "under-weight" categories.

An Asian perspective of occupational stress coping model : a case study of Sri Lankan employees

Sri Lanka has one of the highest rates of natural disasters and violent conflicts in the world. Yet there is a lack of research on its unique socio-cultural characteristics that determine an individual's cognitive and behavioural responses to distressing encounters. This study extends Goh, Sawang and Oei's (2010) revised transactional model to examine the cognitive and behavioural processes of occupational stress experience in the collectivistic society of Sri Lanka. A time series survey was used to measure the participant's stress-coping process. Using the revised transactional model and path analysis, a unique Sri Lankan model is identified that provides theoretical insights on the revised transactional model, and sheds light on socio-cultural dimensions of occupational stress and coping, thus equipping practitioners with a sound theoretical basis for the development of stress management programs in the workplace.

Secure and safe water supplies in remote Australian and rural Sri Lankan regions : common issues and emerging responses

Most urban dwelling Australians take secure and safe water supplies for granted. That is, they have an adequate quantity of water at a quality that can be used by people without harm from human and animal wastes, salinity and hardness or pollutants from agriculture and manufacturing industries. Australia wide urban and peri-urban dwellers use safe water for all domestic as well as industrial purposes. However, this is not the situation remote regions in Australia where availability and poor quality water can be a development constraint. Nor is it the case in Sri Lanka where people in rural regions are struggling to obtain a secure supply of water, irrespective of it being safe because of the impact of faecal and other contaminants. The purposes of this paper are to overview: the population and environmental health challenges arising from the lack of safe water in rural and remote communities; response pathways to address water quality issues; and the status of and need for integrated catchment management (ICM) in selected remote regions of Australia and vulnerable and lagging rural regions in Sri Lanka. Conclusions are drawn that focus on the opportunity for inter-regional collaborations between Australia and Sri Lanka for the delivery of safe water through ICM.

The influence of family history of hypertension on disease prevalence and associated metabolic risk factors among Sri Lankan adults

Background Hypertension is a major contributor to the global non-communicable disease burden. Family history is an important non-modifiable risk factor for hypertension. The present study aims to describe the influence of family history (FH) on hypertension prevalence and associated metabolic risk factors in a large cohort of South Asian adults, from a nationally representative sample from Sri Lanka. Methods A cross-sectional survey among 5,000 Sri Lankan adults, evaluating FH at the levels of parents, grandparents, siblings and children. A binary logistic regression analysis was performed in all patients with ‘presence of hypertension’ as dichotomous dependent variable and using family history in parents, grandparents, siblings and children as binary independent variables. The adjusted odds ratio controlling for confounders (age, gender, body mass index, diabetes, hyperlipidemia and physical activity) are presented below. Results In all adults the prevalence of hypertension was significantly higher in patients with a FH (29.3 %, n = 572/1951) than those without (24.4 %, n = 616/2530) (p < 0.001). Presence of a FH significantly increased the risk of hypertension (OR:1.29; 95 % CI:1.13-1.47), obesity (OR:1.36; 95 % CI: 1.27–1.45), central obesity (OR:1.30; 95 % CI 1.22–1.40) and metabolic syndrome (OR:1.19; 95 % CI: 1.08–1.30). In all adults presence of family history in parents (OR:1.28; 95 % CI: 1.12–1.48), grandparents (OR:1.34; 95 % CI: 1.20–1.50) and siblings (OR:1.27; 95 % CI: 1.21–1.33) all were associated with significantly increased risk of developing hypertension. Conclusions Our results show that the prevalence of hypertension was significantly higher in those with a FH of hypertension. FH of hypertension was also associated with the prevalence of obesity, central obesity and metabolic syndrome. Individuals with a FH of hypertension form an easily identifiable group who may benefit from targeted interventions.

Assessment of body composition of Sri Lankan Australian children using ethnic specific equations

Since ethnic differences exist in body composition, assessment methods need to be validated prior to use in different populations. This study attempts to validate the use of Sri Lankan based body composition assessment tools on a group of 5 - 15 year old Australian children of Sri Lankan origin. The study was conducted at the Body Composition Laboratory of the Children’s Nutrition Research Centre at the Royal Children’s Hospital, Brisbane, Australia. Height (Ht), weight (Wt), segmental length (Lsegment name) and skinfold thickness (SFT) were measured. The whole body and segmental bio impedance analysis (BIA) were also measured. The body composition determined by the deuterium dilution technique (criterion method) was compared with the assessments done using prediction equations developed on Sri Lankan children. 27 boys and 15 girls were studied. All predictions of body composition parameters, except percentage fat mass (FM) assessed by the SFT-FM equation in girls gave statistically significant correlations with the criterion method. They had a low mean bias and most were not influenced by the measured parameter. Although living in a different socioeconomic state, the equations developed on children of the same ethnic background gives a better predictive value of body composition. This highlights the ethnic influence on body composition.

Segmental bioelectrical impedance in the assessment of body composition of Sri Lankan children

Abstract: Over the years bioelectrical impedance assay (BIA) has gained popularity in the assessment of body composition. However, equations for the prediction of whole body composition use whole body BIA. This study attempts to evaluate the usefulness of segmental BIA in the assessment of whole body composition. A cross sectional descriptive study was conducted at the Professorial Paediatric Unit of Lady Ridgeway Hospital, Colombo, involving 259 (M/F:144/115) 5 to 15 year old healthy children. The height, weight, total and segmental BIA were measured and impedance indices and specific resistivity for the whole body and segments were calculated. Segmental BIA indices showed a significant association with whole body composition measures assessed by total body water (TBW) using the isotope dilution method (D2O). Impedance index was better related to TBW and fat free mass (FFM), while specific resistivity was better related to the fat mass of the body. Regression equations with different combinations of variables showed high predictability of whole body composition. Results of this study showed that segmental BIA can be used as an alternative approach to predict the whole body composition in Sri Lankan children.

Adopting healthcare big data in Sri Lankan healthcare sector

The concept of big data has already outperformed traditional data management efforts in almost all industries. Other instances it has succeeded in obtaining promising results that provide value from large-scale integration and analysis of heterogeneous data sources for example Genomic and proteomic information. Big data analytics have become increasingly important in describing the data sets and analytical techniques in software applications that are so large and complex due to its significant advantages including better business decisions, cost reduction and delivery of new product and services [1]. In a similar context, the health community has experienced not only more complex and large data content, but also information systems that contain a large number of data sources with interrelated and interconnected data attributes. That have resulted in challenging, and highly dynamic environments leading to creation of big data with its enumerate complexities, for instant sharing of information with the expected security requirements of stakeholders. When comparing big data analysis with other sectors, the health sector is still in its early stages. Key challenges include accommodating the volume, velocity and variety of healthcare data with the current deluge of exponential growth. Given the complexity of big data, it is understood that while data storage and accessibility are technically manageable, the implementation of Information Accountability measures to healthcare big data might be a practical solution in support of information security, privacy and traceability measures. Transparency is one important measure that can demonstrate integrity which is a vital factor in the healthcare service. Clarity about performance expectations is considered to be another Information Accountability measure which is necessary to avoid data ambiguity and controversy about interpretation and finally, liability [2]. According to current studies [3] Electronic Health Records (EHR) are key information resources for big data analysis and is also composed of varied co-created values [3]. Common healthcare information originates from and is used by different actors and groups that facilitate understanding of the relationship for other data sources. Consequently, healthcare services often serve as an integrated service bundle. Although a critical requirement in healthcare services and analytics, it is difficult to find a comprehensive set of guidelines to adopt EHR to fulfil the big data analysis requirements. Therefore as a remedy, this research work focus on a systematic approach containing comprehensive guidelines with the accurate data that must be provided to apply and evaluate big data analysis until the necessary decision making requirements are fulfilled to improve quality of healthcare services. Hence, we believe that this approach would subsequently improve quality of life.

Energy and nutrient intakes among Sri Lankan adults

Introduction The epidemic of nutrition related non-communicable diseases such as type 2 diabetes mellitus and obesity has reached to epidemic portion in the Sri Lanka. However, to date, detailed data on food consumption in the Sri Lankan population is limited. The aim of this study is to identify energy and major nutrient intake among Sri Lankan adults. Methods A nationally-representative sample of adults was selected using a multi-stage random cluster sampling technique. Results Data from 463 participants (166 Males, 297 Females) were analyzed. Total energy intake was significantly higher in males (1913 ± 567 kcal/d) than females (1514 ± 458 kcal/d). However, there was no significant gender differences in the percentage of energy from carbohydrate (Male: 72.8 ± 6.4%, Female: 73.9 ± 6.7%), fat (Male: 19.9 ± 6.1%, Female: 18.5 ± 5.7%) and proteins (Male: 10.6 ± 2.1%, Female: 10.9 ± 5.6%). Conclusion The present study provides the first national estimates of energy and nutrient intake of the Sri Lankan adult population.

Validity of currently used cutoff values of body mass index as a measure of obesity in Sri Lankan children

The aim of the study was to determine the reliability of body mass index based (BMI) cutoff values in diagnosing obesity among Sri Lankan children. Height, weight, waist circumference (WC) and hip circumference (HC) in 282 children were measured. Total body water was determined by deuterium dilution and fat mass (FM) derived using age and gender specific constants. A percentage FM of 30% for girls and 25% for boys were considered as cutoff levels for obesity. Two hundred and eighty two children (M/F: 158/124) were studied and 99 (80%) girls and 72 (45.5%) boys were obese based on % body fat. Eight (6.4%) girls and nine (5.7%) boys were obese based on International Obesity Task Force (IOTF) cutoff values. Percentage FM and WC centile charts were able to diagnose a significant proportion of children as true obese children. The FM and BMI were closely associated in both girls (r = 0.82, p < 0.001) and boys (r = 0.87, p < 0.001). Percentage FM and BMI had a very low but significant association; girls (r = 0.32, p < 0.001) and boys (r = 0.68, p < 0.001). FM had a significant association with WC and HC. BMI based cutoff values had a specificity of 100% but a very low sensitivity, varying between 8% and 23.6%. BMI is a poor indicator of the percentage fat and the commonly used cutoff values were not sensitive to detect cases of childhood obesity in Sri Lankan children.

Assessment of body composition in Sri Lankan children: Validation of a bioelectrical impedance prediction equation

Objective: To develop bioelectrical impedance analysis (BIA) equations to predict total body water (TBW) and fat-free mass (FFM) of Sri Lankan children. Subjects/Methods: Data were collected from 5- to 15-year-old healthy children. They were randomly assigned to validation (M/F: 105/83) and cross-validation (M/F: 53/41) groups. Height, weight and BIA were measured. TBW was assessed using isotope dilution method (D2 O). Multiple regression analysis was used to develop preliminary equations and cross-validated on an independent group. Final prediction equation was constructed combining the two groups and validated by PRESS (prediction of sum of squares) statistics. Impedance index (height2/impedance; cm2/Ω), weight and sex code (male = 1; female = 0) were used as variables. Results: Independent variables of the final prediction equation for TBW were able to predict 86.3% of variance with root means-squared error (RMSE) of 2.1l. PRESS statistics was 2.1l with press residuals of 1.2l. Independent variables were able to predict 86.9% of variance of FFM with RMSE of 2.7 kg. PRESS statistics was 2.8 kg with press residuals of 1.4 kg. Bland Altman technique showed that the majority of the residuals were within mean bias±1.96 s.d. Conclusions: Results of this study provide BIA equation for the prediction of TBW and FFM in Sri Lankan children. To the best of our knowledge there are no published BIA prediction equations validated on South Asian populations. Results of this study need to be affirmed by more studies on other closely related populations by using multi-component body composition assessment.

Sri Lankan entrepreneurs in Australia: Chance or choice?

Purpose Ethnic entrepreneurship is, and always has been, a means of survival. However, there is limited literature on ethnic entrepreneurship in Australia and therefore, an understanding of ethnic entrepreneurs’ motivations to become self-employed. The purpose of this paper is to report the influential factors in the decision to engage in self-employment through case studies of members of Melbourne’s Sri Lankan community informed by the mixed embeddedness approach. Design/methodology/approach The mixed embeddedness approach frames the study where the authors examine the motivations for business of five Sri Lankan entrepreneurs. Narratives are used to construct individual case studies, which are then analyzed in terms of the motivations for, resources used and challenges faced on the entrepreneurial journey. Findings For these ethnic entrepreneurs, their entrepreneurial activity results from a dynamic match between local market opportunities and the specific ethnic resources available to them at the time of founding. The self-employment decision was not prompted by a lack of human capital but an inability to use that human capital in alternative means of employment at specific points in time. Moreover the authors highlight the importance of social and cultural capital as resources used to overcome challenges on the entrepreneurial journey. Originality/value In this community, entrepreneurship was not a result of a lack of human capital but how it was utilized in combination with social and cultural capitals in the given opportunity structure. The mixed embeddedness approach enables the uncovering of how ethnic network ties were used in light of the opportunities available to build entrepreneurial activity.

Exposure to pesticides, ill health and averting behaviour : costs and determining the relationship

Farmers' exposure to pesticides is high in developing countries. As a result many farmers suffer from ill-health, both short and long term. Deaths are not uncommon. This paper addresses this issue. Field survey data from Sri Lanka are used to estimate farmers' expenditure on defensive behavior (DE) and to determine factors that influence DE. The avertive behavior approach is used to estimate costs. Tobit regression analysis is used to determine factors that influence DE. Field survey data show that farmers' expenditures on DE are low. This is inversely related to high incidence of ill health among farmers using pesticides.

Space and culture: Tradition verses culture

This paper proposes to examine contemporary culture, through communication and technology, in an attempt to expose some of these new or altered spatial concepts evident in film and built form, such as ratefaction and saturation