Type 2 diabetes mellitus in transitional Thailand:incidence, risk factors, mediators, and implications

Background Economic growth in Asia is changing population health profiles. Family structures, environments, occupations, education, and health behaviours have also changed and science-based health services have evolved. As part of this ‘health-risk transition’, noncommunicable diseases including type 2 diabetes mellitus (T2DM) have emerged. While the major causes of the diabetes epidemic in western, high-income countries are well documented, little is known of T2DM in developing Asia. The knowledge gap includes Thailand, which needs to identify local factors driving its T2DM epidemic. Aim This thesis aims to better understand the epidemiology of T2DM emerging in Southeast Asia. Methods Participants were from the Thai Cohort Study (TCS) of the health-risk transition. They were distance-learning adult students living all over Thailand, enrolled at Sukhothai Thammithirat Open University, and surveyed in 2005, 2009, and 2013 using mailed questionnaires that covered socio-demographic characteristics, lifestyle behaviours and self-reported health outcomes. In addition to these data, physician telephone interviews were conducted to validate self-reported questionnaire responses (2015); and a dietary survey was conducted to assess transitional dietary patterns (2015). Multiple logistic regression was used to calculate odds ratios and 95% confidence intervals (CIs) for longitudinal associations between exposures of interest and T2DM. Non-linear associations of body mass index (BMI) and T2DM were modelled using restricted cubic splines. Counterfactual mediation analysis explored sugary drink linkage to T2DM. Population attributable fractions and potential impact fractions were calculated. Principal component analysis identified dietary patterns and multivariable linear regression produced standardized coefficients and 95% CIs for associations between socio-demographic measures and dietary pattern scores. Results Physician telephone interviews of a cohort sample demonstrated high validity of questionnaire self-reported doctor diagnosed T2DM suggesting that self-reported doctor diagnosed T2DM is a feasible and acceptable method for assessing diabetes in epidemiological studies. Overall eight-year T2DM incidence was 177 per 10 000 (95% CI 164-190) with higher incidence in men. For both sexes, factors most strongly associated with T2DM risk were greater age and BMI. Two-thirds of all T2DM cases could be attributed to overweight and obesity. T2DM risk increased at BMI levels <23kg/m2. The increasing T2DM risk associated with body size became statistically significant at a BMI of 22 kg/m2 and 20 kg/m2 in men and women, respectively. For both sexes, living in urban areas increased T2DM and risk of consuming unhealthy dietary patterns, while a higher income associated with healthy dietary patterns. In Thai men, smoking and alcohol consumption increased T2DM risk. In women, sugary-drink consumption increased T2DM risk, of which 23% was mediated through obesity. In men, income and education were associated with increased T2DM risk. In women, education protected against unhealthy dietary intake. Overall, women tended to have safer behaviours (e.g. low prevalence of smoking and alcohol consumption) and better outcomes (e.g. lower prevalence of obesity and lower rates of T2DM). Conclusions Findings from young to middle-aged, educated Thai adults nationwide show that selfreport of incident T2DM is a valid method for assessing diabetes in epidemiological studies, T2DM incidence in Thailand is high, and accompanying lifestyle and sociodemographic transitions are driving the T2DM epidemic. Thai men are likely to be in the middle stages of the health-risk transition while women are more advanced. Health-risks for T2DM are changing substantially and could be modified. These risks need to be targeted to prevent and control diabetes in Thailand

Factors associated with stress among first-year undergraduate students attending an Australian university

Objective: The aim of this study was to examine the relationship between stress and various socio-demographic, health and behavioural factors among undergraduate students studying in an Australian university. Methods: A cross-sectional survey was carried out among firstyear undergraduate students studying at Griffith University. Participants were recruited from four different academic groups (N=728). The questionnaire used in this study comprised of three sections: socio-demographic information, stress scale and a food frequency questionnaire. K-means Cluster analysis was performed to identify the major dietary patterns and multinomial logistic regression analysis was used to examine the factors associated with stress. Results: Nearly 53% of the students had some degree of stress with 37.4% experiencing moderate to severe levels of stress. The factors most strongly associated with having mild or moderate/ severe stress levels included being in a relationship [OR =1.71, 95% CI (1.02-2.87) and OR=1.61, 95% CI (1.06-2.44)], studying a non-health related degree [OR=1.68, 95% CI (1.03-2.73) and OR=1.51, 95% CI (1.04-2.19)], working ≥ 21 hours per week [OR=2.12, 95% CI (1.02-4.40) and OR=2.21, 95% CI (1.32-3.67)], and engaging in an unhealthy dietary pattern [OR=2.67, 95% CI (1.25-5.72) and OR=2.76, 95% CI (1.47-5.16)]. Being a female [OR=1.84, 95% CI (1.25-2.72)], living in a shared accommodation [OR=0.52, 95% CI (0.27-0.98)], rarely exercising [OR=2.64, 95% CI (1.59-4.39)], having a body mass index (BMI) of 25 or over [OR=2.03, 95% CI (1.36-3.04)], and engaging in a dietary pattern that was low in protein, fruit and vegetables [OR=1.72, 95% CI (1.06-2.77)] were also associated with having moderate/severe stress levels. Conclusion: This study found that more than half of the undergraduate students had some levels of stress. Both mild and moderate/severe levels of stress were associated with sociodemographic characteristics, risky health behaviours and poor dietary patterns. Our findings reinforce the need to promote healthy behaviours among undergraduate university students in order to maintain good mental health.</p

Factors Associated with Stress among First-year Undergraduate Students Attending an Australian University

Objective: The aim of this study was to examine the relationship between stress and various socio-demographic, health and behavioural factors among undergraduate students studying in an Australian university. Methods: A cross-sectional survey was carried out among first-year undergraduate students studying at Griffith University. Participants were recruited from four different academic groups (N=728). The questionnaire used in this study comprised of three sections: socio-demographic information, stress scale and a food frequency questionnaire. K-means Cluster analysis was performed to identify the major dietary patterns and multinomial logistic regression analysis was used to examine the factors associated with stress. Results: Nearly 53% of the students had some degree of stress with 37.4% experiencing moderate to severe levels of stress. The factors most strongly associated with having mild or moderate/ severe stress levels included being in a relationship [OR =1.71, 95% CI (1.02-2.87) and OR=1.61, 95% CI (1.06-2.44)], studying a non-health related degree [OR=1.68, 95% CI (1.03-2.73) and OR=1.51, 95% CI (1.04-2.19)], working ≥ 21 hours per week [OR=2.12, 95% CI (1.02-4.40) and OR=2.21, 95% CI (1.32- 3.67)], and engaging in an unhealthy dietary pattern [OR=2.67, 95% CI (1.25-5.72) and OR=2.76, 95% CI (1.47-5.16)]. Being a female [OR=1.84, 95% CI (1.25-2.72)], living in a shared accommodation [OR=0.52, 95% CI (0.27-0.98)], rarely exercising [OR=2.64, 95% CI (1.59-4.39)], having a body mass index (BMI) of 25 or over [OR=2.03, 95% CI (1.36-3.04)], and engaging in a dietary pattern that was low in protein, fruit and vegetables [OR=1.72, 95% CI (1.06-2.77)] were also associated with having moderate/severe stress levels. Conclusion: This study found that more than half of the undergraduate students had some levels of stress. Both mild and moderate/severe levels of stress were associated with sociodemographic characteristics, risky health behaviours and poor dietary patterns. Our findings reinforce the need to promote healthy behaviours among undergraduate university students in order to maintain good mental health

Dietary patterns associated with hypertension risk among adults in Thailand: 8-year findings from the Thai Cohort Study

Dietary intake is a leading risk factor for hypertension. We aimed to assess longitudinal associations between overall dietary patterns and incident hypertension among adults in Thailand. Prospective large Thai Cohort Study (TCS) conducted nationwide from 2005 to 2013. Dietary patterns were identified using factor analysis based on usual intake of fourteen food groups. Multivariable logistic regression assessed associations between dietary patterns and hypertension prevalence and incidence. Emerging hypertension and changing diets in Thailand. TCS participants who were normotensive at baseline in 2005. Among 36293 participants without hypertension at baseline, 1831 reported incident hypertension (5·1 % incidence) at follow-up. Two dietary patterns were identified: 'Modern' and 'Prudent'. The Modern dietary pattern (high intakes of roasted/smoked foods, instant foods, canned foods, fermented fruits/vegetables, fermented foods, soft drinks, deep-fried foods) was associated with increased incident hypertension (comparing extreme quartiles, OR for incident hypertension=1·51; 95 % CI 1·31, 1·75 in 2013). The Prudent dietary pattern (high intakes of soyabean products, milk, fruits, vegetables) was not associated with incident hypertension in a fully adjusted model. The association between the Modern dietary pattern and hypertension was attenuated by BMI. Modern dietary pattern was positively associated with hypertension among Thai adults. BMI had a great impact on the relationship between the Modern dietary pattern and incidence of hypertension. Reduction of Modern diets would be expected to prevent and control hypertension. Such a strategy would be worth testing

Vegans, vegetarians, fish-eaters and meat-eaters in the UK show discrepant environmental impacts

Modelled estimates of the environmental burden associated with low meat consumption suggest that substantial benefits could accrue from shifts in diet. However, modelled dietary scenarios may not reflect true dietary practice and have not previously accounted for variation in the environmental burden of food due to sourcing and production methods. We link dietary data from a sample of 55,504 vegans, vegetarians, fish-eaters and meat-eaters with food-level data on greenhouse gas emissions (CO2, CH4 and N2O and three aggregated measures of CO2 equivalents), land use, water use, eutrophication risk and potential biodiversity loss from a review of 570 life cycle assessments covering more than 38,000 farms in 119 countries. By conducting Monte Carlo analyses drawing from food-level distributions of the environmental indicators that are due to variations in sourcing and production methods we estimate both mean impact and 95% uncertainty intervals for each diet group. We find that for all of the environmental indicators there is a positive association with amount of animal-based food consumed. Dietary impacts for vegans were 25.1% (95% uncertainty interval: 15.1% - 37.0%) of high meat-eaters (>=100g total meat consumed per day) for greenhouse gas emissions, 25.1% (7.1% - 44.5%) for land use, 46.4% (21.0% - 81.0%) for water use, 27.0% (19.4% - 40.4%) for eutrophication and 34.3% (12.0% - 65.3%) for biodiversity. Large differences (at least 30% for GHG emissions, eutrophication, and land use) in the environmental impact of diets are also observed between low (<50g/d) and high meat-eaters. Although there is substantial variation in environmental indicators due to where and how food is produced, the resultant uncertainty does not obscure the strong relationship between animal-based food consumption and environmental impact. Debate about sourcing and production of foods should therefore not prevent action aimed at reducing consumption of animal-based foods

Incidence and risk factors for type 2 diabetes mellitus in transitional Thailand: results from the Thai cohort study

Background: Type 2 diabetes mellitus (T2DM) is increasingly prevalent in countries undergoing rapid development, including Thailand. We assessed T2DM incidence over an 8-year period in a nationwide cohort of Thai adults. Methods: Thai Cohort Study participants were surveyed in 2005, 2009 and 2013. The analysed cohort members were aged (15–88), did not have diabetes in 2005 and were followed up by questionnaire in 2013 (n=39 507). T2DM was ascertained using self-report, which has been validated using physician interviews. We calculated the 8-year cumulative incidence of T2DM. Multivariable logistic regression assessed associations between potential risk factors and T2DM incidence. Results: 8-year cumulative incidence of T2DM (2005 to 2013) was 177 per 10 000 (95% CI 164 to 190). Crude and age-standardised cumulative incidences of T2DM by sex were 249 per 10 000 (95% CI 226 to 272) and 222 per 10 000 (95% CI 219 to 225) for men; and 119 per 10 000 (95% CI 105 to 133) and 96 per 10 000 (95% CI 94 to 98) for women, respectively. T2DM increased significantly for both sexes with increasing age and body mass index (BMI) ( p trend <0.001 for both). Residence in an urban area as a child associated with T2DM among men and women (OR=1.4, 95% CI 1.1 to 1.7 and OR=1.4, 95% CI 1.01 to 1.79); this was no longer statistically significant after adjusting for BMI. Among men, smoking (OR=1.7, 95% CI 1.3 to 2.2) and alcohol intake (OR=1.8, 95% CI 1.1 to 3.0) were associated with T2DM. Conclusions: This study found that the sociodemographic and lifestyle changes that have accompanied Thailand’s economic development are associated with T2DM risk in a large cohort of Thai adults. Our findings highlight the need to address these transitions to prevent a further increase in the national incidence of T2DM, particularly among Thai men

Relationship between 8-year weight change, body size, and health in a large cohort of adults in Thailand

Background: Overweight and obesity have been shown to be risk factors for a range of noncommunicable diseases, especially cardio-metabolic conditions, worldwide. But less is known about the effects of weight change on adults' overall health and wellbeing, particularly in transitional low- and middle-income countries. This study aimed to assess the relationship between 8-year weight change and measures of self-assessed health among Thai adults. Methods: Data were collected from Thai adults aged 25e40 years (n ¼ 27,003) enrolled in the Thai cohort Study and surveyed in 2005, 2009, and 2013. We used self-reported weight and height measurements at baseline and 2013, as well as three standard health questions regarding overall health, energy, and emotion asked at the two time points, to investigate the effects of weight change on health. Results: Between 2005 and 2013, 6.0% of participants lost more than 5% of their baseline weight; 38.5% were stable (5%e10%); 22.8% gained moderate weight (>10%e20%); and 9.4% had heavy weight gain (>20%). Moderate (>10%e20%) and heavy weight gain (>20%) were both associated with an increased risk of reporting ‘poor or very poor‘ overall health in 2013 among participants who had a normal body mass index (BMI) (adjusted odds ratio [AOR] 1.39; 95% confidence interval [CI], 1.13e1.71 and AOR 1.44; 95% CI, 1.09e1.90, respectively), were overweight (AOR 1.53; 955 CI, 1.01e2.29 and AOR 1.82; 95% CI, 1.04e3.19, respectively) or had obesity (AOR 2.47; 95% CI, 1.74e3.51 and AOR 3.20; 95% CI, 2.00e5.16, respectively) in 2005. Weight gain of over 20% also had a negative impact on energy level among cohort members with a normal BMI in 2005 (AOR 1.36; 95% CI, 1.11e1.65) and among participants with obesity in 2005 (AOR 1.93; 95% CI, 1.38e2.71). For those who were underweight, had a normal BMI, or had obesity at baseline, weight loss of more than 5% was associated with reporting emotional problems. Excessive weight gain adversely impacted participants who were underweight or had obesity at baseline. Conclusion: Our study found that weight change, in particular weight gain, was associated with negative health outcomes, and this effect appeared to increase at higher levels of body size. The present findings may be useful to promote weight maintenance and healthy lifestyles.The Thai Cohort study was supported by the International Collaborative Research Grants Scheme with joint grants from the Wellcome Trust UK (GR071587MA) and the Australian National Health and Medical Research Council (268055), and as a global health grant from the NHMRC (585426)

Health impacts and environmental footprints of diets that meet the Eatwell Guide recommendations: analyses of multiple UK studies.

OBJECTIVES: To assess the health impacts and environmental consequences of adherence to national dietary recommendations (the Eatwell Guide (EWG)) in the UK. DESIGN AND SETTING: A secondary analysis of multiple observational studies in the UK. PARTICIPANTS: Adults from the European Prospective Investigation into Cancer - Oxford(EPIC-Oxford), UK Biobank and Million Women Study, and adults and children aged 5 and over from the National Diet and Nutrition Survey (NDNS).Primary and secondary outcome measures risk of total mortality from Cox proportional hazards regression models, total greenhouse gas emissions (GHGe) and blue water footprint (WF) associated with 'very low' (0-2 recommendations), 'low' (3-4 recommendations) or 'intermediate-to-high' (5-9 recommendations) adherence to EWG recommendations. RESULTS: Less than 0.1% of the NDNS sample adhere to all nine EWG recommendations and 30.6% adhere to at least five recommendations. Compared with 'very low' adherence to EWG recommendations, 'intermediate-to-high adherence' was associated with a reduced risk of mortality (risk ratio (RR): 0.93; 99% CI: 0.90 to 0.97) and -1.6 kg CO2eq/day (95% CI: -1.5 to -1.8), or 30% lower dietary GHGe. Dietary WFs were similar across EWG adherence groups. Of the individual Eatwell guidelines, adherence to the recommendation on fruit and vegetable consumption was associated with the largest reduction in total mortality risk: an RR of 0.90 (99% CI: 0.88 to 0.93). Increased adherence to the recommendation on red and processed meat consumption was associated with the largest decrease in environmental footprints (-1.48 kg CO2eq/day, 95% CI: -1.79 to 1.18 for GHGe and -22.5 L/day, 95% CI: -22.7 to 22.3 for blue WF). CONCLUSIONS: The health and environmental benefits of greater adherence to EWG recommendations support increased government efforts to encourage improved diets in the UK that are essential for the health of people and the planet in the Anthropocene

Consumption of sugar-sweetened beverages and type 2 diabetes incidence in Thai adults: results from an 8-year prospective study.

BACKGROUND: The global prevalence of type 2 diabetes mellitus (T2DM) is high and is increasing in countries undergoing rapid socio-economic development, including Thailand. Sugar-sweetened beverage (SSB) intake may contribute to the risk of developing T2DM. However, few studies have assessed this association in Asian populations, and the results have been inconsistent. We aimed to assess that association in a prospective study of Thai adults. METHODS: Data were from Thai Cohort Study participants surveyed in 2005, 2009 and 2013. The nation-wide sample included adult cohort members who were free of diabetes in 2005 and who were followed-up in 2013 (n=39 175). We used multivariable logistic regression to assess associations between SSB intake and eight-year T2DM incidence. We used a counterfactual mediation analysis to explore potential mediation of the SSB intake and T2DM-risk relationship. RESULTS: In women (but not men) consuming SSBs once or more per day (versus rarely) was associated with increased T2DM incidence at the 8-year follow-up (odds ratio (OR)=2.4, 95% confidence interval (CI) 1.5-3.9). Obesity in 2009 was found to mediate ~23% of the total association between SSB intake in 2005 and T2DM risk in 2013 (natural indirect effect 1.15, 95% CI (1.02, 1.31). CONCLUSIONS: Frequent SSB consumption associated with higher T2DM incidence in women but not men. We found that a moderate proportion of the SSB-T2DM relationship was mediated through body mass index (BMI). Our findings suggest that targeting SSB consumption can help prevent a national rise in the incidence of T2DM.This work was supported by the International Collaborative Research Grants Scheme with joint grants from the Wellcome Trust UK (GR071587MA) and the Australian National Health and Medical Research Council (NHMRC, grant No.268055), and by a global health grant from the NHMRC (585426)

Body mass index and type 2 diabetes in Thai adults: defining risk thresholds and population impacts.

Background Body mass index (BMI) cut-off values (>25 and >30) that predict diabetes risk have been well validated in Caucasian populations but less so in Asian populations. We aimed to determine the BMI threshold associated with increased type 2 diabetes (T2DM) risk and to calculate the proportion of T2DM cases attributable to overweight and obesity in the Thai population. Methods Participants were those from the Thai Cohort Study who were diabetes-free in 2005 and were followed-up in 2009 and 2013 (n = 39,021). We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the BMI-T2DM association. We modelled non-linear associations using restricted cubic splines. We estimated population attributable fractions (PAF) and the number of T2DM incident cases attributed to overweight and obesity. We also calculated the impact of reducing the prevalence of overweight and obesity on T2DM incidence in the Thai population. Results Non-linear modelling indicated that the points of inflection where the BMI-T2DM association became statistically significant compared to a reference of 20.00 kg/m2 were 21.60 (OR = 1.27, 95% CI 1.00–1.61) and 20.03 (OR = 1.02, 95% CI 1.02–1.03) for men and women, respectively. Approximately two-thirds of T2DM cases in Thai adults could be attributed to overweight and obesity. Annually, if prevalent obesity was 5% lower, ~13,000 cases of T2DM might be prevented in the Thai population. Conclusions A BMI cut-point of 22 kg/m2, one point lower than the current 23 kg/m2, would be justified for defining T2DM risk in Thai adults. Lowering obesity prevalence would greatly reduce T2DM incidence.This study was supported by the International Collaborative Research Grants Scheme with joint grants from the Wellcome Trust UK (GR071587MA). SJ is supported by a Career Development Fellowship from the NHMRC. KP has an Australian Postgraduate Award from the Australian National University