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Background Lipid-lowering medications (LLM) are commonly used for secondary prevention, as well as for primary prevention among patients with high global cardiovascular risk and with diabetes. This study aimed to determine the prevalence of LLM use among high-risk individuals [participants with diabetes, high Framingham general cardiovascular (FRS-CVD) score, existing cardiovascular disease (CVD)] and the factors associated with it. Methods This is a cross-sectional analysis from the baseline recruitment (years 2007 to 2011) of an ongoing prospective study involving 11,288 participants from 40 rural and urban communities in Malaysia. Multiple logistic regression was used to identify characteristics associated with LLM use. Results Majority (74.2%) of participants with CVD were not on LLM. Only 10.5% of participants with high FRS-CVD score, and 17.1% with diabetes were on LLM. Participants who were obese (OR = 1.80, 95% CI: 1.15–2.83), have diabetes (OR = 2.38, 95% CI: 1.78–3.19), have hypertension (OR = 2.87, 95% CI: 2.09–3.95), and attained tertiary education (OR = 2.25, 95% CI: 1.06–4.78) were more likely to be on LLM. Rural residents had lower odds of being on LLM (OR = 0.58, 95% CI: 0.41–0.82). In the primary prevention group, participants with high FRS-CVD score (OR = 3.81, 95% CI: 2.78–5.23) and high-income earners (OR = 1.54, 95% CI: 1.06–2.24) had higher odds of being on LLM. Conclusions LLM use among high CVD-risk individuals in the primary prevention group, and also among individuals with existing CVD was low. While CVD risk factors and global cardiovascular risk score were positively associated with LLM use, sociodemographic disparities were observed among the less-educated, rural residents and low-income earners. Measures are needed to ensure optimal and equitable use of LLM.

Background Globally, the Coronavirus Disease-2019 (COVID-19) pandemic results in major psychological sequalae across age groups including adolescents. Mental illness rates are high, yet mental help seeking attitude (MHSA) among adolescents is evidently low in developed countries during the pandemic. However, data is scarce in developing countries, hence the aim of this study was to determine the MHSA and its predictors including psychological wellbeing of Malaysian college foundation students during the COVID-19 pandemic. Methods A cross sectional study was conducted among college foundation students, aged 18 to 19 years old, from a private college in Klang Valley from 1st December 2021 until 30th March 2022. All college foundation students were invited, and eligible students completed self-administered online questionnaires. Data on MHSA, sociodemographic, clinical factors, availability, accessibility and affordability of mental health service, mental health literacy, self-stigma of seeking help and psychological wellbeing were collected. An independent T-test analysis was performed to compare mean of MHSA between psychological distressed and non-psychological distressed. Multiple linear regression analysis was done to identify predictors of MHSA. Results 345 participants completed the questionnaires and the response rate was 62.9%. The mean age was 18.7 (± 0.75) years old. More than half were female (64.3%, n=222) and a majority had no past history of mental health illness (95.1%, n=328). Almost half had personal history of COVID-19 infection (49.3%, n=170). The mean of MHSA was 50.98 ±10.39. The predictors associated with MHSA were; self-stigma of help seeking (β=-0.59 (95% CI: -0.76, -0.42) p The prevalence of psychologically distressed was 23.2%, (95%CI: 20.4, 26.1), in which psychological distressed had a higher mean of MHSA than that of non-psychological distressed (53.29 ±10.48 vs. 50.29 ±10.29, p=0.02) Conclusion Mental help seeking attitude among Malaysian college foundation students was low during the COVID-19 pandemic. This may result in lost opportunities for early diagnosis and treatment. Strategies to reduce self-stigma of seeking help for mental illness is vital, while efforts to educate young adults about mental health and make mental health services affordable are warranted.

Background There is a paucity of data on the prevalence of risk factors and their associations with incident cardiovascular disease in women compared with men, especially from low-income and middle-income countries. Methods In the Prospective Urban Rural Epidemiological (PURE) study, we enrolled participants from the general population from 21 high-income, middle-income, and low-income countries and followed them up for approximately 10 years. We recorded information on participants’ metabolic, behavioural, and psychosocial risk factors. For this analysis, we included participants aged 35–70 years at baseline without a history of cardiovascular disease, with at least one follow-up visit. The primary outcome was a composite of major cardiovascular events (cardiovascular disease deaths, myocardial infarction, stroke, and heart failure). We report the prevalence of each risk factor in women and men, their hazard ratios (HRs), and population-attributable fractions (PAFs) associated with major cardiovascular disease. The PURE study is registered with ClinicalTrials.gov, NCT03225586. Findings In this analysis, we included 155 724 participants enrolled and followed-up between Jan 5, 2005, and Sept 13, 2021, (90 934 [58·4%] women and 64 790 [41·6%] men), with a median follow-up of 10·1 years (IQR 8·5–12·0). At study entry, the mean age of women was 49·8 years (SD 9·7) compared with 50·8 years (9·8) in men. As of data cutoff (Sept 13, 2021), 4280 major cardiovascular disease events had occurred in women (age-standardised incidence rate of 5·0 events [95% CI 4·9–5·2] per 1000 person-years) and 4911 in men (8·2 [8·0–8·4] per 1000 person-years). Compared with men, women presented with a more favourable cardiovascular risk profile, especially at younger ages. The HRs for metabolic risk factors were similar in women and men, except for non-HDL cholesterol, for which high non-HDL cholesterol was associated with an HR for major cardiovascular disease of 1·11 (95% CI 1·01–1·21) in women and 1·28 (1·19–1·39) in men, with a consistent pattern for higher risk among men than among women with other lipid markers. Symptoms of depression had a HR of 1·09 (0·98–1·21) in women and 1·42 (1·25–1·60) in men. By contrast, consumption of a diet with a PURE score of 4 or lower (score ranges from 0 to 8), was more strongly associated with major cardiovascular disease in women (1·17 [1·08–1·26]) than in men (1·07 [0·99–1·15]). The total PAFs associated with behavioural and psychosocial risk factors were greater in men (15·7%) than in women (8·4%) predominantly due to the larger contribution of smoking to PAFs in men (ie, 1·3% [95% CI 0·5–2·1] in women vs 10·7% [8·8–12·6] in men). Interpretation Lipid markers and depression are more strongly associated with the risk of cardiovascular disease in men than in women, whereas diet is more strongly associated with the risk of cardiovascular disease in women than in men. The similar associations of other risk factors with cardiovascular disease in women and men emphasise the importance of a similar strategy for the prevention of cardiovascular disease in men and women.

Cardiovascular disease (CVD) has been a burden to many developing countries for decades, including Malaysia. Although various steps have been taken to prevent and manage CVD, it remains the leading cause of morbidity and mortality. The rising prevalence of CVD risk factors such as hypertension, hypercholesterolaemia, diabetes, overweight and obesity is the main driving force behind the CVD epidemic. Therefore, a nationwide health study coined as the Malaysian Health and Wellbeing Assessment (MyHEBAT) was designed. It aimed to investigate the prevalence of CVD and the associated risk factors in the community across Malaysia. The MyHEBAT study recruited participants (18-75 years old) through community health screening programmes from 11 states in Malaysia. The MyHEBAT study was further divided into two sub-studies, namely, the Cardiovascular Risk Epidemiological Study (MyHEBAT-CRES) and the MyHEBAT Familial Hypercholesterolaemia Study (MyHEBAT-FH). These studies assessed the prevalence of CVD risk factors and the prevalence of FH in the community, respectively. The data garnered from the MyHEBAT study will provide information for healthcare providers to devise better prevention and clinical practice guidelines for managing CVD in Malaysia.

AIM: The objective of this study was to evaluate the effectiveness of the EMPOWER- participatory action research (PAR) intervention, a multifaceted strategy based on the chronic care model (CCM) on primary care providers (PCP)’ adherence to type 2 diabetes mellitus (T2DM) clinical practice guideline (CPG) in the Malaysian primary care setting. METHODS: This was a pragmatic cluster randomized controlled trial –PAR conducted in ten public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. The outcome measure was the absolute change in the proportion of PCP’s adherence to T2DM CPG captured using the “Indicators of Care Pro forma,” based on the recommendation by the Malaysian CPG on the Management of T2DM. Data were collected from the patients’ medical records, at baseline and at 1-year follow-up; and were analyzed using mixed method model. RESULTS: A total of 888 patients were recruited at baseline; 471 were in the intervention and 417 were in the control group. There was no significant demographic difference between the two groups at baseline except for ethnicity. At 1-year, 455 (96.6%) and 406 (97.3%) patients in the intervention and control groups completed the study, respectively. There were significant improvements in the absolute change in the proportion of PCPs’ adherence to T2DM CPG in the intervention group compared to the control group at 1-year follow-up in several indicators of care. These included the recording of BMI (0.6% vs. −1.8%, p

Background Epidemiological studies conducted in various parts of the world have clearly demonstrated that metabolic syndrome (MetS) is an increasing global health problem, not only in Western societies but also in Asian populations. Web-based and mobile phone-based self-management applications have been proven to be effective in improving self-management behaviour of patients with MetS components (i.e., diabetes or hypertension). However, evidence is lacking in terms of their effectiveness specifically for patients with MetS. The aim of this pilot study is to evaluate the feasibility and potential effectiveness of the EMPOWER-SUSTAIN Self-Management e-Health Intervention in improving activation and self-management behaviours among patients with MetS. This paper presents the study protocol. Methods A pilot randomised controlled trial will be conducted in a university primary care clinic. A total of 232 patients aged 18–60 years with MetS will be recruited; 116 will be randomised to receive the EMPOWER-SUSTAIN intervention for 6 months, and another 116 patients will continue with usual care. The EMPOWER-SUSTAIN intervention is a multifaceted chronic disease management strategy based on the Chronic Care Model and persuasive technology theory. It consists of training primary care physicians, nurses and patients to use the EMPOWER-SUSTAIN web-based self-management mobile app, strengthening the patient–physician relationship and reinforcing the use of relevant clinical practice guidelines to guide management and prescribing. The primary outcome is the mean change in patient activation score using the Patient Activation Measure short form Malay version (PAM-13-M) questionnaire. The secondary outcomes include the changes in waist circumference, body mass index, blood pressure, patient physical activity level, eating behaviour, perception of chronic illness care, satisfaction with patient–physician interaction, and perceived absolute 10-year cardiovascular disease risk. Feasibility of implementing the intervention will be evaluated. This includes acceptability of the intervention, estimating the likely rate of participant recruitment and retention, appropriateness of the outcome measures, calculation of sample size, and the intervention’s potential effectiveness. Conclusion To our knowledge, this is the first study in Malaysia that aims to determine the feasibility of a multifaceted e-health intervention, as well as to indicate more useful aspects of this intervention for further exploration in a larger trial. Trial registration ClinicalTrials.gov, NCT04120779. Registered on 9 October 2019, protocol version 1.

Introduction: Erectile dysfunction (ED) is a serious health problem and an independent predictor for cardiovascular diseases (CVD). The prevalence increases with age, but little is known about the relationship between physical fitness and ED especially among men with high risk of CVD. Hence, this study aimed to determine the prevalence of ED among men with Metabolic Syndrome (MetS) and its association with hand-grip strength in which is a measurement of physical fitness and muscle strength. Methods: A cross-sectional study was conducted among Malaysian men aged ≥ 40 years who had their follow-up between 1st June 2021 and 30th October 2021 at an institutional primary care clinic in Gombak district, Selangor, Malaysia. The participants were recruited via computer generated simple random sampling. Data on sociodemographic, comorbidities, anthropometry, clinical examinations including hand-grip strength (HGS) and blood chemical profiles were collected. While a validated English and Malay versions of the 5-item International Index of Erectile Function (IIEF-5) were used to assess presence of ED. Multiple logistic regression analysis were conducted to determine the association between sociodemographic, comorbidities, blood chemical profiles, and HGS with ED.Results: There were 334 participants recruited in the study. The mean age was 58.8 (±8.84) years old, with majority were Malays (95.2%, n= 318) and married (98.8 %, n=330). The overall prevalence of self-reported ED was 79% (95% confidence interval [CI]: 0.75-0.84). Multivariable analysis showed that ED was associated with elderly aged ≥ 60 years (odds ratio [OR] 3.27, 95% CI: 1.60-6.69), HGS (OR 15.34, 95% CI: 5.64-41.81) and abnormal total cholesterol (OR 0.36, 95% CI: 0.16-0.78). Conclusion: ED was highly prevalent among Malaysian men aged ≥ 40 years with MetS. Being older than 60 years of age and low HGS are associated with higher risk of ED. Robust screening of ED among men with Mets and intervention to improve muscle strength and physical fitness may be warranted.

IntroductionDyslipidaemia is one of the established risk factors for cardiovascular disease. Evidence from large-scale trials showed that effective treatment of dyslipidaemia can reduce all-cause and coronary mortality. To date, there is no published systematic review on the worldwide prevalence of dyslipidaemia in adults. We propose to perform a systematic review on the global prevalence of dyslipidaemia in adults 18 years and older.Methods and analysisWe will identify observational studies through comprehensive literature searches. We will search: MEDLINE, Cochrane Central Register of Controlled Trials for published studies and trial registries including the WHO International Trial Registry Platform and ClinicalTrials.gov. Two reviewers will independently screen the titles and abstracts, attain full text of eligible articles, extract data, and appraise the quality and bias of the included studies. Disagreement among the authors will be resolved by discussion leading to a consensus. Next, we will perform a narrative synthesis of the study results. Study heterogeneity will be assessed using I2 statistics. If I2 is high (≥75%), and plausible heterogeneity contributors are found, we will divide the studies into appropriate subgroups for pooling of results or assess the association of plausible covariates and the prevalence estimates using meta-regression. If I2Ethics and disseminationEthics approval is not a requirement as this study is based on available published data. Results of this systematic review will be presented at conferences, shared with relevant health authorities, and published in a peer-reviewed journal. These results may help quantify the magnitude of dyslipidaemia globally, and guide preventative and therapeutic interventions.PROSPERO registration numberCRD42020200281

Cardiovascular disease (CVD) has been a burden to many developing countries for decades, including Malaysia. Although various steps have been taken to prevent and manage CVD, it remains the leading cause of morbidity and mortality. The rising prevalence of CVD risk factors such as hypertension, hypercholesterolaemia, diabetes, overweight and obesity is the main driving force behind the CVD epidemic. Therefore, a nationwide health study coined as the Malaysian Health and Wellbeing Assessment (MyHEBAT) was designed. It aimed to investigate the prevalence of CVD and the associated risk factors in the community across Malaysia. The MyHEBAT study recruited participants (18–75 years old) through community health screening programmes from 11 states in Malaysia. The MyHEBAT study was further divided into two sub-studies, namely, the Cardiovascular Risk Epidemiological Study (MyHEBAT-CRES) and the MyHEBAT Familial Hypercholesterolaemia Study (MyHEBAT-FH). These studies assessed the prevalence of CVD risk factors and the prevalence of FH in the community, respectively. The data garnered from the MyHEBAT study will provide information for healthcare providers to devise better prevention and clinical practice guidelines for managing CVD in Malaysia.

Limited health literacy (HL) is linked to many negative health outcomes, including poor self-management of chronic diseases and medication adherence among patients. There are a lack of data regarding HL in the elderly population in Malaysia. This study aimed to determine the prevalence of limited HL levels and its associated factors among elderly patients in an urban academic primary care clinic in Selangor, Malaysia. A cross-sectional study was conducted among 413 elderly patients (≥60 years old) who attended this academic primary care clinic between January 2020 and January 2021. Sociodemographic data, clinical characteristics, and health literacy scores were collected. Descriptive statistics (median with interquartile ranges (IQR), frequency, and percentages) and multiple logistic regression were utilized. The prevalence of limited HL in our population was 19.1% (95% CI: 15.3, 23). The middle-old (70–79 years) and very-old (≥80 years) age groups were more likely to have limited HL (aOR 4.05, 95% CI: 2.19, 7.52 and aOR 4.36, 95% CI: 1.02, 18.63, respectively). Those with at least secondary school education (aOR 0.06, 95% CI: 0.02, 0.24) and those who found medical information via the internet/television (aOR 0.21, 95% CI: 0.05, 0.93) had lower odds of having limited HL. In conclusion, having limited HL levels was not common among elderly patients in this primary care clinic. Further studies involving rural and larger primary care clinics in Malaysia are required to support these findings.

Background: Coronary artery disease (CAD) is one of the major causes of morbidity and mortality worldwide. Early identification of the coronary risk factors (CRF) among youths assists in determining the high-risk group to develop CAD in later life. In view of the modernised lifestyle, both urban and rural residing youths are thought to be equally exposed to various CRF. This study aimed to describe the common CRF including obesity, dyslipidaemia, hypertension, smoking and family history of premature CAD in Malaysian youths residing in urban and rural areas. Methods: We recruited 942 Malaysian subjects aged 15–24 years old [(males=257, and urban=555 vs rural=387, (mean age + SD = 20.5 + 2.1 years)] from the community health screening programmes organised in both rural and urban regions throughout Malaysia. Medical history and standardised anthropometric measurements were recorded. Laboratory investigations were obtained for fasting serum lipid profiles and plasma glucose levels. Results: Youths in the rural were more overweight and obese (49.4% vs 42.7%, p pppConclusion: In conclusion, rural youths have significantly higher BMI with higher family history of hyperlipidaemia compared to urban youths. However, urban youths have higher LDL-c and TC levels. Other coronary risk factors are not significantly different between urban and rural youths. CRF were significantly more prevalent among rural compared to urban youths.

Background Dyslipidaemia refers to lipid abnormalities consisting of either one or any combination of the following: elevated total cholesterol (TC), elevated low-density lipoprotein cholesterol (LDL-c), elevated triglycerides (TG), and low high-density lipoprotein cholesterol (HDL-c). The prevalence of hypercholesterolaemia is steadily increasing in Malaysia. However, data on the prevalence of dyslipidaemia subtypes among Malaysians are lacking. This is important as it may have implications for preventive and management strategies for this increasing public health challenge. This study is aimed at determining the prevalence of dyslipidaemia subtypes and their associated personal and clinical attributes in Malaysians. Methods REDISCOVER, a prospective study, enrolled 11,288 adults where sociodemographic data, anthropometric and blood pressure measurements, fasting lipid profile and glucose, and history of diabetes, hypertension, and smoking were obtained. The cross-sectional analytic sample presented in this article comprised 10,482 participants from baseline recruitment. The data was analysed by descriptive statistics and multivariable logistic regression. Results The overall prevalence of elevated TC, elevated LDL-c, elevated TG, low HDL-c, and elevated non-HDL-c were 64.0% (95% CI 63.0–65.0), 56.7% (CI 55.7–57.7), 37.4% (CI 36.5–38.4), 36.2% (CI 35.2–37.1), and 56.2% (CI 55.3–57.2), respectively. Overweight, obesity, and central obesity were highly prevalent and significantly associated with elevated TC and all dyslipidaemia subtypes. Older age was associated with elevated TC, elevated LDL-c and elevated non-HDL-c. Hypertension was associated with elevated TC, elevated TG, and elevated non-HDL-c, while diabetes was associated with elevated TG and low HDL-c. Conclusions Elevated TC and all dyslipidaemia subtypes are highly prevalent in Malaysia where increased body mass seems the main driver. Differences in the prevalence and associated personal and clinical attributes may facilitate specific preventive and management strategies.

Background Primary care physicians (PCP) play an important role in detecting Familial Hypercholesterolaemia (FH) early. However, knowledge, awareness and practice (KAP) regarding FH among Malaysian PCP are not well established, and there was no validated tool to assess their FH KAP. Thus, the aim of this study was to adapt an FH KAP questionnaire and determine its validity and reliability among Malaysian PCP. Methods This cross-sectional validation study involved Malaysian PCP with ≥ 1-year work experience in the primary care settings. In Phase 1, the original 19-item FH KAP questionnaire underwent content validation and adaptation by 7 experts. The questionnaire was then converted into an online survey instrument and was face validated by 10 PCP. In Phase 2, the adapted questionnaire was disseminated through e-mail to 1500 PCP. Data were collected on their KAP, demography, qualification and work experience. The construct validity was tested using known-groups validation method. The hypothesis was PCP holding postgraduate qualification (PCP-PG-Qual) would have better FH KAP compared with PCP without postgraduate qualification (PCP-noPG-Qual). Internal consistency reliability was calculated using Kuder Richardson formula-20 (KR-20) and test–retest reliability was tested on 26 PCP using kappa statistics. Results During content validation and adaptation, 10 items remained unchanged, 8 items were modified, 1 item was moved to demography and 7 items were added. The adapted questionnaire consisted of 25 items (11 knowledge, 5 awareness and 9 practice items). A total of 130 out of 1500 PCP (response rate: 8.7%) completed the questionnaire. The mean percentage knowledge score was found to be significantly higher in PCP-PG-Qual compared with PCP-noPG-Qual (53.5, SD ± 13.9 vs. 35.9, SD ± 11.79), t(128) = 6.90, p Conclusion This study has proven that the 25-item adapted FH KAP questionnaire is valid and reliable. It can be used to measure and establish FH KAP among PCP in Malaysia.

Background The European Atherosclerosis Society Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry provides a platform for the global surveillance of familial hypercholesterolaemia through harmonisation and pooling of multinational data. In this study, we aimed to characterise the adult population with heterozygous familial hypercholesterolaemia and described how it is detected and managed globally. Methods Using FHSC global registry data, we did a cross-sectional assessment of adults (aged 18 years or older) with a clinical or genetic diagnosis of probable or definite heterozygous familial hypercholesterolaemia at the time they were entered into the registries. Data were assessed overall and by WHO regions, sex, and index versus non-index cases. Findings Of the 61 612 individuals in the registry, 42 167 adults (21 999 [53.6%] women) from 56 countries were included in the study. Of these, 31 798 (75.4%) were diagnosed with the Dutch Lipid Clinic Network criteria, and 35 490 (84.2%) were from the WHO region of Europe. Median age of participants at entry in the registry was 46.2 years (IQR 34.3-58.0); median age at diagnosis of familial hypercholesterolaemia was 44.4 years (32.5-56.5), with 40.2% of participants younger than 40 years when diagnosed. Prevalence of cardiovascular risk factors increased progressively with age and varied by WHO region. Prevalence of coronary disease was 17.4% (2.1% for stroke and 5.2% for peripheral artery disease), increasing with concentrations of untreated LDL cholesterol, and was about two times lower in women than in men. Among patients receiving lipid-lowering medications, 16 803 (81.1%) were receiving statins and 3691 (21.2%) were on combination therapy, with greater use of more potent lipid-lowering medication in men than in women. Median LDL cholesterol was 5.43 mmol/L (IQR 4.32-6.72) among patients not taking lipid-lowering medications and 4.23 mmol/L (3.20-5.66) among those taking them. Among patients taking lipid-lowering medications, 2.7% had LDL cholesterol lower than 1.8 mmol/L; the use of combination therapy, particularly with three drugs and with proprotein convertase subtilisin-kexin type 9 inhibitors, was associated with a higher proportion and greater odds of having LDL cholesterol lower than 1.8 mmol/L. Compared with index cases, patients who were non-index cases were younger, with lower LDL cholesterol and lower prevalence of cardiovascular risk factors and cardiovascular diseases (all p, Pfizer Independent Grant for Learning Change [16157823]; Amgen; Merck Sharp Dohme; Sanofi-Aventis; Daiichi Sankyo; Regeneron; National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, UK; NIHR; Czech Ministry of Health [NU20-02-00261]; Canadian Institutes of Health Research; Austrian Heart Foundation; Tyrolean Regional Government; Gulf Heart Association, The EAS FHSC is an academic initiative that has received funding from a Pfizer Independent Grant for Learning & Change 2014 (16157823) and from investigator-initiated research grants to the European Atherosclerosis Society-Imperial College London from Amgen, Merck Sharp & Dohme, Sanofi-Aventis, Daiichi Sankyo, and Regeneron. KKR acknowledges support from the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, UK. KID acknowledges support from a PhD Studentship from NIHR under the Applied Health Research programme for Northwest London, UK (the views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health). TF was supported by a grant from the Czech Ministry of Health (NU20-02-00261). JG receives support from the Canadian Institutes of Health Research. The Austrian Familial Hypercholesterolaemia registry has been supported by funds from the Austrian Heart Foundation and the Tyrolean Regional Government. The Gulf Familial Hypercholesterolaemia registry was done under the auspices of the Gulf Heart Association.

Background: Epidemiological studies from various parts of the world have clearly demonstrated that metabolic syndrome (MetS) is an increasing global health problem, not only in the western societies but also in the Asian populations. Web-based and mobile phone-based self-management applications have been proven to be effective in improving self-management behaviour in patients with MetS components i.e. diabetes or hypertension. However, evidence is lacking in terms of its effectiveness specifically for patients with MetS. The aim of this pilot study is to evaluate the feasibility and potential effectiveness of the EMPOWER-SUSTAIN Self-Management e-Health Intervention in improving patient activation and self-management behaviours among patients with MetS. This paper presents the study protocol. Methods: A pilot randomised controlled trial will be conducted in a university primary care clinic. A total of 232 patients with MetS will be recruited; 116 will be randomised to receive the EMPOWER-SUSTAIN intervention for 6 months and another 116 patients will continue with usual care. The EMPOWER-SUSTAIN intervention is a multifaceted chronic disease management strategy based on the Chronic Care Model (CCM) and persuasive technology (PT) theory. It consists of training physicians and patients to use the EMPOWER-SUSTAIN web-based self-management intervention mobile apps, strengthening patient-physician relationship and reinforcing the use of relevant clinical practice guidelines (CPG) to guide management and prescribing. The primary outcome is the mean change in patient activation score using the Patient Activation Measure short form Malay version (PAM-13-M) questionnaire. The secondary outcomes include the change in patients’ physical activity level, eating behavior, patients’ perception on chronic illness care, satisfaction in patient-physician interaction and perceived absolute 10-year cardiovascular disease (CVD) risk. Feasibility of implementing the intervention will be evaluated. These include acceptability of the intervention, estimating the likely rate of participant recruitment and retention, appropriateness of the outcome measures, calculation of sample size, and its potential effectiveness. Conclusion: To our knowledge, this is the first study in Malaysia that aims to determine the feasibility of a multifaceted e-health intervention, as well as to indicate more useful aspects of this intervention for further exploration in a larger trial.

Aim The epidemiological transition has resulted in a large population of adolescents in Malaysia, whose health burden is poorly described. We set out to provide a comprehensive profile of health in Malaysian adolescents to illustrate important targets for health actions. Methods A conceptual framework for reporting health and wellbeing of Malaysian adolescents was defined to measure health outcomes, health risks and sociocultural determinants. Data from the Global Burden of Disease 2017 study were used to analyse mortality (all-cause and cause-specific mortality), morbidity, total disease burden and selected health risks and determinants for 10-24-year-old Malaysians, by three age groups (10–14, 15–19 and 20–24 years) and sex, from 1990 to 2017. Results While the total disease burden decreased, most of this decrease was due to mortality, with morbidity mostly unchanged for all age groups and sexes between 1990 and 2017. Most of the reductions in disability-adjusted life years (DALYs) appear driven by a reduction of mortality from vaccine preventable diseases and maternal causes, across all age groups. Communicable diseases remain most prevalent in the 10–14-year-olds and some causes (e.g. diarrheal diseases, dietary iron deficiency) have increased by 2017. Morbidity from non-communicable diseases (NCDs) continued to be high in 2017. By 2017, mental disorders (e.g. anxiety, depression, conduct disorders) and chronic physical disorders (e.g. migraine, low back pain) were important contributors of morbidity for all adolescents. Motor-vehicle accidents were the principal cause of death in 15–19 and 20–24-year-olds of both sexes, while drowning and lower respiratory infections were the leading causes of death in 10–14-year-old males and females, respectively. The prevalence of male tobacco smoking had changed little across all groups, highest for males aged 20-24 years at 49.4% in 1990 and 44.4% in 2017. In contrast, rates of overweight and obesity had tripled in females and quintupled in males. Rates of youth not in education, employment and training rates had decreased, while adolescent fertility rate has halved from 1990. Conclusion These data highlight that adolescent specific interventions are inadequate and health actions are required to address the disease burden from NCDs, injuries, some communicable diseases and obesity, which in addition to the health sector, will require multisector actions.

Background: Primary care physicians (PCP) play an important role in early detection of Familial Hypercholesterolaemia (FH). However, knowledge, awareness and practice (KAP) regarding FH among Malaysian PCP are not well established, and there was no validated tool to assess their FH KAP. Therefore, this study aimed to adapt an FH KAP questionnaire and to determine its validity and reliability among Malaysian PCP. Methods: This cross-sectional validation study involved PCP with ≥1-year working experience in the Malaysian primary care settings. In Phase 1, the original 19-item FH KAP questionnaire was content validated and adapted by 7 experts. The questionnaire was then converted into an online survey instrument and was face validated by 10 PCP. In Phase 2, the adapted questionnaire was distributed via e-mail to 1500 PCP for self-administration. Data were collected on their KAP, demography, qualification and work experience. The construct validity was tested using known-groups validation method. PCP with postgraduate qualification (PCP-PG-Qual) were hypothesized to have better FH KAP compared with PCP without postgraduate qualification (PCP-noPG-Qual). The internal consistency reliability was tested using Kuder Richardson formula-20 (KR-20) and test-retest reliability was tested on 26 PCP using kappa statistics. Results: During content validation and adaptation, 10 items remained unchanged, 8 items were modified, 1 item was moved to demography and 7 items were added. The adapted questionnaire contained 25 items (11 knowledge, 5 awareness and 9 practice items). A total of 130 out of 1500 PCP (response rate: 8.7%) completed the questionnaire. The mean percentage knowledge score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (53.5, SD±13.9 vs. 35.9, SD±11.79), t(128)=6.90, p

Vaccine hesitant parents are linked with re-emergence of vaccine preventable diseases, but evidence is scarce locally. The Parent Attitudes about Childhood Vaccines (PACV) questionnaire was validated and used in the USA to identify vaccine hesitant parents. This study aimed to adapt and translate the 15-item PACV questionnaire from English into the Malay language, and to examine its validity and reliability. The sample population was parents of children aged 0–24 months, recruited at an urban government health clinic between November 2016-June 2017. During content validation, two items from the “Behavior” subdomain were identified as items with formative scale and excluded from exploratory factor analysis (EFA) but retained as part of demography. A total of 151 parents completed the questionnaire with response rate of 93.3%. Test-retest reliability was tested in 25 respondents four weeks later and the intra-class correlation was between 0.53 and 1.00. EFA of the 13 items showed possibility of two to four factor domains, but three domains were most conceptually equivalent. Two of the domains were similar to the original and one factor was identified de novo. One item was deleted due to poor factor loading of < 0.3. Therefore, the validated final PACV-Malay consisted of 12 items framed within three-factor domains. The PACV-Malay was reliable with total Cronbach alpha of 0.77. In conclusion, the PACV-Malay is a valid and reliable tool which can be used to identify vaccine hesitant parents in Malaysia. Confirmatory factor analysis and predictive validity are recommended for future studies.

Introduction: Abdominal obesity is associated with cardiovascular risk factors. Metabolic Syndrome (MS) describes a constellation of metabolic abnormalities, including abdominal obesity. However, there is limited data on the comparison of inflammatory biomarkers in centrally obese subjects without MS. Aim: To examine the biomarkers of inflammation in subjects with MS, central obesity without MS, and normal controls. Materials and Methods: This was a cross-sectional study involving 501 subjects categorised into MS, central obesity without MS (COBXMS), and healthy controls (NC). Soluble biomarkers of inflammation {high sensitivity C-reactive protein (hs-CRP), Interleukin-6 (IL-6), Soluble Intercellular Adhesion Molecule-1 (sICAM-1), Soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1) and soluble E-selectin} were measured. Results: MS had significant elevation in all biomarkers, while COBXMS had higher concentrations of all biomarkers except sVCAM-1 compared to NC. COBXMS had elevated hs-CRP, IL-6 and sICAM-1 comparable with MS. Obesity categories of subjects (MS, COBXMS or NC) were associated with quartiles of each biomarker concentration (p

This chapter describes adolescence as a highly dynamic developmental period where health risks and outcomes are shaped by biological development and social influences. Previously neglected, the world’s 1.8 billion adolescents constitute a quarter of the population and are supported by the new Global Strategy on Women’s Children’s and Adolescents’ Health. Investing in building adolescent capabilities and assets yields a ‘triple dividend’ by improving the health of adolescents, reducing the burden of disease in adults, and improving the health and development of the next generation. Adolescent health profiles differ greatly between and within countries, reflecting different social, educational, economic, cultural, and technological opportunities and risks; the focus of required investments must therefore match different needs. Investments extend from actions directed towards conspicuous health problems (e.g. HIV, asthma, anxiety) to emergent health risks (e.g. tobacco smoking), to broader social determinants (e.g. quality schooling, avoidance of child marriage).

This is a case of a 68-year-old man who was diagnosed late with Hashimoto’s thyroiditis following a few admissions for symptomatic anaemia. Although hypothyroidism is common among the elderly, the classic symptoms are less likely to be evident and anaemia can be the first sign of hypothyroidism. This patient had multiple comorbidities including ischaemic heart disease, diabetes and chronic kidney disease which might have contributed to the delay in finding the underlying cause of his anaemia. He initially presented with symptomatic anaemia and received blood transfusions and iron supplementation. On subsequent follow up, his anaemia failed to improve. He was then referred to our primary care clinic. Hashimoto’s thyroiditis was diagnosed based on his clinical features, thyroid function test results and antithyroid peroxidase level. This case highlights the importance of determining the cause of anaemia as his haemoglobin level improved significantly after thyroxine was commenced. It also serves as a reminder that hypothyroidism should be considered in patients with anaemia, especially in those with uncertain aetiology.

Background Majority of patients with chronic illnesses such as diabetes, receive care at primary care setting. Efforts have been made to restructure diabetes care in the Malaysian primary care setting in accordance with the Chronic Care Model (CCM). The Patient Assessment on Chronic Illness Care (PACIC) is a validated self-report tool to measure the extent to which patients with chronic illness receive care that aligns with the CCM. To date, no validated tool is available to evaluate healthcare delivery based on the CCM in the Malay language. Thus, the study aimed to translate the PACIC into the Malay language and validate the questionnaire among patients with diabetes in the Malaysian public primary care setting. Methods The English version of the PACIC questionnaire is a 20-item scale measuring five key components, which are patient activation, decision support, goal setting, problem solving and follow-up care. The PACIC underwent forward - backward translation and cross cultural adaptation process to produce the PACIC-Malay version (PACIC-M). Reliability was tested using internal consistencies and test-retest reliability analyses, while construct validity was tested using the exploratory factor analysis (EFA). Results The content of PACIC-M and the original version were conceptually equivalent. Overall, the internal consistency by Cronbach’s α was .94 and the intra-class correlation coefficient was .93. One item was deleted (item 1) when the factor loading was

This study aimed to determine knowledge, awareness and practice (KAP) regarding familial hypercholesterolaemia (FH) among Malaysian primary care physicians (PCP), and to compare KAP between PCP with postgraduate qualification (PCP-PG-Qual) and PCP without PG qualification (PCP-noPG-Qual).This was a cross-sectional study involving PCP with ≥1-year working experience in Malaysian primary care settings. An adapted and validated 25-item FH-KAP questionnaire was disseminated during primary care courses. Total score for each domain was calculated by summing-up the correct responses, converted into percentage scores. Normality distribution was examined and comparisons of mean/median percentage scores were made between the two groups of PCP.A total of 372 PCP completed the questionnaire. Regarding knowledge, 77.7% correctly defined FH. However, only 8.3% correctly identified coronary artery disease risk in untreated FH. The mean percentage knowledge score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (48.9, SD ± 13.92 vs. 35.2, SD ± 14.13), t(370) = 8.66, p 0.001. Regarding awareness, 39% were aware of the NICE FH guideline and only 27.2% were aware of FH diagnostic criteria. The median percentage awareness score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (15.4, IqR ± 23.08 vs. 7.7, IqR ± 11.54), p = 0.013. Regarding practice, only 19.1% stratified FH patients as high risk irrespective of other risk factors. The mean percentage practice score was significantly higher in PCP-PG-Qual compared to PCP-noPG-Qual (52.4, SD ± 12.92 vs. 42.7, SD ± 16.63), t(370) = 9.65, p 0.001.Substantial gaps in FH-KAP among Malaysian PCP were identified, with PCP-PG-Qual having better knowledge, awareness and practice than PCP-noPG-Qual, emphasising the importance of professional training and certification.

The objectives of this study were toinvestigate the inflammation and endothelial activation biomarkers in subjects with metabolic syndrome (MS)subgroups irrespective of status. Subjects (n=319) were categorized into MS subgroups [diabetes mellitus (MSDM), impaired fastig glucose (MSIFG) and normoglycemia (MSNG)] and normal controls (NC). Inflammatory biomarkers (high-sensitivity C-reactive protein and interleukin-6) and endothelial activation (soluble intercellular adhesion molecule-1, vascular cell adhesion molecule-1 and E-selectin) were measured and compared between the groups. MS subjects had significant increase in all biomarkers compared to NC subjects. Glycaemic status in MS subgroups did not show any association with the quartiles of all biomarkers, except for interleukin-6. This may partially explain their increased coronary risk. Keywords : metabolic syndrome; glycaemic status; inflammation; endothelial activation

Objective. There is limited data comparing prothrombogenic or fibrinolysis biomarkers (tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1)) simultaneously in subjects with Metabolic Syndrome (MS), simple central obesity without MS (COB) and normal controls (NC). We investigated the concentrations of fibrinolysis biomarkers in subjects with MS, COB and NC.Methods. A cross-sectional study involving 503 drug naive subjects (163 males, aged 30–65 years old (mean age ± SD = 47.4 ± 8.3 years)) divided into MS, COB and NC groups. COB was defined as central obesity (waist circumference (WC) males ≥90 cm, females ≥80 cm) in the absence of MS according to the International Diabetes Federation 2006. Fasting blood levels of tPA and PAI-1were analyzed.Results. MS and COB had significantly higher concentration of all biomarkers compared to NC. The MS group had significantly higher concentration of tPA and PAI-1 compared to COB. WC and HDL-c had significant correlation with all biomarkers (tPAp<0.001, PAI-1p<0.001). Fasting plasma glucose and diastolic blood pressure were independent predictors after correcting for confounding factors.Conclusion. Central obesity with or without MS both demonstrated enhanced prothrombogenesis. This suggests that simple obesity possibly increases the risk of coronary artery disease in part, via increased susceptibility to thrombogenesis.

Background Familial hypercholesterolaemia (FH) is a genetic disorder with a high risk of developing premature coronary artery disease that should be diagnosed as early as possible. Several clinical diagnostic criteria for FH are available, with the Dutch Lipid Clinic Criteria (DLCC) being widely used. Information regarding diagnostic performances of the other criteria against the DLCC is scarce. We aimed to examine the diagnostic performance of the Simon-Broom (SB) Register criteria, the US Make Early Diagnosis to Prevent Early Deaths (US MEDPED) and the Japanese FH Management Criteria (JFHMC) compared to the DLCC. Methods Seven hundered fifty five individuals from specialist clinics and community health screenings with LDL-c level ≥ 4.0 mmol/L were selected and diagnosed as FH using the DLCC, the SB Register criteria, the US MEDPED and the JFHMC. The sensitivity, specificity, efficiency, positive and negative predictive values of individuals screened with the SB register criteria, US MEDPED and JFHMC were assessed against the DLCC. Results We found the SB register criteria identified more individuals with FH compared to the US MEDPED and the JFHMC (212 vs. 105 vs. 195; p

Purpose A rapid epidemiological transition in developing countries in Southeast Asia has been accompanied by major shifts in the health status of children and adolescents. In this article, mortality estimates in Malaysian children and adolescents from 1990 to 2013 are used to illustrate these changes. Methods All-cause and cause-specific mortality estimates were obtained from the 2013 Global Burden of Disease Study. Data were extracted from 1990 to 2013 for the developmental age range from 1 to 24 years, for both sexes. Trends in all-cause and cause-specific mortality for the major epidemiological causes were estimated. Results From 1990 to 2013, all-cause mortality decreased in all age groups. Reduction of all-cause mortality was greatest in 1- to 4-year-olds (2.4% per year reduction) and least in 20- to 24-year-olds (.9% per year reduction). Accordingly, in 2013, all-cause mortality was highest in 20- to 24-year-old males (129 per 100,000 per year). In 1990, the principal cause of death for 1- to 9-year boys and girls was vaccine preventable diseases. By 2013, neoplasms had become the major cause of death in 1–9 year olds of both sexes. The major cause of death in 10- to 24-year-old females was typhoid in 1990 and neoplasms in 2013, whereas the major cause of death in 10- to 24-year-old males remained road traffic injuries. Conclusions The reduction in mortality across the epidemiological transition in Malaysia has been much less pronounced for adolescents than younger children. The contribution of injuries and noncommunicable diseases to adolescent mortality suggests where public health strategies should focus.

Background Hypertension is the leading cardiovascular risk factor globally as well as in Malaysia. This study aimed to estimate the prevalence, awareness, treatment, control and the socio demographic determinants of hypertension among Malaysian adults. Method The analytic sample consisted of 11,288 adults aged ≥ 30 years recruited at baseline in 2007–2011 from the REDISCOVER Study which is an ongoing, prospective cohort study involving 18 urban and 22 rural communities in Malaysia. Socio-demographics, anti-hypertensive treatment details and an average of at least two blood pressure measurements were obtained. Results The age-adjusted prevalence was 42.0 % (CI: 40.9–43.2) and was higher in men [43.5 % (CI: 41.2–45.0)] than women [41.0 % (CI: 39.8–42.3)]. Participants from rural areas (APR: 1.12, CI: 1.04–1.20); aged at least 40–49 years (APR: 1.86, CI: 1.62–2.14); who were overweight (APR: 1.24, CI: 1.15–1.34) and obese (APR: 1.54, CI: 1.43–1.6) were more likely to have hypertension. The Indigenous ethnic group was less likely to be aware (APR: 0.81, CI: 0.69–0.92) and to be on treatment (APR: 0.66, CI: 0.55–0.79). Those in rural areas were less likely to have their hypertension controlled (APR: 0.61, CI: 0.49–0.75). On the other hand, control was more likely in females (APR: 1.25, CI: 1.01–1.54) and Indigenous group (APR: 1.64, CI: 1.19–2.25). Conclusion Hypertension is common in the Malaysian adults. The control of hypertension has increased over the years but is still quite low. Public health measures, as well as individual interventions in primary care are crucial to reduce their risk of developing complications.