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Abstract Evaluating dietary guidelines using diet quality (DQ) offers valuable insights into the healthfulness of a population’s diet. We conducted a forensic analysis using DQ metrics to compare the Malaysian Dietary Guidelines (MDG-2020) with its former version (MDG-2010) in relation to cardiometabolic risk (CMR) for an adult Malaysian population. A DQ analysis of cross-sectional data from the Malaysia Lipid Study (MLS) cohort (n = 577, age: 20-65yrs) was performed using the healthy eating index-2015 (HEI-2015) framework in conformation with MDG-2020 (MHEI2020) and MDG-2010 (MHEI2010). Of 13 dietary components, recommended servings for whole grain, refined grain, beans and legumes, total protein, and dairy differed between MDGs. DQ score associations with CMR, dietary patterns and sociodemographic factors were examined. Out of 100, total DQ scores of MLS participants were ‘poor’ for both MHEI2020 (37.1 ± 10.3) and MHEI2010 (39.1 ± 10.4), especially among young adults, males, Malays, and those frequently ‘eating out’ as well as those with greatest adherence to Sugar-Sweetened Beverages pattern and lowest adherence to Food Plant pattern. Both metrics shared similar correlations with CMR markers, with MHEI2020 exhibiting stronger correlations with WC, BF%, TG, insulin, HOMA2-IR, and small LDL than MHEI2010, primarily attributed to reduced refined grain serving. Notably, participants with the highest adherence to MHEI2020 scores exhibited significantly reduced odds for elevated TG (AOR 0.44, 95% CI 0.21–0.93, p = 0.030), HOMA2-IR (AOR 0.44, 95% CI 0.21–0.88, p = 0.022), and hsCRP (AOR 0.54, 95% CI 0.31–0.96, p = 0.040, compared to those with the lowest adherence. Each 5-unit increase in MHEI2020 scores reduced odds for elevated BMI (− 14%), WC (− 9%), LDL-C (− 32%), TG (− 15%), HOMA2-IR (− 9%) and hsCRP (− 12%). While MHEI2020 scores demonstrated better calibration with CMR indicators, the overall sub-optimally ‘poor’ DQ scores of this population call for health promotion activities to target the public to achieve adequate intake of healthful fruits, non-starchy vegetables and whole grain, and moderate intake of refined grain, added sugar and saturated fat.

Objective When considering proposals to improve diets, it is important to understand how factors like price and income can affect saturated fat (SF) intake and demand. In this study, we examine and estimate the influence of price and income on intake across 160 countries, by age and sex, and derive sensitivity measures (price elasticities) that vary by age, sex and world region.Design We econometrically estimate intake responsiveness to income and prices across countries, accounting for differences by world region, age and sex. Intake data by age, sex and country were obtained from the 2018 Global Dietary Database. These data were then linked to global price data for select food groups from the World Bank International Comparison Programme and income data from the World Development Indicators Databank (World Bank).Results Intake differences due to price were highly significant, with a 1% increase in price associated with a lower SF intake (% energy/d) of about 4.3 percentage points. We also find significant differences across regions. In high-income countries, median (age 40) intake reductions were 1.4, 0.8 and 0.2 percentage points, given a 1% increase in the price of meat, dairy, and oils and fats, respectively. Price elasticities varied with age but not sex. Intake differences due to income were insignificant when regional binary variables were included in the analysis.Conclusion The results of this study show heterogeneous associations among prices and intake within and across countries. Policymakers should consider these heterogeneous effects as they address global nutrition and health challenges.

Hemodialysis (HD) is a treatment for ensuring the survival of end-stage kidney disease (ESKD) patients, and nutrition care is integral to their management. We sent questionnaires to evaluate the total dialysis service capacity and nutrition services across all dialysis facilities (DF) in Bangladesh, with responses from 149 out of 166 active DFs. Survey results revealed that 49.7% of DFs operated two shifts, and 42.3% operated three shifts daily, with 74.5% holding between one and ten dialysis machines. Sixty-three percent of DFs served between one and 25 patients per week, and 77% of patients received twice-weekly dialysis. The average cost for first-time dialysis was 2800 BDT per session (range: 2500-3000 BDT), but it was lower if reused dialyzers were used (2100 BDT, range: 1700-2800 BDT). Nutritionists were available in only 21% of the DFs. Parameters related to nutritional health screening (serum albumin, BMI, MIS-malnutrition inflammation assessment, and dietary intakes) were carried out in 37.6%, 23.5%, 2%, and 2% of the DFs, respectively, only if recommended by physicians. Nutrition education, if recommended, was provided in 68.5% of DFs, but only in 17.6% of them were these delivered by nutritionists. The recommendation for using renal-specific oral nutrition supplements (ONS) is not a familiar practice in Bangladeshi DFs and, therefore, was scarcely recommended. Dialysis capacity across Bangladesh is inadequate to meet current or projected needs and nutrition education and support across the DFs to benefit improving patients' quality of life is also inadequate.

Abstract Background The festival of Ramadan is a month of spiritual reflection for Muslims worldwide. During Ramadan, Muslims are required to refrain from eating and drinking during daylight hours. Although exempted from fasting, many patients undergoing maintenance haemodialysis (HD) opt to participate in this religious practice. Many studies have explored the effects of Ramadan on health outcomes, however, the exploration from patients’ own point of view pertaining to this religious practice is lacking. Thus, we aimed to explore the experiences and perceptions of Muslim HD patients observing Ramadan fasting from three HD centres in Klang Valley, Malaysia. Method An exploratory phenomenology qualitative study was conducted whereby subjects were purposively selected based on previous experience in observing Ramadan fasting. Face-to-face in-depth interviews were conducted, and study data were analyzed thematically and iteratively coded using a constant comparison method. Results Four major themes emerged from the data, namely: (i) “fasting experiences”, (ii) “perceived side effects of fasting”, (iii) “health-seeking behavior” and, (iv) “education and awareness needs”. Patients expressed the significance of Ramadan fasting as well as the perceived impact of fasting on their health. Additionally, there is lack of health-seeking behaviour observed among patients thus, raising needs for awareness and education related to Ramadan fasting. Conclusions Findings of this study shed light on patients’ experiences and perceptions regarding Ramadan fasting which warrants the needs for an effective communication between patients and health care practitioners through a structured-Ramadan specific education program.

Abstract The metabolic impact of circulating fatty acids (FAs) in patients requiring hemodialysis (HD) is unknown. We investigated the associations between plasma triglyceride (TG) FAs and markers of inflammation, insulin resistance, nutritional status and body composition. Plasma TG-FAs were measured using gas chromatography in 341 patients on HD (age = 55.2 ± 14.0 years and 54.3% males). Cross-sectional associations of TG-FAs with 13 markers were examined using multivariate linear regression adjusted for potential confounders. Higher levels of TG saturated fatty acids were associated with greater body mass index (BMI, r = 0.230), waist circumference (r = 0.203), triceps skinfold (r = 0.197), fat tissue index (r = 0.150), serum insulin (r = 0.280), and homeostatic model assessment of insulin resistance (r = 0.276), but lower malnutrition inflammation score (MIS, r = − 0.160). Greater TG monounsaturated fatty acid levels were associated with lower lean tissue index (r = − 0.197) and serum albumin (r = − 0.188), but higher MIS (r = 0.176). Higher levels of TG n-3 polyunsaturated fatty acids (PUFAs) were associated with lower MIS (r = − 0.168) and interleukin-6 concentrations (r = − 0.115). Higher levels of TG n-6 PUFAs were associated with lower BMI (r = − 0.149) but greater serum albumin (r = 0.112). In conclusion, TG monounsaturated fatty acids were associated with poor nutritional status, while TG n-3 PUFAs were associated with good nutritional status. On the other hand, TG saturated fatty acids and TG n-6 PUFAs had both favorable and unfavorable associations with nutritional parameters.

Abstract Background The aim of this study was to assess the commitments of food companies in Malaysia to improving population nutrition using the Business Impact Assessment on population nutrition and obesity (BIA-Obesity) tool and process, and proposing recommendations for industry action in line with government priorities and international norms. Methods BIA-Obesity good practice indicators for food industry commitments across a range of domains (n = 6) were adapted to the Malaysian context. Euromonitor market share data was used to identify major food and non-alcoholic beverage manufacturers (n = 22), quick service restaurants (5), and retailers (6) for inclusion in the assessment. Evidence of commitments, including from national and international entities, were compiled from publicly available information for each company published between 2014 and 2017. Companies were invited to review their gathered evidence and provide further information wherever available. A qualified Expert Panel (≥5 members for each domain) assessed commitments and disclosures collected against the BIA-Obesity scoring criteria. Weighted scores across domains were added and the derived percentage was used to rank companies. A Review Panel, comprising of the Expert Panel and additional government officials (n = 13), then formulated recommendations. Results Of the 33 selected companies, 6 participating companies agreed to provide more information. The median overall BIA-Obesity score was 11% across food industry sectors with only 8/33 companies achieving a score of > 25%. Participating (p

Background: Muscle wasting, observed in patients with end-stage kidney disease and protein energy wasting (PEW), is associated with increased mortality for those on hemodialysis (HD). Oral nutritional supplementation (ONS) and nutrition counseling (NC) are treatment options for PEW but research targeting muscle status, as an outcome metric, is limited.Aim: We compared the effects of combined treatment (ONS + NC) vs. NC alone on muscle status and nutritional parameters in HD patients with PEW.Methods: This multi-center randomized, open label-controlled trial, registered under ClinicalTrials.gov (Identifier no. NCT04789031), recruited 56 HD patients identified with PEW using the International Society of Renal Nutrition and Metabolism criteria. Patients were randomly allocated to intervention (ONS + NC, n = 29) and control (NC, n = 27) groups. The ONS + NC received commercial renal-specific ONS providing 475 kcal and 21.7 g of protein daily for 6 months. Both groups also received standard NC during the study period. Differences in quadriceps muscle status assessed using ultrasound (US) imaging, arm muscle area and circumference, bio-impedance spectroscopy (BIS), and handgrip strength (HGS) methods were analyzed using the generalized linear model for repeated measures.Results: Muscle indices as per US metrics indicated significance (p < 0.001) for group × time interaction only in the ONS + NC group, with increases by 8.3 and 7.7% for quadriceps muscle thickness and 4.5% for cross-sectional area (all p < 0.05). This effect was not observed for arm muscle area and circumference, BIS metrics and HGS in both the groups. ONS + NC compared to NC demonstrated increased dry weight (p = 0.039), mid-thigh girth (p = 0.004), serum prealbumin (p = 0.005), normalized protein catabolic rate (p = 0.025), and dietary intakes (p < 0.001), along with lower malnutrition–inflammation score (MIS) (p = 0.041). At the end of the study, lesser patients in the ONS + NC group were diagnosed with PEW (24.1%, p = 0.008) as they had achieved dietary adequacy with ONS provision.Conclusion: Combination of ONS with NC was effective in treating PEW and contributed to a gain in the muscle status as assessed by the US, suggesting that the treatment for PEW requires nutritional optimization via ONS.

The capacity to deliver intradialytic parenteral nutrition (IDPN) for patients on hemodialysis (HD) diagnosed with protein energy wasting (PEW) in low resource settings is unknown. This study aimed to examine the extent of IDPN practice in HD units in Malaysia, and its implementation to treat PEW. We surveyed pharmacists (n = 56), who are central to parenteral nutrition delivery in Malaysia including IDPN. Seventeen healthcare stakeholders engaging with the Promoting Action on Research Implementation in Health Services (PARIHS) framework used the Likert scale to rate survey outcomes on IDPN implementation to treat PEW, according to the Evidence, Context, and Facilitation elements. IDPN for HD patients was available in 28 of 56 hospitals providing parenteral nutrition services, with only 13 hospitals (23.2%) providing IDPN to outpatients. Outpatient treatment was concentrated to urban locations (12/13) and significantly associated (p < 0.001) with resident nephrologists. The Evidence domain was rated poorly (2.18 ± 0.15) pertaining to IDPN indication when the oral spontaneous intake was ≤20 kcal/kg/day. The Context domain indicated good adherence to international best practice relating to IDPN administration (4.59 ± 0.15) and infusion time (4.59 ± 0.12). Poor adherence was observed in the Facilitation domain on ’Access to pharmacist and dietitian at HD units’ (2.65 ± 0.21) and ’Access to continuous medical education on managing PEW patients on HD’ (2.53 ± 0.15). The IDPN outpatient service was concentrated to urban hospitals with greater manpower resources. The PARIHS evaluation on IDPN implementation to treat PEW revealed facilitators in good practice adherence for prescribing and administration of IDPN but highlighted major barriers relating to IDPN indication and nutrient calculation.

This study aims to determine the effectiveness of a phosphate mobile app (PMA), MyKidneyDiet-Phosphate Tracker ©2019, on hemodialysis (HD) patients with hyperphosphatemia. A multicenter, open-label, randomized controlled trial design allowed randomization of patients with hyperphosphatemia to either the usual care group (UG; receiving a single dietitian-led session with an education booklet) or the PMA group (PG). Thirty-three patients in each intervention group completed the 12-week study. Post-intervention, serum phosphorus levels were reduced in both groups (PG: −0.25 ± 0.42 mmol/L, p = 0.001; UG: −0.23 ± 0.33 mmol/L, p < 0.001) without any treatment difference (p > 0.05). Patients in both groups increased their phosphate knowledge (PG: 2.18 ± 3.40, p = 0.001; UG: 2.50 ± 4.50, p = 0.003), without any treatment difference (p > 0.05). Dietary phosphorus intake of both groups was reduced (PG: −188.1 ± 161.3 mg/d, p < 0.001; UG: −266.0 ± 193.3 mg/d, p < 0.001), without any treatment difference (p > 0.05). The serum calcium levels of patients in the UG group increased significantly (0.09 ± 0.20 mmol/L, p = 0.013) but not for the PG group (−0.03 ± 0.13 mmol/L, p = 0.386), and the treatment difference was significant (p = 0.007). As per phosphate binder adherence, both groups reported a significant increase in Morisky Medication Adherence Scale scores (PG: 1.1 ± 1.2, p < 0.001; UGa: 0.8 ± 1.5, p = 0.007), without any treatment difference (p > 0.05). HD patients with hyperphosphatemia using the PMA achieved reductions in serum phosphorus levels and dietary phosphorus intakes along with improved phosphate knowledge and phosphate binder adherence that were not significantly different from a one-off dietitian intervention. However, binder dose adjustment with meal phosphate content facilitated by the PMA allowed stability of corrected calcium levels, which was not attained by UC patients whose binder dose was fixed.

Malnutrition is associated with high rates of mortality among patients with end stage kidney disease (ESKD). There is a paucity of data from Bangladesh, where around 35,000–40,000 people reach ESKD annually. We assessed protein-energy wasting (PEW) amongst 133 patients at a single hemodialysis setting in Dhaka. Patients were 49% male, age 50 ± 13 years, 62% were on twice-weekly hemodialysis. Anthropometric, biochemical, and laboratory evaluations revealed: BMI 24.1 ± 5.2 kg/m2, mid-arm muscle circumference (MAMC) 21.6 ± 3.6 cm, and serum albumin 3.7 ± 0.6 g/dL. Based on published criteria, 18% patients had PEW and for these patients, BMI (19.8 ± 2.4 vs. 25.2 ± 5.2 kg/m2), MAMC (19.4 ± 2.4 vs. 22.2 ± 3.8 cm), serum albumin (3.5 ± 0.7 vs. 3.8 ± 0.5 g/dL), and total cholesterol (135 ± 34 vs. 159 ± 40 mg/dL), were significantly lower as compared to non-PEW patients, while hand grip strength was similar (19.5 ± 7.6 vs. 19.7 ± 7.3 kg). Inflammatory C-reactive protein levels tended to be higher in the PEW group (20.0 ± 34.8 vs. 10.0 ± 13.9 p = 0.065). Lipoprotein analyses revealed PEW patients had significantly lower low density lipoprotein cholesterol (71 ± 29 vs. 88 ± 31 mg/dL, p < 0.05) and plasma triglyceride (132 ± 51 vs. 189 ± 103 mg/dL, p < 0.05), while high density lipoprotein cholesterol was similar. Nutritional assessments using a single 24 h recall were possible from 115 of the patients, but only 66 of these were acceptable reporters. Amongst these, while no major differences were noted between PEW and non-PEW patients, the majority of patients did not meet dietary recommendations for energy, protein, fiber, and several micronutrients (in some cases intakes were 60–90% below recommendations). Malnutrition Inflammation Scores were significantly higher in PEW patients (7.6 ± 3.1 vs. 5.3 ± 2.7 p < 0.004). No discernible differences were apparent in measured parameters between patients on twice- vs. thrice-weekly dialysis. Data from a larger cohort are needed prior to establishing patient-management guidelines for PEW in this population.

Abstract Background This study aimed to assess the situational capacity for nutrition care delivery in the outpatient hemodialysis (HD) setting in Malaysia by evaluating dietitian accessibility, nutrition practices and patients’ outcomes. Methods A 17-item questionnaire was developed to assess nutrition practices and administered to dialysis managers of 150 HD centers, identified through the National Renal Registry. Nutritional outcomes of 4362 patients enabled crosscutting comparisons as per dietitian accessibility and center sector. Results Dedicated dietitian (18%) and visiting/shared dietitian (14.7%) service availability was limited, with greatest accessibility at government centers (82.4%) > non-governmental organization (NGO) centers (26.7%) > private centers (15.1%). Nutritional monitoring varied across HD centers as per albumin (100%) > normalized protein catabolic rate (32.7%) > body mass index (BMI, 30.7%) > dietary intake (6.0%). Both sector and dietitian accessibility was not associated with achieving albumin ≥40 g/L. However, NGO centers were 36% more likely (p = 0.030) to achieve pre-dialysis serum creatinine ≥884 μmol/L compared to government centers, whilst centers with dedicated dietitian service were 29% less likely (p = 0.017) to achieve pre-dialysis serum creatinine ≥884 μmol/L. In terms of BMI, private centers were 32% more likely (p = 0.022) to achieve BMI ≥ 25.0 kg/m2 compared to government centers. Private centers were 62% less likely (p

Studies investigating the effects of tocotrienols on inflammation and oxidative stress have yielded inconsistent results. This systematic review and meta-analysis aimed to evaluate the effects of tocotrienols supplementation on inflammatory and oxidative stress biomarkers. We searched PubMed, Scopus, and Cochrane Central Register of Controlled Trials from inception until 13 July 2020 to identify randomized controlled trials supplementing tocotrienols and reporting circulating inflammatory or oxidative stress outcomes. Weighted mean difference (WMD) and corresponding 95% confidence interval (CI) were determined by pooling eligible studies. Nineteen studies were included for qualitative analysis, and 13 studies were included for the meta-analyses. A significant reduction in C-reactive protein levels (WMD: -0.52 mg/L, 95% CI: -0.73, -0.32, p < 0.001) following tocotrienols supplementation was observed, but this finding was attributed to a single study using δ-tocotrienols, not mixed tocotrienols. There were no effects on interleukin-6 (WMD: 0.03 pg/mL, 95% CI: -1.51, 1.58, p = 0.966), tumor necrosis factor-alpha (WMD: -0.28 pg/mL, 95% CI: -1.24, 0.68, p = 0.571), and malondialdehyde (WMD: -0.42 μmol/L, 95% CI: -1.05, 0.21, p = 0.189). A subgroup analysis suggested that tocotrienols at 400 mg/day might reduce malondialdehyde levels (WMD: -0.90 μmol/L, 95% CI: -1.20, -0.59, p < 0.001). Future well-designed studies are warranted to confirm the effects of tocotrienols on inflammatory and oxidative stress biomarkers, particularly on different types and dosages of supplementation. PROSPERO registration number: CRD42020198241.

Hyperphosphatemia afflicts end-stage chronic kidney disease (CKD) patients, contributing to comorbidities and mortality. Management strategies are dialysis, phosphate binder, and limiting dietary phosphate intake, but treatment barriers are poor patient compliance and low health literacy arising from low self-efficacy and lack of educational resources. This study describes developing and validating a phosphate mobile application (PMA). The PMA development based on the seven-stage Precaution Adoption Process Model prioritized titrating dietary phosphate intake with phosphate binder dose supported by educational videography. Experts (n = 13) first evaluated the PMA for knowledge-based accuracy, mobile heuristics, and clinical value. Adult HD patients validated the improved PMA using the seven-point mHealth App Usability Questionnaire (MAUQ). Patient feedback (n = 139) indicated agreement for ease of use (69.2%), interface and satisfaction (69.0%), and usefulness (70.1%), while 72.7% said they would recommend this PMA. The expectation confirmation for 25 PMA features ranged from 92.1% (lifestyle) up to 100.0% (language option); and the utilization rate of each feature varied from 21.6% (goal setting and feature-based log) to 91.4% (information on dietary phosphate and phosphate binder). The Conclusions: MyKidneyDiet-Phosphate Tracker PMA was acceptable to adult Malaysian HD patients as part of clinical phosphate management in low-resource settings.

Lipid emulsions (LEs), an integral component in parenteral nutrition (PN) feeding, have shifted from the primary aim of delivering non-protein calories and essential fatty acids to defined therapeutic outcomes such as reducing inflammation, and improving metabolic and clinical outcomes. Use of LEs in PN for surgical and critically ill patients is particularly well established, and there is enough literature assigning therapeutic and adverse effects to specific LEs. This narrative review contrarily puts into perspective the fatty acid compositional (FAC) nature of LE formulations, and discusses clinical applications and outcomes according to the biological function and structural functionality of fatty acids and co-factors such as phytosterols, α-tocopherol, emulsifiers and vitamin K. In addition to soybean oil-based LEs, this review covers clinical studies using the alternate LEs that incorporates physical mixtures combining medium- and long-chain triglycerides or structured triglycerides or the unusual olive oil or fish oil. The Jaded score was applied to assess the quality of these studies, and we report outcomes categorized as per immuno-inflammatory, nutritional, clinical, and cellular level FAC changes. It appears that the FAC nature of LEs is the primary determinant of desired clinical outcomes, and we conclude that one type of LE alone cannot be uniformly applied to patient care.

Diet is a recognized risk factor and cornerstone for chronic kidney disease (CKD) management; however, a tool to assess dietary intake among Bangladeshi dialysis patients is scarce. This study aims to validate a prototype Bangladeshi Hemodialysis Food Frequency Questionnaire (BDHD-FFQ) against 3-day dietary recall (3DDR) and corresponding serum biomarkers. Nutrients of interest were energy, macronutrients, potassium, phosphate, iron, sodium and calcium. The BDHD-FFQ, comprising 132 food items, was developed from 606 24-h recalls and had undergone face and content validation. Comprehensive facets of relative validity were ascertained using six statistical tests (correlation coefficient, percent difference, paired t-test, cross-quartiles classification, weighted kappa, and Bland-Altman analysis). Overall, the BDHD-FFQ showed acceptable to good correlations (p < 0.05) with 3DDR for the concerned nutrients in unadjusted and energy-adjusted models, but this correlation was diminished when adjusted for other covariates (age, gender, and BMI). Phosphate and potassium intake, estimated by the BDHD-FFQ, also correlated well with the corresponding serum biomarkers (p < 0.01) when compared to 3DDR (p > 0.05). Cross-quartile classification indicated that

Plant-based low protein diets (LPDs) have gained popularity for managing chronic kidney disease (CKD) patients. The nutritional adequacy of these and other LPDs prescribed for CKD patients have not been carefully examined. This study assessed the nutrient composition of such LPDs and moderately high protein diets (MHPDs) that might be prescribed for patients in the Asia Pacific region with CKD who are not dialyzed or undergoing maintenance dialysis. Conventional diets containing at least 50% animal-based proteins and plant-based diets were also planned with protein prescriptions of 0.5 to 0.8 g/kg/day and MHPDs with protein prescriptions of 1.0 to 1.2 g/kg/day. Plant-based, lacto-, ovo-, and lacto-ovo-vegetarian and vegan LPDs and MHPDs were planned by replacing some or all of the animal proteins from the conventional diet. With 0.5 g protein/kg/day, all diets were below the Recommended Dietary Allowances (RDA) for at least one essential amino acid (EAA). At a protein prescription of 0.6 g/kg/day, only the conventional LPD met the RDA for all EAAs. This deficiency with the plant-based LPDs persisted even with several plant food substitutions. With a protein prescription ≥0.7 g/kg/day, all the plant-based and vegetarian LPDs provided the RDA for all EAA. The plant-based and vegetarian diets also contained relatively greater potassium, phosphorus, and calcium content but lower long-chain n-3 polyunsaturated fatty acids and vitamin B-12 than the conventional diet. Other essential micronutrients were commonly below the RDA even at higher protein intakes. The low contents of some essential micronutrients were found in both animal-based and plant-based diets. Prescription of all LPDs for CKD patients, especially plant-based and vegetarian LPDs, requires careful planning to ensure the adequacy of all nutrients, particularly essential amino acids. Consideration should be given to supplementing all animal-based and plant-based LPDs and MHPDs with multivitamins and certain trace elements.

Mandatory nutrition labelling, introduced in Malaysia in 2003, received a “medium implementation” rating from public health experts when previously benchmarked against international best practices by our group. The rating prompted this qualitative case study to explore barriers and facilitators during the policy process. Methods incorporated semi-structured interviews supplemented with cited documents and historical mapping of local and international directions up to 2017. Case participants held senior positions in the Federal government (n = 6), food industry (n = 3) and civil society representations (n = 3). Historical mapping revealed that international directions stimulated policy processes in Malaysia but policy inertia caused implementation gaps. Barriers hindering policy processes included lack of resources, governance complexity, lack of monitoring, technical challenges, policy characteristics linked to costing, lack of sustained efforts in policy advocacy, implementer characteristics and/or industry resistance, including corporate political activities (e.g., lobbying, policy substitution). Facilitators to the policy processes were resource maximization, leadership, stakeholder partnerships or support, policy windows and industry engagement or support. Progressing policy implementation required stronger leadership, resources, inter-ministerial coordination, advocacy partnerships and an accountability monitoring system. This study provides insights for national and global policy entrepreneurs when formulating strategies towards fostering healthy food environments.

To address limited food frequency questionnaire (FFQ) capacity in public health monitoring in Malaysia, we aimed to develop a semi-quantitative FFQ for an adult multiethnic population for comprehensive fatty acid (FA) profiling inclusive of saturated (SFA), monounsaturated (MUFA), polyunsaturated fatty acids (PUFA), PUFA:SFA ratio, trans fatty acids, omega-3 and omega-6 FAs. A 240-food itemed FFQ used diet records (DR) of Malaysia Lipid Study (MLS) participants and fatty acid composition database from laboratory analyzed foods. The developed MLS-FFQ underwent face and content validation before relative validation in a free-living population (n = 114). Validation was facilitated for macronutrient data comparisons between DR and FFQ via Spearman’s correlation coefficient analyses; and for fatty acid composition data by independent pairing of DR, FFQ and plasma triglyceride using the triads method. Moderate correlation between dietary methods was obtained for macronutrients and FAs (r = 0.225–0.457, p < 0.05) except for ω-3 FAs, presenting good agreement with grossly misclassified nutrients z) for SFA, PUFA, PUFA:SFA ratios and ω-6 FAs by all 3 methods were not significantly different (p > 0.05). In conclusion, the MLS-FFQ was shown to be a valid tool to assess population dietary intakes.

The authors wish to make the following correction to this paper [...]

This study aimed to assess muscle wasting and risk of protein energy wasting (PEW) in hemodialysis (HD) patients using an ultrasound (US) imaging method. PEW was identified using the ISRNM criteria in 351 HD patients. Quadriceps muscle thickness of rectus femoris (RF) and vastus intermedius (VI) muscles and cross-sectional area (CSA) of the RF muscle (RFCSA) were measured using US and compared with other physical measures. Associations of US indices with PEW were determined by logistic regression. Irrespective of gender, PEW vs. non-PEW patients had smaller RF, VI muscles, and RFCSA (all p < 0.001). US muscle sites (all p < 0.001) discriminated PEW from non-PEW patients, but the RFCSA compared to bio-impedance spectroscopy had a greater area under the curve (AUC, 0.686 vs. 0.581), sensitivity (72.8% vs. 65.8%), and specificity (55.6% vs. 53.9%). AUC of the RFCSA was greatest for PEW risk in men (0.74, 95% CI: 0.66–0.82) and women (0.80, 95% CI: 0.70–0.90) (both p < 0.001). Gender-specific RFCSA values (men < 6.00 cm2; women < 4.47 cm2) indicated HD patients with smaller RFCSA were 8 times more likely to have PEW (AOR = 8.63, 95% CI: 4.80–15.50, p < 0.001). The US approach enabled discrimination of muscle wasting in HD patients with PEW. The RFCSA was identified as the best US site with gender-specific RFCSA values to associate with PEW risk, suggesting potential diagnostic criteria for muscle wasting.

Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.

End-stage renal disease patients undergoing maintenance hemodialysis (HD) are vulnerable to the protein energy wasting (PEW) syndrome. Identification and diagnosis of PEW relies on clinical processes of judgment dependent on fulfilling multiple criteria drawn from serum biochemistry, weight status, predictive muscle mass, dietary energy and protein intakes. Therefore, we sought to explore the biomarkers’ signature with plasma metabolites of PEW by using 1H-nuclear magnetic resonance for an untargeted metabolomics approach in the HD population, to understand metabolic alteration of PEW. In this case-controlled study, a total of 53 patients undergoing chronic HD were identified having PEW based on established diagnostic criteria and were age- and sex-matched with non-PEW (n = 53) HD patients. Fasting predialysis plasma samples were analyzed. Partial least square discriminant analysis demonstrated a significant separation between groups for specific metabolic pattern alterations. Further quantitative analysis showed that the level of 3-hydroxybutyrate, acetate, arabinose, maltose, ribose, sucrose and tartrate were significantly increased whilst creatinine was significantly decreased (all p < 0.05) in PEW subjects. Pathway analysis indicated that PEW-related metabolites reflected perturbations in fatty acid mechanism and induction of glyoxylate and dicarboxylate pathway attributed to gluconeogenesis. These results provide preliminary data in understanding metabolic alteration of PEW and corresponding abnormal metabolites that could potentially serve as biomarkers of PEW.

Cardiometabolic risk is scarcely explored related to dietary patterns (DPs) in Asian populations. Dietary data (n = 562) from the cross-sectional Malaysia Lipid Study were used to derive DPs through principal component analysis. Associations of DPs were examined with metabolic syndrome (MetS), atherogenic, inflammation and insulinemic status. Four DPs with distinctive eating modes were Home meal (HM), Chinese traditional (CT), Plant foods (PF) and Sugar-sweetened beverages (SSB). Within DP tertiles (T3 vs. T1), the significantly lowest risk was associated with CT for hsCRP (AOR = 0.44, 95% CI 0.28, 0.70, p < 0.001) levels. However, SSB was associated with the significantly highest risks for BMI (AOR = 2.01, 95% CI 1.28, 3.17, p = 0.003), waist circumference (AOR = 1.81, 95% CI 1.14, 2.87, p = 0.013), small LDL-C particles (AOR= 1.69, 95% CI 1.02, 2.79, p = 0.043), HOMA2-IR (AOR = 2.63, 95% CI 1.25, 5.57, p = 0.011), hsCRP (AOR = 2.21, 95% CI 1.40, 3.50, p = 0.001), and MetS (AOR = 2.78, 95% CI 1.49, 5.22, p = 0.001). Adherence behaviors to SSBs (T3) included consuming coffee/tea with condensed milk (29%) or plain with sugar (20.7%) and eating out (12 ± 8 times/week, p < 0.001). Overall, the SSB pattern with a highest frequency of eating out was detrimentally associated with cardiometabolic risks.

A rapid and reliable tool appropriate to quantifying macronutrient and micronutrient intakes in diets consumed by Malaysian hemodialysis (HD) patients is lacking. We aimed to develop and validate a novel HD-food frequency questionnaire (HD-FFQ) to assess habitual nutritional intakes of HD patients with diverse ethnic backgrounds. This study was conducted in three phases. In Phase I, a HD-FFQ comprising 118 food items was developed using 3-day diet recalls (3DDR) from 388 HD patients. Phase II was the face and content validation using the Scale-Content Validity Index (S-CVI). After successfully developing the FFQ, Phase III tested relative validation against a reference method, the 3DDR. Results from Phase III showed that the mean difference for absolute intakes of nutrients assessed by HD-FFQ and 3DDR were significant (p < 0.05). However, there was a significant correlation between the HD-FFQ and reference method ranging from 0.35–0.47 (p < 0.05). Cross-quartile classification showed that

The association between dietary patterns and health outcomes, such as quality of life (QOL), in maintenance hemodialysis (MHD) patients with certain racial backgrounds has not been studied in detail. QOL is a powerful outcome measure in which dietary patterns could be a modifying factor. This study is a secondary analysis examining the association between dietary patterns and health outcomes in 101 African American (AA) maintenance hemodialysis (MHD) patients participating in the Palm Tocotrienols in Chronic Hemodialysis (PATCH) study. Quality of life (QOL) was assessed using the Kidney Disease Quality of Life 36-item survey (KDQOL-36™). Blood samples were analyzed for lipids, lipoprotein subfractions, and inflammatory markers. Food intake was measured using six non-consecutive 24-h dietary recalls over 15 months. Implausible energy intake reports were screened out by comparing reported energy intake (rEI) with predicted total energy expenditure (pTEE). Cluster analysis, using the k-means algorithm, identified two distinct dietary patterns in the study population: a high “sugar sweetened beverage” pattern (hiSSB) and a low “sugar sweetened beverage pattern” (loSSB). In the hiSSB group, consumption of SSB accounted for ~28% of energy intake, while SSB represented only 9% of energy intake in the loSSB group. The hiSSB group was characterized by a higher intake of total calories, sugar and percentage of kilocalories from carbohydrates, whereas the percentage of kilocalories from protein and fat was lower. While additional micronutrient intakes differed between groups (vitamin C, zinc, chromium), these were significantly lower than recommended values in the entire cohort. Patients in the hiSSB group presented with lower high-density lipoprotein cholesterol (HDL-C), lower large HDL particles and smaller low density lipoprotein (LDL) particle diameters. Antidepressant usage was significantly higher in the hiSSB group. Patients in the hiSSB group scored lower across all five KDQOL domains and scored significantly lower in the mental composite domain. MHD patients following a hiSSB dietary pattern had smaller dense LDL particles, lower HDL-C, and a lower QOL. Suboptimal intakes of fruits, vegetables, and grains as well as key micronutrients were evident in both patterns.

Background: Food advertising on television (TV) is well known to influence children's purchasing requests and models negative food habits in Western countries. Advertising of unhealthy foods is a contributor to the obesogenic environment that is a key driver of rising rates of childhood obesity. Children in developing countries are more at risk of being targeted by such advertising, as there is a huge potential for market growth of unhealthy foods concomitant with poor regulatory infrastructure. Further, in developing countries with multi-ethnic societies, information is scarce on the nature of TV advertising targeting children. Objectives: To measure exposure and power of TV food marketing to children on popular multi-ethnic TV stations in Malaysia. Design: Ethnic-specific popular TV channels were identified using industry data. TV transmissions were recorded for each channel from November 2012 to August 2013 (16 hr/day) for randomly selected weekdays and weekend days during normal days and repeated during school holidays (n=88 days). Coded food/beverage advertisements were grouped into core (healthy), non-core (non-healthy), or miscellaneous (unclassified) food categories. Peak viewing time (PVT) and persuasive marketing techniques were identified. Results: Non-core foods were predominant in TV food advertising, and rates were greater during school holidays compared to normal days (3.51 vs 1.93 food ads/hr/channel, p

The protective effects of oil palm vitamin E and phenolics against atherosclerosis, either singly or in combination, were studied in an atherogenic rabbit model. Rabbits were either fed atherogenic diet only (CTR), or atherogenic diet with vitamin E (VIT E), or atherogenic diet with oil palm phenolics (OPP), or atherogenic diet with both vitamin E and oil palm phenolics (VIT E + OPP). Results from lipid profile and antioxidant analyses were not significantly different between groups (p > 0.05). However, fibrous plaques were associated with the CTR group (8.90 ± 5.41%) and these were significantly less (p

The period of Ramadan (R) is associated with dramatic changes in eating habits involving extended periods of fasting on a daily basis. The current study assessed whether lipids and lipoproteins were impacted during R in chronic hemodialysis (HD) patients. Forty-five subjects in an outpatient dialysis clinic in Saudi Arabia were evaluated for anthropometric and lipid changes on a monthly basis before, during as well as one and two months after R. In addition to routine biochemical measures, anthropometric assessments including hand-grip strength (HGS), mid-arm muscle circumference (MAMC), plasma lipids and lipoproteins were evaluated. Dietary assessment was carried out using 24 h recalls. Over the course of the study, changes in renal-related parameters (creatinine, albumin, Kt/V) were minor, as were changes in plasma lipids. Large high-density lipoproteins (HDLs) and low-density lipoproteins (LDLs) accounted for the majority of their respective lipoproteins and their proportions did not change over the study period. Mean LDL particle diameters were higher during the R period, but the changes over the study period were small. Calorie intake during R (2139 ± 709 kcal/d) was significantly higher than the value noted two month post-R (1755 ± 424 kcal/d) and this was associated with significant increases in protein (69 ± 24 vs. 60 ± 24 g/d) and fat (97 ± 38, vs. 73 ± 35 g/d), respectively. No changes were noted with respect to HGS and MAMC. These data show that for HD patients, the period of R results in temporal or non-significant effects on plasma lipids, despite changes in nutrient intake.

Patients with chronic kidney disease (CKD) are often instructed to adhere to a renal-specific diet depending on the severity and stage of their kidney disease. The prescribed diet may limit certain nutrients, such as phosphorus and potassium, or encourage the consumption of others, such as high biological value (HBV) proteins. Eggs are an inexpensive, easily available and high-quality source of protein, as well as a rich source of leucine, an essential amino acid that plays a role in muscle protein synthesis. However, egg yolk is a concentrated source of both phosphorus and the trimethylamine N-oxide precursor, choline, both of which may have potentially harmful effects in CKD. The yolk is also an abundant source of cholesterol which has been extensively studied for its effects on lipoprotein cholesterol and the risk of cardiovascular disease. Efforts to reduce dietary cholesterol to manage dyslipidemia in dialysis patients (already following a renal diet) have not been shown to offer additional benefit. There is a paucity of data regarding the impact of egg consumption on lipid profiles of CKD patients. Additionally, egg consumption has not been associated with the risk of developing CKD based on epidemiological studies. The egg yolk also contains bioactive compounds, including lutein, zeaxanthin, and vitamin D, which may confer health benefits in CKD patients. Here we review research on egg intake and CKD, discuss both potential contraindications and favorable effects of egg consumption, and describe the need for further research examining egg intake and outcomes in the CKD and end-stage renal disease population.

Blood fatty acids (FAs) are derived from endogenous and dietary routes. Metabolic abnormalities from kidney dysfunction, as well as cross-cultural dietary habits, may alter the FA profile of dialysis patients (DP), leading to detrimental clinical outcomes. Therefore, we aimed to (i) summarize FA status of DP from different countries, (ii) compare blood FA composition between healthy controls and DP, and (iii) evaluate FA profile and clinical endpoints in DP. Fifty-three articles from 1980 onwards, reporting FA profile in hemodialysis and peritoneal DP, were identified from PubMed, Embase, and the Cochrane library. Studies on pediatric, predialysis chronic kidney disease, acute kidney injury, and transplant patients were excluded. Moderate to high levels of n-3 polyunsaturated fatty acids (PUFA) were reported in Japan, Korea, Denmark, and Sweden. Compared to healthy adults, DP had lower proportions of n-3 and n-6 PUFA, but higher proportion of monounsaturated fatty acids. Two studies reported inverse associations between n-3 PUFAs and risks of sudden cardiac death, while one reported eicosapentaenoic acid + docosahexaenoic acid)/arachidonic acid ratio was inversely associated with cardiovascular events. The relationship between all-cause mortality and blood FA composition in DP remained inconclusive. The current evidence highlights a critical role for essential FA in nutritional management of DP.

Consumption of white rice predisposes some Asian populations to increased risk of type 2 diabetes. We compared the postprandial glucometabolic responses to three newly-developed crossbred red rice variants (UKMRC9, UKMRC10, UKMRC11) against three selected commercial rice types (Thai red, Basmati white, Jasmine white) using 50-g carbohydrate equivalents provided to 12 normoglycaemic adults in a crossover design. Venous blood was drawn fasted and postprandially for three hours. Glycaemic (GI) and insulin (II) indices, incremental areas-under-the-curves for glucose and insulin (IAUCins), indices of insulin sensitivity and secretion, lactate and peptide hormones (motilin, neuropeptide-Y, orexin-A) were analyzed. The lowest to highest trends for GI and II were similar i.e., UKMRC9 < Basmati < Thai red < UKMRC10 < UKMRC11 < Jasmine. Postprandial insulinaemia and IAUCins of only UKMRC9 were significantly the lowest compared to Jasmine. Crude protein and fiber content correlated negatively with the GI values of the test rice. Although peptide hormones were not associated with GI and II characteristics of test rice, early and late phases of prandial neuropeptide-Y changes were negatively correlated with postprandial insulinaemia. This study indicated that only UKMRC9 among the new rice crossbreeds could serve as an alternative cereal option to improve diet quality of Asians with its lowest glycaemic and insulinaemic burden.

Malnutrition is prevalent (>50%) in maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients in Malaysia. The priority is to identify a suitable nutritional screening tool for use in dialysis units. We conducted a study between June to November 2011 testing simplified nutritional screening tools on 155 HD and 90 CAPD patients to validate their potential application. Routine nutritional screening tools commonly used for hospitalized patients (NRS–2002, MST, MUST) were compared against tools specific to dialysis such as the malnutrition-inflammation score (MIS), modified Subjective Global Assessment (mSGA) and geriatric nutritional risk index (GNRI) with diagnostic values inclusive of anthropometry, biochemistry and dietary itnake. The mSGA compared to MIS indicated greater specificity for BMI