Are Chinese Women Maximizing their Lifelong Health Potential? Georgia S. Guldan Asian University for...

Are Chinese Women

Maximizing their

Lifelong Health Potential?Georgia S. Guldan

Asian University for Women Chittagong, Bangladesh

[email protected]

mailto:[email protected]

Rapid transition in women’s diets, behaviors, health

• What are the health consequences of these rapid diet and lifestyle changes?

• Are women aware of the effects on their health?

• Is public health helping them maximize their health potential?

BMI

Pro

po

rtio

n

2000

20-45-year-old Chinese women’s BMI distributions in 1989 and 2000

1989

Mean BMI +SD

1989 2000

21.8+2.7 22.4+3.2

Wang et al. IJO 2005

Risk factors for overweight and obesity in Chinese women in Shanghai

• A study followed 3,032 Shanghai males and females aged 25 to 95 for 3.6 years, from about 2000 to 2004.

• The women’s overweight rate was 29.9% and obesity 10.0% at baseline using Chinese references.

• For the 1,768 women, the BMIs increased significantly only in the 35-44-year-old age group.

• The risk factors for the women’s obesity:– Age and family history (shared for both genders)– Education in women only, inversely– Income was only associated at univariate level

Hou et al., BMC Pub Hlth 2008

0%

20%

40%

60%

80%

100%

20-20 30-39 40-49 50-59 60-69 70-84

OW

N

UW

Hong Kong 20- to 84-year-old women’s BMI category * distribution 2005-2007

Age group in years*OW = BMI>23

N = BMI >18.5; <23UW = BMI <18.5

Women’s Food Intakes from 2002 China National Nutrition and Health Survey

Li & Huang, Curr Wom Hlth Rev 2009

Foods Need, g 7- 11- 14- 18- 30- 45- 60-Grains 250-400 345 393 415 432 456 446 406

Veg 300-500 199 228 238 271 284 290 264

Fruits 200-400 47 46 58 53 45 37 35

Beans 30-50 11 13 13 14 16 15 15

Pork, Poultry

50-75 54 56 64 74 69 65 60

Eggs 25-50 18 18 21 23 22 21 21

Dairy 300 21 19 27 21 17 23 28

Oil, fat 25-30% 28 33 35 40 41 42 38

The Shanghai Women’s Health Study (SWHS)

• Population-based prospective cohort study among 64,191 middle-aged women aged 40-70 years from 7 urban Shanghai communities recruited from 1996 to 2000

• 92.3% response rate

• Detailed dietary intake survey, anthropometric measurements and other lifestyle factor inquiries in 2000 at baseline and 2y later

Villegas et al. 2010

SWHS Dietary Intake Measurement• Follow-up interviews conducted in 2002

with response rate 99.2%

• Dietary intake assessed using an interviewer-administered validated food frequency questionnaire with 77 items

• For women with diagnosed diabetes, cancer or CVD, only baseline dietary data used.

• For others, average of baseline and follow-up used. Villegas et al. 2010

• Cluster analysis grouped the women into groups with similar dietary patterns

• A cluster solution with four clusters, one very small (N=241) emerged for further analysis:

Cluster N women

High staple and soy foods intakes 36,159

High dairy intake 25,948

High protein, fruit, vegetable, energy 1,843


SWHS Dietary intake analysis

Clusters’ nutrient and other characteristics

Cluster Other characteristics

Staple and soy

Lowest vitamin, mineral, fiber, protein and fat and highest carbohydrate intakes; less education, less employment, more retired or not working (303.6g/d staples)

Dairy

Lowest prevalence of general or central obesity or hypertension; highest income and professionals, least likely to have ever smoked. (266.4g/d staples)

Protein, fruit, veg, energy, processed

foods

Highest proportion of alcohol drinkers, fried and processed meat eaters and nutrients except carbohydrates (286.2g/d staples)


Results

Cluster Relationship with T2D

Staple (Used as reference group)

Dairy Less T2D: RR 0.78 (0.71-0.86)

Protein, fruit, veg, energy,

processed foods No relationship with T2D


1,514 cases of incident T2D were observed over the 6.9-y follow-up period.

Discussion (1)

• Might the lower intake of staples in the dairy group have been responsible for the lower risk of T2D?

• Previous studies in– Japan showed a higher rice consumption

associated with higher levels of glycated hemoglobin

– Beijing showed higher refined staples associated with higher homocysteine levels


• Might the higher intakes of calcium, magnesium from more dairy and fiber, antioxidants and magnesium from more vegetables have contributed to the lower T2D incidence in the dairy group?

• Other studies have showed magnesium and calcium intakes to be associated with lower risk of T2D.

Discussion (2)


Conclusions• A dietary pattern low in staples and

high in dairy milk in middle aged Chinese women – was associated with a lower risk of T2D.– when combined with low BMI, low WHR,

this pattern was associated with an 86% reduction in T2D.

• Might point to some ‘protective’ factors for a public health focus for prevention in this population.


SWHS II: Dietary carbohydrates, glycemic load, glycemic index and T2DM

• Same study group (N=64,227)

• 4.6y follow-up

• Examined relationships between glycemic index and load and T2DM incidence (N=1,608 cases)


Dietary carbohydrates, glycemic load glycemic index and T2DM from SWHS• GL associated with dietary carbohydrate,

overall and central obesity, and inversely associated with protein, fat and fiber intakes.

• Higher carbohydrate intake, percent energy from carbohydrate, high intake of staples, rice consumption and dietary GI and GL were all associated with increased risk of T2D.

• Tuber and potato intakes were inversely associate with increased risk of T2D.

• Lowest quartile of physical activity participation had a modestly higher risk of T2D.


Glycemic Load, Cereal Fiber Intake, Diabetes Risk

2.5 2.3 2.052.17

1.8 1.62

1.51 1.28 1

0

0.5

1

1.5

2

2.5

High (>165) Medium(165-143)

Low (<143)

High (>5.8g/d)Medium (2.5-5.8g/d)

Low (<2.5 g/d)

Cereal FiberIntake

Rel

ativ

e R

isk

of

Dia

bet

es

Glycemic Load

2.171.80

1.62

2.052.302.50

Nurses’ Health Study

Minimal Whole Grain Consumption in Hong Kong in 2005-2007

• The mean daily consumption for the cereals and grains products was 489 g.

• The rice subgroup, was by far the most common type of grain consumed, made up 61% of the total.

• Rice and wheat together made up 94%.

• However, whole grain items made up less than 2%, or only about 9 grams of the total amount of cereals and grains consumed. The whole grains include oatmeal, pearl barley, brown rice, red rice, brown rice congee, red rice congee, rye bread and wheat bran breakfast cereal.

FEHD 2010

SWHS III:Resting heart rate and T2DM (1)

• Resting heart rate (RHR) predicts cardiovascular mortality in the general population—could it be a risk factor for T2DM in Chinese women?

• Heart rates were measured after 5 min rest by pulse palpation over 30 sec

• 47,571 women with mean baseline age 53.5(+8.7) y were followed for 4.9 y

Zhang et al. Int J Epi 2010

SWHS III:Resting heart rate and T2DM (2)Results• 849 incident cases of T2DM occurred

Resting heart rate categories

<68 69-72 73-76 77-80 >80 P for trend

N subjects 12,613 13,060 8,110 8,620 5,168

N cases 180 212 147 176 134

Age-adjusted

HR1.00

1.19(0.98-1.46)

1.32 (1.06--1.65)

1.48 (1.21-1.83)

1.83 (1.47-2.29)

<0.0001

Multi-variate

HRa

1.001.21

(0.99-1.47)

1.30 (1.05-1.62)

1.29(0.99-1.69)

1.60 (1.28-2.00)

<0.0001

aAdjusted for age, education, occupation, family income, cigarette smoking, alcohol consumption, BMI Zhang et al. Int J Epi 2010

• A high RHRwas associated with moderate increase in the risk of T2D after accounting for BMI, WHR, BP, physical activity and other confounders.

• RHR elevation reflects autonomic tone and imbalance in autonomic nervous system favouring sympathetic activation

• RHR linked to insulin insensitivity, high BP, obesity, sub-clinical inflammation and metabolic syndrome, all associated with T2D


Zhang et al. Int J Epi 2010

• A high resting heart rate independently predicted moderate increase in the risk of T2D after accounting for BMI, WHR, BP, physical activity and other confounders in middle-aged and older Chinese women.

• Resting heart rate may be a simple measure of autonomic tone and T2DM risk for use in public screenings, along with other measurements.


Zhang et al., Int J Epi 2010

• Effect of weight change on blood pressure in normotensive individuals was lacking.

• SWHS examined 36,075 non-hypertensive women for whom odds ratios were calculated for prehypertension in association with recalled weight change over time since age 20

SWHS IV: Weight gain after age 20 and prehypertension (1)

Yang et al. IJO 2007

Weight change

OR(95% CI)

<-10 0.47 (0.38-0.49)

-6-10 0.76 (0.67-0.87)

-5-5 1.0 (reference)

6-10 1.36 (1.28-1.45)

11-15 1.64 (1.54-1.75)

16-20 2.32 (2.14-2.51)

21-25 2.91 (2.60-3.26)

>25 3.65 (3.13-4.26)

Yang et al. IJO 2007

SWHS IV: Weight gain after age 20and prehypertension (2)

Conclusions: • A graded positive association was seen between weight gain ad hypertension.

• Weight loss associated with reduction in risk.

• Avoiding a 1-kg weight gain slowed down 1 year of ‘aging’ on a woman’s risk of developing hypertension.

• Weight gain in early life and throughout adulthood should be avoided.

• Association between waist hip ratio (WHR) and mortality among 72,773 women followed for 5.7 years

• Mean age of the women was 54 y, mean BMI 24 at enrollment and mean WHR 0.81

• 1,456 deaths documented: cancer, 50%; CVD, 25%; diabetes, 7%; and other causes, 18%.

Zhang et al. Arch Int Med 2007

SWHS V: Abdominal adiposityand mortality (1)

• Using WHR quintiles, WHR positively and significantly associated with risk of death from all causes as well as from CVD, stroke and diabetes in a dose-response fashion (P<0.01 for trend). Findings more evident in women with lower BMIs.

• A less significant positive association was found for cancer.



• When waist circumference was examined individually, positive associations appeared for total mortality and death from CVD [RR 1.95 (1.46-2.60)], diabetes [RR 6.37 (2.00-20.33)], cancer [RR 1.61 (1.07-2.42)] and other causes [RR 2.22 (1.15-4.27)] .

• Waist circumference appeared to be more predictive for women 50 y or younger than for women over 50.

• Hip circumference showed no independent association.



• Results underscore the significance of fat distribution, and not simply BMI.

• Apparently lean but abdominally obese patients should receive guidance from their health care providers about their enhanced risk.

• WHR findings consistent with findings from both the Nurses’ and Iowa Women’s Health Studies and a Swedish Study.



Other consequences of Obesity• A study of 1,532 HK women aged 30 to 60 y

found a 2.1% prevalence of sleep-disordered breathing among women, in which increasing age and BMI were significant independent predictors. –Ip et al. Chest 2008

• Increasing BMI associated with adverse pregnancy outcomes such as caesarian section, pre-eclampsia, gestational diabetes, preterm delivery, LGA as well as SGA in a study of 29,303 HK women.

--Leung et al BJOG 2008

Brown Rice Acceptable?• Focus group with 32 Shanghai adults• Prior to focus group, brown rice considered

to have– Rough texture– Unpalatable taste

• Only 8 had tried it before• After learning of its nutritional value,

– All thought large-scale promotion needed– 27/32 willing to participate in long-term brown rice

intervention

Zhang et al., JADA 2010

Public health initiatives for women?• reducing edible oil intake• increasing whole grains, fruit and

vegetable intakes• increasing activity levels• raising awareness about the diet- and

weight- related risk factors of NCDs• managing weight throughout

adulthood

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