Dr Noor Hassim Ismail (third right) with the team of researchers showing the published papers in The Lancet.
"Moderation in most aspects of diet is to be preferred, as opposed to very low or very high intakes of most nutrients." -- Dr NOOR HASSIM ISMAIL, UKM professor and group head for RESTU
Mohd Ekhwan Toriman

BASED on the latest scientific evidence, there is a need to propose changes to the current clinical practise guidelines in Malaysia, pertaining to dietary recommendations with regards to the prevention and management of risks related to deaths, heart disease and strokes.

This follows the publication of three papers in The Lancet, produced from a major global study led by researchers at the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences in Hamilton, Canada.

Data from the Prospective Urban Rural Epidemiology (PURE) study which followed more than 135,000 people from 18 low-income, middle-income and high-income countries uncovered findings that challenged current perception in diet practices. The study asked people about their diet and followed them for an average of seven and a half years.

Among the researchers involved in the global study is a team from Universiti Kebangsaan Malaysia (UKM) called RESTU headed by Professor Dr Noor Hassim Ismail.

“The PURE study is groundbreaking because it focuses on food patterns in a wider range of countries. Before this, all policies and recommendation in countries like Malaysia, for example, are based on research done by advanced and high income countries. But findings in this new research can be applied to countries in the middle and low income band as they provide information from a wide range of socioeconomic, food availability, and cultural food intakes data. And this is the first study where samples are followed from when they had no illnesses and diseases to their current situations,” said Dr Noor Hassim.

While PURE kicked off in 2003, the UKM group only began their portion of the research in May 2008 — starting with the recruitment of cohort members from Tanjung Karang in Selangor using only existing resources and staff. By the end of the first year, they had 8,000 participants recruited from places like Felda Soeharto in Selangor and urban areas in Kuala Lumpur.

The researchers thoroughly collected health updates and did verbal autopsy for information on the recruited population over a one-year, three-year and five-year follow-up. In 2012, the group presented the initial findings at an international conference in Toronto, Canada.

The input and analysis of all involved led to two reports published recently which highlighted the message “Global dietary guidelines should be reconsidered in light of these findings.”

Dr Noor Hassim said the first paper focused on the research on dietary fats where it was found that they are not associated with major cardiovascular disease, but higher fat consumption was associated with lower mortality. This was seen for all major types of fats (saturated fats, polyunsaturated fats and mono unsaturated fats), with saturated fats being associated with lower stroke risk.

“A decrease in fat intake automatically led to an increase in carbohydrate consumption and our findings may explain why certain populations such as South Asians, who do not consume much fat but consume a lot of carbohydrates, have higher mortality rates and this is where the problem lies,” he said, citing from the paper.

In Malaysia, the Ministry of Health had suggested food intake to be taken in the portion of quarter carbohydrate, quarter protein and a half portion of vegetables/fruits. And this, Dr Noor Hassim said, should be reinforced and emphasised.

The second paper from the PURE study assessed fruit, vegetable and legume consumption and related them to deaths, heart disease and strokes.

The study found current fruit, vegetable and legume intake globally is between three to four servings per day, but most dietary guidelines recommend a minimum of five daily servings. Given that fruits and vegetables are relatively expensive in most middle-income and low-income countries, this level of consumption is unaffordable for most people in many regions of the world such as South Asia, China, Southeast Asia and Africa, where the levels of their consumption is much lower than in Western countries.

“Raw vegetable intake was more strongly associated with a lower risk of death compared to cooked vegetable intake, but raw vegetables are rarely eaten in South Asia, Africa and Southeast Asia. Dietary guidelines do not differentiate between the benefits of raw versus cooked vegetables. The study results indicate that recommendations should emphasise raw vegetable intake over cooked,” Dr Noor Hassim added.

In light of the finding, he suggested that there be a programme to encourage Malaysians plant their own garden vegetables for consumption like ulam.

In a third study published concurrently by The Lancet Diabetes and Endocrinology, the same researchers looked at the impact of fats and carbohydrates on blood lipids and blood pressure.

They found that LDL (so-called ‘bad’ cholesterol) is not reliable in predicting effects of saturated fat on future cardiovascular events. Instead, the ratio of Apolipoprotein B (ApoB) and Apolipoprotein A1 (ApoA1) or organising proteins in the blood, give the best indication of the impact of saturated fat on cardiovascular risk.

“Moderation in most aspects of diet is to be preferred, as opposed to very low or very high intakes of most nutrients,” said Dr Noor Hassim with regards to the content of the reports.

He highlighted that the RESTU group plans to follow the cohort up to a period of 15 years as there are many papers yet to be published at the global, regional and local levels. However, this kind of study requires permanent dedicated staff and that requires a lot of funds.

Other than RESTU from UKM, Universiti Teknologi MARA (UiTM) is also involved in the PURE study.

UKM deputy vice-chancellor (Research and Innovation Affairs) Professor Dr Mohd Ekhwan Toriman said the group’s work is indeed commendable as not many Malaysian medical and health sciences researchers get published in The Lancet.

“The Lancet has a high impact factor particularly to society, globally and locally. The study has high value in translational research as it could become a model or an idea for practices in society,” he said.

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