Innovating behaviour and health surveillance for cardiovascular disease prevention in Malaysia

Lead Research Organisation: University of Bristol
Department Name: Sch for Policy Studies

Abstract

In Malaysia the prevalence of obesity among adolescents is increasing and non-communicable diseases, like type 2 diabetes and cardiovascular disease, account for two out of three deaths. While research in European and US-based populations has found that particular lifestyle factors might cause adolescents to be fatter and less fit we do not have a complete picture of what causes these problems in Malaysia. In this study we are going to look at how different lifestyle factors, like foods eaten, timing or frequency of eating, physical activity, sedentary behaviours and their timing or location, relate to whether adolescents have good health.
We plan to use a reproducible laboratory technique, known as metabolomics, to measure 150 different components of blood that indicate a range of metabolic processes. This will help us find out in much more detail than ever before how behaviour leads to better cardiovascular health via metabolic pathways. When we know more about the pathway that leads from lifestyle to disease we will be better able to predict who will stay healthy and who will not.
This research is possible because of an ongoing large community study including over 6000 adolescents, called SEACO, in Segamat, Malaysia. The aim of SEACO is to monitor changes in population health using annual surveys. Data collection started in 2012 and is repeated yearly from over 13000 households. The participants have already had measurements of their height and weight at two previous times, which we will use to look at how body size changes in different groups. We will approach children in the cohort at school to collect samples of blood and urine and ask them to wear an activity monitor on their wrist for 7 days. In a smaller selection of the sample we'll measure metabolic components in urine and see if they can tell us about what foods have been eaten recently. We also give a small group of children a smartwatch to ask them regular questions about eating so we can explore the possibility of measuring eating behaviour using the activity monitors without have to ask in future. We are interested to see whether lifestyle behaviours are associated with changes in the blood chemical profile of participants before they develop clear symptoms of cardiovascular disease or diabetes. Finally, within this project we will lay the foundations for improving the measurement of food intake to make methods passive, rather than relying on participants to tell you every time they eat.

Technical Summary

We propose a combination of new data collection, secondary analysis of SEACO cohort data, metabolic analysis of blood and urine samples, methodological innovation using urinary biomarkers and wearable sensors to measure diet and physical activity. We will generate detailed data on diet, physical activity and intermediate cardiometabolic risk factors from 1500 children aged 7-17 years. We will collect objective physical activity data using a wrist-worn accelerometer worn for 7 days. Newly collected blood samples will be analysed using an automated high-throughput serum nuclear magnetic resonance (NMR) to estimate quantitative molecular information >150 metabolites. A targeted assay designed to measure selected putative food biomarkers relevant to Malaysian diets will be applied to n=750 urine samples. Machine learning will be applied to labelled motion sensor data (n=150) to identify eating events and if robust the model will be applied to wrist-worn accelerometer data (n=1500). We will then explore associations of objective measures of physical activity and diet with metabolic health using linear and logistic regression.

Planned Impact

We will utilise and build on an established cohort, SEACO, and engage with regional and national stakeholders through all phases of the proposed study, to maximise the potential for impact in Malaysia. Short-term, our findings will be useful to researchers. In addition to academic beneficiaries (outlined elsewhere) in the medium to long-term, the proposed study is expected to have a sustained impact on: 1) Adolescents; 3) Policy makers; 4) Society and the Economy. The way in which each group could benefit are summarised below:
1. Adolescents: Our approach to data collection and method development engages with adolescents, therefore they are directly involved in creating solutions to health problems they face. Over the long-term, if the methods developed prove feasibility they will be scaled up for wider use, for which further funding will be sought.
3. Policy makers: Our project will provide policy makers in Malaysia with information about the most important behaviours contributing to cardiometabolic health based on a large cohort of Malaysian children and adolescents. To maximise information exchange and knowledge transfer, a dissemination event will be held at the end of the project. Findings from all phases of the study will also be disseminated via scientific reports, press releases and policy briefings to policy makers and professional groups in Malaysia, including the WHO national director, Malaysian Association for the Study of Obesity, Malaysian Paediatric Association and the ASM Obesity Task Force. Information about the potential utility of the methods will become available and will help policy makers in Malaysia develop public health surveillance over the next 5-10 years.
4. Society and the economy: Our project aims to identify intervention targets for preventing obesity and promoting cardiovascular health in Malaysian adolescents. In the longer-term (i.e. 5-10 years), it is envisaged that methodological innovation in this proposal will lead directly to a better estimation of physical activity and diet. The identification of dietary and physical activity behaviours linked to improved cardiometabolic health will help target public health strategies and improve cost-effectiveness.
 
Description Please note that due to staffing issues there were a number of no cost extensions on this grant and therefore it only ended on December 31st 2023. Therefore, we are still in the process of writing up many of the papers from this grant.

Objective 1: Identify associations of prospective of parent cardiovascular risk, age, ethnicity, and urbanicity changes in child body mass index (BMI).
We found that overall obesity prevalence was stable at 16-17% over time. Having either parent with obesity was associated with increased incidence of obesity among adolescents. There was no evidence of associations of child BMI change or obesity incidence with parental hypertension or hyperglycaemia.
Our findings support the importance of early childhood as a key period for obesity prevention.

Please see below regarding objective 2.

Objective 3. Collect objective wrist-worn accelerometry, derive time-series physical activity data and examine associations with metabolic health.
To our knowledge, this was the first study investigating 24-hour movement behaviours measured continuously over 7 days among both children and adolescents in South East Asia.

Our findings suggest that Malaysian children and adolescents engage in relatively low levels of Moderate to Vigorous Physical Activity (MVPA). We observed higher MVPA among children vs adolescents, males vs females, Indian and Chinese vs Malay ethnic groups and children from higher income vs lower income households. Our data collection spanned a dynamic period with external events that may affect physical activity, such as Ramadan and COVID-19 movement restrictions. Although these events seemed to be related to physical activity engagement, demographic characteristics were the factors most associated with 24-hour movement behaviours in Malaysian children and adolescents.

The associations between Physical Activity with specific cardiometabolic risk factors were mostly inconclusive, but our findings suggest that lower inactive time is associated with lower diastolic blood pressure and fasting glucose, and more sleep is associated with lower diastolic blood pressure. Our study serves as a foundational step to prompt further investigation into the extent to which reducing inactivity, increasing physical activity, and improving sleep can contribute to better cardiometabolic health outcomes in children and adolescents within similar populations.

Objective 4. Conduct sub-studies designed to innovate dietary assessment by exploring wearable sensors to identify eating occasions.
We have conducted a feasibility study on the use of smartwatches for recording dietary intake in this population. We found that uptake was high, with 95% of those who were asked being willing to wear a smartwatch. Most participants liked wearing the smartwatch and said they wore it for the whole study. The most common reason for not wearing it was comfort. Participants broadly had a positive experience using it and charging the watch wasn't an issue. We found that Compliance was generally high, but fell by 4.5% during the study, with girls being more compliant. Only a minority of participants failed to wear the watch for the duration of the study.
Exploitation Route The data we collected for this project can be accessed and used by others through an application to SEACO.

Our findings from objective 1 support the importance of early childhood as a key period for obesity prevention. Other researchers can use this as justification for the development of obesity prevention interventions for this age-group in the Malaysian population.

Our findings from objective 3 suggest that future studies should seek to understand why predominantly girls, adolescents and children from Malay ethnicities have particularly low movement behaviours within Malaysia.

Our findings from objective 4, that Smartwatch dietary data collection are on the whole acceptable to this population, should be encouraging to other researchers hoping to collect similar data in their own studies.
Sectors Agriculture

Food and Drink

Healthcare

Leisure Activities

including Sports

Recreation and Tourism

 
Description In 2021 we wrote a World Health Organisation briefing note produced from a sub-study on physical activity change during the movement control order in Malaysia which we submitted to the WHO.
First Year Of Impact 2021
Sector Leisure Activities, including Sports, Recreation and Tourism
Impact Types Policy & public services

 
Description World Health Organisation briefing note
Geographic Reach National 
Policy Influence Type Implementation circular/rapid advice/letter to e.g. Ministry of Health
 
Description Staying active at home: the impact of COVID-19 movement restrictions on physical activity in a low-income semi-rural population. Funder: Elizabeth Blackwell Institute Rapid Response(COVID-19) Global Public Health call 2020
Amount £19,988 (GBP)
Organisation University of Bristol 
Sector Academic/University
Country United Kingdom
Start 05/2020 
End 07/2020
 
Title SEACO-CH20 Dataset 
Description The data collected for this study includes: Survey: Physical activity behaviour, food intake, eating behaviour, sleep, tanner staging Anthropometric measures: Devices-based measure (smartwatch and AX6 accelerometer), height, weight, BMI, waist circumference and blood pressure Biosample collection: Blood samples for analysing metabolites The data can be accessed by applying to the South East Asia Community Observatory (https://www.monash.edu.my/seaco/research-and-training/how-to-collaborate-with-seaco) 
Type Of Material Database/Collection of data 
Year Produced 2023 
Provided To Others? Yes  
Impact N/A 
URL https://www.monash.edu.my/seaco/research-and-training/seaco-research-project
 
Description SEACO 
Organisation Monash University Malaysia
Country Malaysia 
Sector Academic/University 
PI Contribution Partnership enables data collection in SEACO and to develop impact for the Malaysian community
Collaborator Contribution Local expertise and biobank storage
Impact EBI grant for physical activity during COVID project
Start Year 2019
 
Description Dissemination, networking, and mapping workshop in Malaysia, at Monash University 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact FINAL REPORT
CHILD HEALTH MAPPING AND DISSEMINATION WORKSHOP

Date: 14th February 2023
Venue: Active Learning Classroom 6-3-16, Monash University Malaysia
Time: 9.00am - 5.00pm
Link Photos: https://photos.app.goo.gl/ftD2iPsGGGDXet2ZA

OVERALL FLOW OF EVENT
Time Schedule Description
0830 - 0900 Registration Attendance: 42 (Physical) and 8 (Online)
0900 - 0910 Welcoming speech Prof Dr Matthew Gordon Nicholson, Interim Pro Vice-Chancellor and President of Monash University Malaysia
0910 - 0920 Introduction to SEACO Prof Dr Shajahan Yasin, Head of School, Jeffery Cheah School of Medicine and Health Science Monash University Malaysia

0920 - 0930 Photography session Led by Mr Roshidi
0930 - 1000 Brief introduction from the attendee Each participant shared their name, expertise, and institution
1000 - 1020 Break
1020 - 1040 Overview of SEACO Child Health Update -2020 (SEACO-CH20) project Prof Dr Tin Tin Su
1040 - 1100 Preliminary findings on metabolic syndrome and its parameter Mrs Sutha Rajakumar
1100 - 1130 Physical activity in SEACO-CH20 and activity monitor and smartwatch feasibility Dr Sophia Brady
1130 - 1150 Feasibility of device-based measure and current data population Mrs Izzah Nasruddin
1150 - 1200 SEACO dietary data for children and adolescent Dr Amutha Ramadas
1200 - 1300 Panel discussion Facilitated by Dr Miranda Armstrong and Prof Dr Tin Tin Su.
The panellists were:
1. Prof Dr Patrick Olivier [Monash University Australia]
2. A/P Dr Mohd Nahar Azmi Mohamed [Universiti Malaya]
3. Prof Dr Poh Bee Koon [National University of Malaysia]
4. Dr Feisul Mustapha [Ministry of Health]
1300 - 1400 Break
1400 - 1530 Breakout Session Led by Dr Miranda Armstrong and Prof Dr Tin Tin Su
1530 - 1600 Closing Closed by Dr Miranda Armstrong and Prof Dr Tin Tin Su

BRIEF REPORT
The South East Asia Community Observatory (SEACO) and the Jeffrey Cheah School of Medicine and Health Sciences in collaboration with Bristol University, United Kingdom (UK) have successfully conducted a Mapping and Dissemination workshop on the topic of child health on the 14th of February 2023 in the main campus, Monash University Malaysia. The aim was to conduct a dissemination, networking, and mapping workshop to utilise a mapping tool to identify gaps where there is scope for future research, policy, and practice in digital health and device-based measure among Malaysian children and adolescents, particularly on physical activity and diet.
Prof Dr Matthew Gordon Nicholson gave the welcoming remark, followed by an introductory talk on SEACO by Prof Shajahan Yasin as well as the talk on the Child Health Update-2020 Project (SEACO-CH20) given by Prof Dr Tin Tin Su. Mrs Sutha Rajakumar, Dr Sophia Brady, Mrs Izzah Nasruddin as well as Dr Amutha Ramadas gave their respective talks on their topics of interest related to SEACO-CH20 project. After disseminating the findings in the morning session, it came time to discuss in-depth the topic of device based measure on Malaysian children and adolescents via a panel discussion and subsequently through the breakout session during the afternoon session.
Panel Discussion
The workshop involved a broad range of stakeholders including researchers, policy makers, practitioners, and funders. Notable attendees were from the Institute of Health Behavioural Research (IHBR) from the Ministry of Health (MOH), the Malaysian Palm Board Oil, heads of department from various academic institution. The main event of the workshop was the panellists discussion facilitated by Dr Miranda Armstrong and Prof Dr Tin Tin Su. The four panellists were Prof Dr Patrick Olivier from Monash University Australia, Associate Prof Dr Mohd Nahar Azmi from Universiti Malaya, Prof Dr Poh Bee Koon from Universiti Kebangsaan Malaysia and Dr Feisul Mustapha from Ministry of Health. Each panellist gave their insights on how device-based measure can be utilised in different fields and its application through intervention and its feasibility in the larger Malaysian setting.
Prof Patrick Olivier talked about the development of the Axivity accelerometer device which was originally developed for dementia patients and then pivoted for use in the UK Biobank study which collected physical activity data on ~100,000 people. It stores raw data and allows researchers to access it in the raw form using an open-source device, which was not available at that time.
Prof Nahar Azmi talked about the trend of childhood obesity and metabolic syndrome in the clinical setting. Initially their referrals were for adult patients for Non-communicable Diseases but post-pandemic the number of referrals among children and adolescents for obesity has increased. He cited challenges in trying to assess very young children (2-5) years and how to increase their physical activity level. Further challenges include lack of family support and lack of family finances for lower SES families to afford activity trackers to encourage physical activity. He suggested avenues to pursue might include trying to encourage physical activity (PA) through social media approaches, and suggested parents buy even very basic activity trackers for their children as this could still give pre post information.
Prof Poh Bee Koon talked about her experience of the contributions of diet towards the trend of childhood obesity and metabolic syndrome in the research setting. Processed foods are popular among children in Malaysia and she suggests that this is likely what is leading to obesity and then metabolic syndrome in children. She pointed out that dietary fibre intake data is not collected by the Malaysian food composition table, it only collects crude fibre data. Further, the price of wholegrain food and low sugar options are high and prohibitive for lower socio-economic income (SES) groups.
Dr Feisul Mustapha talked about the current actions that the Ministry of Health (MOH) is doing to deal with the trend of childhood obesity and metabolic syndrome. He noted Malaysia has high rates of stunting which can be a risk factor for developing overweight and obesity. Challenges he identified included, motivation levels when considering the use of technology in trying to encourage more physical activity, challenges around SES, and challenges around distrust with respect to giving data. One specific activity championed by the MOH includes a focus on pregnancy and postpartum to increase knowledge and awareness. He indicated that there were insufficient regulatory interventions for food.
Prof Patrick Olivier responded to this by saying that for the general population, he believes that self-monitoring your PA level is not an effective intervention. He challenged that we should think wider in terms of how to harness the benefits of technology to create digital infrastructures to help facilitate increases in PA. Prof Patrick Olivier then talked about future plans for device-based measure, for low- and middle-income countries, especially Malaysia and Indonesia. He suggested that the lack of very strong infrastructures for health in these countries helps with the facilitation of innovation. In places like UK this can get in the way of progress.
Prof Nahar Azmi considered the practical use of devices in his clinical practice. He pointed out that despite SES challenges, many will still for example own mobile phones. He is using TikTok as a platform to encourage group activity. He also encourages the use of mobile phones as pedometers. If parents can afford them, he encourages the use of even basic activity trackers.
Prof Poh Bee Koon discussed the use of device-based measured for gathering dietary data. She talked about the use of apps to take pictures of food before eating. She highlighted the challenges of using images to do this with Malaysian specific foods given their composition. She indicated that compliance in her experience in research studies was low when asking participants to take pictures of their meals.
Finally, Dr Feisul Mustapha commented that while we have technology available for measuring physical activity, technology for measuring diet is more limited. As a policy maker he would find insidious sensors very useful, although he recognised privacy aspects of this. Prof Patrick Olivier talked about the challenges of sharing data between researchers and how it was important to be very careful so that trust can be re-established with participants sharing their data with researchers.
Dr Miranda Armstrong summarised the session by saying that there were more technology options available for physical activity measurement, but options for dietary measurement were limited. She suggested that considering possible other technological options for dietary measurement might be important whereas the focus for PA might be more on the appropriate application of available PA technologies.


Device Based Measures - Breakout Session Discussion
The aim of the mapping workshop activity was to use a specially developed mapping tool to examine the evidence for device-based measures and health in children and adolescents. Relevant topics were grouped together, and questions were provided under each topic to guide breakout discussions. The three discussion groups were basic epidemiology; Correlates and interventions and Health, social and climate economics, and the transfer of knowledge to actionable decisions and policymaking. Prior to the workshop, we also collated information on some previous research studies as an additional resource.

With respect to the use of device-based measures in relation to health outcomes a number of studies were identified by the group including: NHMS 2017/2019 - adolescent (nutrition status) technology capture; SeaNUTS 1 (10 years ago), pedometer; SeaNUTS 2, accelerometer; TOYBOX, accelerometer; SUnrise study, a multi-country study using accelerometer with an Australian PI; Imbas, photo based diet with human input to label the food in the photo; Universiti Malaya (UM) in collaboration with the Engineering faculty assess Athletes dietary intake by using a scanner to detect food and calories; UM is developing an app for mental health (Prof Maznah). The use of Samsung Health and iPhone fitness apps were also mentioned.
Challenges that were identified included: being harder to identify the type of food when it comes to Asian food; privacy issues in technology, such as children wearing a camera; tax on devices being brought into Malaysia for measurement purposes; the need to know how to extract, clean, analyse and interpret the data.
With respect to data collected through phone specifically, challenges identified were that they are not brought around everywhere by women, children are not allowed to bring phones to school, wearables provide more accurate data than smartphones. However, given the expense of wearables, some studies might choose to use smartphones for cost cutting.
In terms of mechanisms to achieve health outcomes, the group debated whether the use of device-based measures was worth the trouble and concluded that it was if it fulfilled the given study objectives. They felt new studies were needed to compare the accuracy of devices vs pen-and-paper. Further discussion was around suitable ages to start implementing the use of devices. For monitor it was thought that wearables that can be played with can be used from about 7 years of age. If children were required to provide inputs, they would need to be much older children. There was a fear that data might be manipulated by children, if rewards were involved and therefore considering how to avoid this would be important. There were questions around how long to wear devices for and it was concluded the longer the better.
With respect to Dose and Responses, it was pointed out that most studies use cut-points to classify different intensities. Device can be used to assess this, but they have further options such as being able to look at intensity / gradients. Taking these into consideration might give different perspectives to the association & give rise to new hypothesis or even new outcomes / behaviours that might be considered.
There was a discussion around the accuracy of different device-based measure options. For example, Fitbit and others correlated about 80% with accelerometers. However, access to raw data from Fitbit/smartwatches is challenging and deals need to be made with the companies to get raw data to understand this accuracy. It was pointed out that the assessment of diet via device was very preliminary. It was suggested that maybe in the future, the creation of devices that assess colours of the food could be used to assess the number of fruits and vegetable intake to get an idea of dose and response.
In terms of Behavioural patterns, numerous aspects were identified that should be considered when assessing patterns when considering device-based measures. These included consciously considering which wrist device is worn on as some people will be left-handed. Motivation was highlighted as an important factor with need to consider if a project or intervention relied on self-motivation on a reward to encourage motivation. Changes in dietary pattern, e.g., Ramadan fasting (as early as 6 or 7) should also be taken into consideration.
In the Malaysian context, PA is not given priority in schools which can affect assessment of PA level of students. Health-related behaviours may differ according to socioeconomic status. The top 20% income group may think of life habits differently and take a balanced approach. The bottom 40% income group may still be prioritising education related expenses for their kids and may not be very interested in investing in these kinds of devices.
To capture comprehensive patterns, it is necessary to collect both weekday and weekend patterns. However, for some studies (eg. SUNRISE), weekend was not assessed due to the fear of watches going missing during the weekend. A gap was identified in health literacy as it was felt that it was a relatively new area in Malaysia and could be assessed in relation to behaviours and use of devices.
The Correlates and Interventions group decided to focus on diet given the gap that was identified in the panel discussion. They started off by considering different options for data collection points. One suggestion was using the family unit, e.g., convincing parents to collect data for better commitment. There was a suggestion as to whether school data collection might be possible for example through introducing it as part of the curriculum in a single contained lesson. Another option that was suggested was to use friends and peers for data collection. This model is currently in use for other types of data collection. Ultimately it was thought that a co-design approach might work best to make decisions around this.
Further discussion looked as features that may improve accuracy of data collection. Suggestions included: Visual builders; simple and short probing questions; careful consideration of the level of detail to be collected; the possible use of verbal interactions with a nutritionist or chat bot. There was also the suggestion of providing Recommended Nutrient Intake (RNI) as a reference for better understanding (but social desirability bias should be considered here). Challenges to dietary measurement in the current context included the common consumption of shared meals and the level of commitment to collect data if a peer data collection method was used. There were also some conversations around the possibilities for device-based measures in mental health. However, the conclusions were that these may need further advancements in technology before they become practical.
With respect to Health, social and climate economics discussions were around whether everyone was able to benefit from device-based measures and given costs, it was proposed that if it was possible to cut device costs, more people could use the devices.
The cost and reliability of the device was considered across four points including the need to consider the accuracy of different app options versus their price; network coverage might be an important consideration in rural area as it might limit benefits experienced in those areas; equally level of access for implementation of device-based measures might differ across different settings in Malaysia; and different groups will have different levels of digital literacy.
A further challenge identified in the use of device-based measures was that some schools might not allow high tech devices in school. A suggestion was to then use a simple step counter instead. Questions outstanding included the return on investment of device-based measures to reduce the disease burden and research direct healthcare costs relating to device use.
Discussions around knowledge transfer included differing levels of digital literacy. It was felt that rural residents might need education on device use. Opportunities for increasing children's physical activities might include the use of app like TikTok. While the group said that the burden should not be left to the government, and personal responsibility is important, they made some suggestions for area of support. These included: device maintenance; M40 support from the government; The ministry of education can assist in encouraging higher student physical activities and encouraging healthy diets; subsidising the cost of healthy foods; and providing opportunities for children to be empowered to prepare healthy foods as part of the extra curriculum at school. Finally, role models might be needed to motivate users.
In terms of Evaluation four main factors were identified. These included the need for the device to be age appropriate; attractive (colour/design) for children; children should be educated on the target/s; and children should be offered rewards (i.e., points given for physical activities) e.g., grab points, token system, award from the school (MOH and commercial groups should be involved). Gaps highlighted included the need to identify if the device can motivate the student and to explore the needs of the student.
CONCLUSION
Overall, while there were challenges, device-based measures related to basic epidemiology, correlates, and interventions, seemed to be fairly well established for physical activity, but much less so for diet for which a gap was evident. The other main gaps identified were around health economics, knowledge transfer and evaluation.
Year(s) Of Engagement Activity 2023
URL https://padlet.com/mirandaarmstrong1/device-based-measures-health-mapping-workshop-iwophp3vo5vlu9na
 
Description Segamat research dissemination workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact A visit by University of Bristol and Monash University Malaysia researchers to SEACO on the 16th Feb 2023. Engagement was with school teachers, principals, study participants, parents, local health professionals and officials from the district public health office.
Aims were to provide a lay summary of some of the main findings and to gain input from stakeholders on the project and its findings.
Year(s) Of Engagement Activity 2023