Innovating behaviour and health surveillance for cardiovascular disease prevention in Malaysia

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.

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.

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.