Are Chinese Women Maximizing their Lifelong Health Potential?

1. Are Chinese Women Maximizing their Lifelong Health Potential? Georgia S. GuldanAsian University for Women Chittagong, Bangladesh georgia.guldan@auw.edu.bd

2. 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?

3. 20-45-year-old Chinese women’s BMI distributions in 1989 and 2000 1989 Proportion  2000 BMI Wang et al. IJO 2005

4. 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

5. Hong Kong 20- to 84-year-old women’s BMI category * distribution 2005-2007 *OW = BMI>23 N = BMI >18.5; <23 UW = BMI <18.5 Age group in years

6. Women’s Food Intakes from 2002 China National Nutrition and Health Survey Li & Huang, Curr Wom Hlth Rev 2009

7. 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

8. 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

9. SWHS Dietary intake analysis • 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: Villegas et al. 2010

10. Clusters’ nutrient and other characteristics Villegas et al. 2010

11. Results 1,514 cases of incident T2D were observed over the 6.9-y follow-up period. Villegas et al. 2010

12. 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 Villegas et al. 2010

13. Discussion (2) • 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. Villegas et al. 2010

14. 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. Villegas et al. 2010

15. 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) Villegas et al. 2007

16. 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. Villegas et al. 2007

17. Glycemic Load, Cereal Fiber Intake, Diabetes Risk 2.50 2.30 2.05 2.17 1.80 1.62 Relative Risk of Diabetes Cereal Fiber Intake Glycemic Load Nurses’ Health Study

18. 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

19. 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

20. SWHS III:Resting heart rate and T2DM (2) Results • 849 incident cases of T2DM occurred aAdjusted for age, education, occupation, family income, cigarette smoking, alcohol consumption, BMI Zhang et al. Int J Epi 2010

21. SWHS III:Resting heart rate and T2DM (3) • 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

22. SWHS III:Resting heart rate and T2DM (4) • 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

23. SWHS IV: Weight gain after age 20 and prehypertension (1) • 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 Yang et al. IJO 2007

24. 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. Yang et al. IJO 2007

25. SWHS V: Abdominal adiposityand mortality (1) • 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

26. SWHS V: Abdominal adiposityand mortality (2) • 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. Zhang et al. Arch Int Med 2007

27. SWHS V: Abdominal adiposityand mortality (3) • 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. Zhang et al. Arch Int Med 2007

28. SWHS V: Abdominal adiposityand mortality (4) • 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. Zhang et al. Arch Int Med 2007

29. 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

30. 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

31. 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