Urban Asian Population Research Articles

Symptom Appraisal and Help-seeking among Patients with Autoimmune Rheumatic Diseases: A Qualitative Study.

Long diagnostic delay remains an unsolved problem in many autoimmune rheumatic diseases (ARDs). One of the major contributing factors is poor symptom appraisal and the resulting delayed help-seeking by patients themselves. We thus aimed to understand the experience of symptom appraisal and help-seeking among patients with ARDs in a multi-ethnic urban Asian population and to explore its influencing factors. Semi-structured interviews with 33 patients with ARDs were audio recorded and transcribed verbatim. We coded the transcripts deductively using the reported three stages of symptom appraisal (detection, interpretation and response) as the framework and inductively for newly emerging (sub)themes. All three stages of the symptom appraisal and help-seeking journey, i.e., symptom detection (by self and by others), symptom interpretation (causes, consequences and actions required) and symptom response (no action, self-management, help-seeking from non-healthcare professionals and help-seeking from healthcare professionals), were observed among patients. Interactions among these three stages were also observed: symptom interpretation was found to influence subsequent symptom detection, and the outcome of symptom response was found to influence both subsequent symptom detection and symptom interpretation. Various personal and social environmental factors (e.g., knowledge and cultural beliefs about the symptom) influencing the symptom appraisal and help-seeking journey were identified from the interviews. The symptom appraisal and help-seeking journey of patients with ARDs is an iterative process of detection, interpretation and response and is influenced by various personal and social environmental factors. Addressing modifiable factors could shorten the symptom appraisal and help-seeking interval and improve patient outcomes.

Return to work following knee arthroplasty: a retrospective review in urban Asian population.

An increasing number of working adults undergo knee arthroplasty in Singapore. There is limited data concerning Southeast Asian patients returning to work (RTW) following knee replacement surgery. Our aim was to identify and study factors influencing patients RTW following total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA). Patients who underwent TKA or UKA between August 2017 and March 2020 in our center were included in this study. Outcomes include RTW and duration prior to RTW. 441 patients underwent TKA (295 women, 146 men, mean age 67.3years) and 69 underwent UKA (48 women, 21 men, mean age 61.1years). Patients who underwent TKA returned to work earlier (mean 83.7 ± 27.1days) compared to UKA (mean 94.4 ± 42.3days). 90.0% of TKA patients RTW compared to 95.5% who underwent UKA. Of patients who RTW, 94.3% of the TKA group returned to employment of the same nature compared to 92.9% of UKA patients. Patients who RTW were of a younger age (p = 0.03), white collared workers (p = 0.04), and had independent preoperative ambulatory status (p < 0.01). Younger and independently ambulating patients may have better capacity for rehabilitation and RTW post arthroplasty surgery.

Barriers to and Facilitators of Adherence to Prescribed Home Exercise in Older Adults at Risk of Falling in Singapore: A Qualitative Study.

Adherence to prescribed exercise poses significant challenges for older adults despite proven benefits. The aim of this exploratory descriptive qualitative study was to explore the perceived barriers to and facilitators of prescribed home exercise adherence in community-dwelling adults 65 years and older. Three focus groups with 17 older adults (Mage ± SD = 77 ± 5.12) living in Singapore were conducted. Inductive thematic analysis revealed that "the level of motivation" of individuals constantly influenced their exercise adherence (core theme). The level of motivation appeared to be a fluid concept and changed due to interactions with two subthemes: (a)individual factors (exercise needs to be tailored to the individual) and (b)environmental factors (i.e.,support is essential). Hence, these factors must be considered when designing strategies to enhance exercise adherence in this vulnerable population. Strategies must be informed by the culturally unique context, in this case, a developed country with a multiethnic urban Asian population.

Return to work after injury in Hong Kong: prospective multi-center cohort study.

Trauma remains a major cause of morbidity and disability worldwide; however, reliable data on the health status of an urban Asian population after injury are scarce. The aim was to evaluate 1-year post-trauma return to work (RTW) status in Hong Kong. This was a prospective, multi-center cohort study involving four regional trauma centers from 2017 to 2019 in Hong Kong. Participants included adult patients entered into the trauma registry who were working or seeking employment at the time of injury. The primary outcome was the RTW status up to 1 year. The Extended Glasgow Outcome Scale, 12-item Short Form (SF-12) survey and EQ5D were also obtained during 1-, 3-, 6-, 9-, and 12-month follow-ups. Multivariable Cox proportional hazards regression analysis was used for analysis. Six hundred and seven of the 1115 (54%) recruited patients had RTW during the first year after injury. Lower physical requirements (p = 0.003, HR 1.51) in pre-injury job nature, higher educational levels (p < 0.001, HR 1.95), non-work-related injuries (p < 0.001, HR 1.85), shorter hospital length of stay (p = 0.007, HR 0.98), no requirement for surgery (p = 0.006, HR 1.34), and patients who could be discharged home (p = 0.006, HR 1.43) were associated with RTW within 12 months post-injury. In addition, 1-month outcomes including extended Glasgow Outcome Scale ≥ 6 (p = 0.001, HR 7.34), higher mean SF-12 physical component summary (p = 0.002, HR 1.02) and mental component summary (p < 0.001, HR 1.03), and higher EQ5D health index (p = 0.018, HR 2.14) were strongly associated with RTW. We have identified factors associated with failure to RTW during the first year following in Hong Kong including socioeconomic factors, injury factors and treatment-related factors and 1-month outcomes. Future studies should focus on the interventions that can impact on RTW outcomes. ClinicalTrials.gov Identifier NCT03219424.

COVID-19 awareness, knowledge and perception towards digital health in an urban multi-ethnic Asian population

This study aimed to determine COVID-19-related awareness, knowledge, impact and preparedness among elderly Asians; and to evaluate their acceptance towards digital health services amidst the pandemic. 523 participants (177 Malays, 171 Indians, 175 Chinese) were recruited and underwent standardised phone interview during Singapore’s lockdown period (07 April till 01 June 2020). Multivariable logistic regression models were performed to evaluate the associations between demographic, socio-economic, lifestyle, and systemic factors, with COVID-19 awareness, knowledge, preparedness, well-being and digital health service acceptance. The average perception score on the seriousness of COVID-19 was 7.6 ± 2.4 (out of 10). 75.5% of participants were aware that COVID-19 carriers can be asymptomatic. Nearly all (≥ 90%) were aware of major prevention methods for COVID-19 (i.e. wearing of mask, social distancing). 66.2% felt prepared for the pandemic, and 86.8% felt confident with government’s handling and measures. 78.4% felt their daily routine was impacted. 98.1% reported no prior experience in using digital health services, but 52.2% felt these services would be helpful to reduce non-essential contact. 77.8% were uncomfortable with artificial intelligence software interpreting their medical results. In multivariable analyses, Chinese participants felt less prepared, and more likely felt impacted by COVID-19. Older and lower income participants were less likely to use digital health services. In conclusion, we observed a high level of awareness and knowledge on COVID-19. However, acceptance towards digital health service was low. These findings are valuable for examining the effectiveness of COVID-19 communication in Singapore, and the remaining gaps in digital health adoption among elderly.

Sleep Duration, Sleep Quality and Physical Activity, but Not Sedentary Behaviour, Are Associated with Positive Mental Health in a Multi-Ethnic Asian Population: A Cross-Sectional Evaluation.

Background: We assessed the associations of sleep, physical activity and sedentary behaviour with positive mental health (PMH) in the multi-ethnic population of Singapore. Methods: The Singapore Health 2 study is a nationally representative cross-sectional survey among residents aged 18–79 years. A PMH instrument was administered to 1925 participants to obtain total PMH and six sub-component scores. Self-rated sleep duration, sleep quality, sedentary behaviour and physical activity were assessed. Multivariable linear regression analyses were conducted. Results: The mean age of the participants was 40.1 (SD 14.3) years. Sleep duration (≥8 h/night: β = 0.17,95% CI: 0.02–0.32; 7–< 8 h/night: β = 0.17,95% CI: 0.03–0.30 versus <6 h/night, p = 0.002), sleep quality (very good: β = 0.45,95% CI: 0.29–0.60; fairly good: β = 0.20,95% CI: 0.06–0.33 versus very/fairly bad; ptrend < 0.001) and physical activity (high: β = 0.19,95% CI: 0.05–0.32; moderate: β = 0.15, 95% CI: 0.03–0.27 versus low; ptrend < 0.001) were directly associated with total PMH. Sedentary behaviour was not significantly associated with PMH. Sleep duration, sleep quality and physical activity were directly associated with the PMH sub-components ‘emotional support’ and ‘personal growth and autonomy’. Conclusions: Duration and quality of sleep and physical activity were directly associated with PMH in an urban Asian population. These findings support incorporating sleep and physical activity interventions to improve population mental health.

Accelerometer Profile of Physical Activity and Sedentary Behavior in a Multi-Ethnic Urban Asian Population

ABSTRACT Purpose: Variability in accelerometry-data processing decisions limited data comparability across studies. We aimed to examine different accelerometry-data processing rules: varying bout lengths and allowance of 0- and 2-min interruptions on the total and bout-accumulated time spent in moderate-to-vigorous physical activity (MVPA) and sedentary behavior estimates, and describe the distribution of activity time based on counts per min (CPM) in granular categories. Method: Using the Singapore Health 2 survey, this study included 746 adults (41.8% women, median age 45.0 years) who provided valid ActiGraph GT3X+ accelerometer-data (≥4 valid days with ≥10-h/day). Quantile regression analysis adjusting for accelerometry daily wear time, age, and gender was performed to calculate the median and interquartile range of accelerometry estimates. Results: Median MVPA time accumulated in bouts of 1-min versus bouts of 10-min was 39.2 min/day and 6.0 min/day, respectively. MVPA time was higher when considering a 2-min interruption (range: 1.8–39.2 min/day) compared to 0-min interruption (range: 0–35.5 min/day) across bout lengths of 1- to 15-min. Participants were sedentary (≤100 CPM) for a daily median of 7.6 h/day. Median activities min/day on the lower-intensity activity spectrum (100–2499 CPM) decreased from 63.4 to 4.6 min/day, while on the higher-intensity activity spectrum (≥2500 CPM) was ≤2.9 min/day. Men generally spent more time in MVPA than women. Conclusions: This study highlights the differences in accelerometry estimates based on data processing decisions, and the importance of quantifying accelerometry-based activity time across the granular intensity spectrum. More studies are warranted to understand the determinants and health impact of these behaviors.

Patterns and Risk Factor Profiles of Visual Loss in a Multiethnic Asian Population: The Singapore Epidemiology of Eye Diseases Study

To describe the pattern and risk factor traits associated with visual loss (defined as either visual impairment [VI] or blindness) in a multiethnic Asian cohort of Malay, Indian, and Chinese individuals living in Singapore. A total of 10 020 participants from the Singapore Epidemiology of Eye Diseases Study were examined between 2004 and 2011. All underwent standardized examinations. VI (visual acuity <20/40 to ≥20/200) and blindness (visual acuity <20/200) were defined based on the US definition, better-seeing eye. Singapore Population Census 2010 was used to calculate age-standardized prevalence. Multiple logistic regression analysis was performed to determine the independent and joint risk factors associated with visual loss. Malay individuals had higher age-standardized prevalence of best-corrected and presenting VI (5.4% and 19.9%, respectively) than Indian (3.6% and 18.0%) and Chinese individuals (3.3% and 17.2%). Cataract was the main cause for presenting and best-corrected blindness; cataract and diabetic retinopathy were the top causes for best-corrected VI, consistently observed across the 3 ethnic groups. Older age, female sex, lower socioeconomic status, diabetes, systemic comorbidities, and cognitive impairment were independently associated with increased risk of best-corrected visual loss (all P ≤ .027). Individuals aged ≥60 years with diabetes were 12.7 times (95% confidence interval, 8.39-19.23) likely to have best-corrected visual loss, compared with younger, nondiabetic individuals. Lower income and education explained 58.1% and 23.2% of best-corrected visual loss in this population, respectively. In this urban multiethnic Asian population, we identified common traits associated with visual loss across Malay, Indian, and Chinese individuals. These results will be useful for the planning and designing of eye health services and strategies for Asia's rapidly developing populations living in urban communities. NOTE: Publication of this article is sponsored bythe American Ophthalmological Society.

Stepping volume and intensity patterns in a multi-ethnic urban Asian population

BackgroundAccelerometer measured physical activity (PA) studies particularly in non-western populations are lacking. Therefore, this study investigated stepping activity in a multi-ethnic urban Asian population.MethodsAdult participants from the Singapore Health Study 2 consented to accelerometer activity monitoring for 7-consecutive days. Mean daily step count, peak stepping intensity (i.e. cadence) over 1-min, 30-min and 60-min and time spent in each cadence band: 0 (non-movement), 1–19, 20–39, 40–59, 60–79, 80–99 and ≥ 100 steps/minute (moderate to vigorous PA) were calculated.ResultsA total of 713 participants (42% male, mean age 47.8 years) were included. Overall, the mean daily step count was 7549. Mean daily step count was significantly lower in Indians (7083 adjusted p = 0.02) but not Malays 7140 (adjusted p = 0.052) compared to Chinese (7745 steps). The proportion of Malays, Indians, and Chinese achieving < 5000 daily steps was 26%, 23% and 14%, respectively (p < 0.01). Regardless of ethnicity, approximately half of the recorded time was spent undertaking 0-steps/minute (7.9 h).ConclusionsGreater promotion of brisk walking is required in light of the low step volume and pace observed in this multi-ethnic Asian population. Ethnic differences in stepping activity were also identified which indicates a need for targeted ethnic specific health promotion interventions.

Self-reported domain-specific and accelerometer-based physical activity and sedentary behaviour in relation to psychological distress among an urban Asian population

BackgroundThe interpretation of previous studies on the association of physical activity and sedentary behaviour with psychological health is limited by the use of mostly self-reported physical activity and sedentary behaviour, and a focus on Western populations. We aimed to explore the association of self-reported and devise-based measures of physical activity and sedentary behaviour domains on psychological distress in an urban multi-ethnic Asian population.MethodsFrom a population-based cross-sectional study of adults aged 18–79 years, data were used from an overall sample (n = 2653) with complete self-reported total physical activity/sedentary behaviour and domain-specific physical activity data, and a subsample (n = 703) with self-reported domain-specific sedentary behaviour and accelerometry data. Physical activity and sedentary behaviour data were collected using the Global Physical Activity Questionnaire (GPAQ), a domain-specific sedentary behaviour questionnaire and accelerometers. The Kessler Screening Scale (K6) and General Health Questionnaire (GHQ-12) were used to assess psychological distress. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals, adjusted for socio-demographic and lifestyle characteristics.ResultsThe sample comprised 45.0% men (median age = 45.0 years). The prevalence of psychological distress based on the K6 and GHQ-12 was 8.4% and 21.7%, respectively. In the adjusted model, higher levels of self-reported moderate-to-vigorous physical activity (MVPA) were associated with significantly higher odds for K6 (OR = 1.47 [1.03–2.10]; p-trend = 0.03) but not GHQ-12 (OR = 0.97 [0.77–1.23]; p-trend = 0.79), when comparing the highest with the lowest tertile. Accelerometry-assessed MVPA was not significantly associated with K6 (p-trend = 0.50) nor GHQ-12 (p-trend = 0.74). The highest tertile of leisure-time physical activity, but not work- or transport-domain activity, was associated with less psychological distress using K6 (OR = 0.65 [0.43–0.97]; p-trend = 0.02) and GHQ-12 (OR = 0.72 [0.55–0.93]; p-trend = 0.01). Self-reported sedentary behaviour was not associated with K6 (p-trend = 0.90) and GHQ-12 (p-trend = 0.33). The highest tertile of accelerometry-assessed sedentary behaviour was associated with significantly higher odds for K6 (OR = 1.93 [1.00–3.75]; p-trend = 0.04), but not GHQ-12 (OR = 1.34 [0.86–2.08]; p-trend = 0.18).ConclusionsHigher levels of leisure-time physical activity and lower levels of accelerometer-based sedentary behaviour were associated with lower psychological distress. This study underscores the importance of assessing accelerometer-based and domain-specific activity in relation to mental health, instead of solely focusing on total volume of activity.

A pragmatic lifestyle modification programme reduces the incidence of predictors of cardio-metabolic disease and dysglycaemia in a young healthy urban South Asian population: a randomised controlled trial

BackgroundThere is an increasing incidence of type 2 diabetes mellitus (T2DM) in young urban South-Asians. We tested the effect of a pragmatic trimonthly lifestyle modification (LSM) programme (P-LSM) versus a less-intensive 12-monthly control LSM (C-LSM) intervention on a primary composite endpoint of predictors of cardio-metabolic disease (new onset T2DM, hypertension, impaired glucose tolerance (IGT), impaired fasting glycaemia (IFG) and markers of cardio-renal disease) in participants aged 5–40 years with risk factors for T2DM.MethodsThis was a randomised controlled trial performed at the National Diabetes Centre, Sri-Lanka. We individually randomised 4672 participants at risk of T2DM, of whom 3539 (mean age 22.5 (range 6–40 years, 48% males) received either trimonthly (P-LSM n = 1726) or 12-monthly (C-LSM n = 1813) peer educator advice aimed at reducing weight, improving diet, reducing psychological stress and increasing physical activity.ResultsDuring a median follow-up of 3 years, the cumulative incidence of the primary endpoint was n = 479 in P-LSM (74 per 1000 person years) vs. 561 in C-LSM (96 per 1000 person years), with an incident rate ratio (IRR) of 0.89 (95% CI 0.83–0.96, P = 0.02). In post hoc analyses, new onset dysglycaemia (T2DM, IFG and IGT), was the major contributor to the composite and was significantly reduced by P-LSM (IRR 0.9, 95% CI 0.83–0.97, P = 0.01). A significant impact of P-LSM on the incidence of the composite endpoint was noted in 1725 participants (P-LSM n = 850, C-LSM n = 875) aged below 18; P-LSM n = 140 (48 per 1000 person years) versus C-LSM n = 174 (55.4 per 1000 person years), with an IRR of 0.83 (95% CI 0.73–0.94, P = 0.004).ConclusionsIn a young at-risk South-Asian population, a pragmatic LSM programme significantly reduces the incidence of predictors of cardio-metabolic disease. Our results highlight the importance of early intervention in young at-risk subjects.Trial registrationWorld Health Organization international clinical trial registry platform (SLCTR/2008/003). Registration Date: March 28, 2008. Retrospectively registered.

Determinants of eating at local and western fast-food venues in an urban Asian population: a mixed methods approach

BackgroundLike several Southeast Asian countries, Singapore has a complex eating-out environment and a rising eating-out prevalence. However the determinants and drivers of eating-out in urban Asian environments are poorly understood.MethodsWe examined the socio-demographic characteristics of persons who frequently ate away from home in local eateries called hawker centres and Western fast-food restaurants, using data from 1647 Singaporean adults participating in the National Nutrition Survey (NNS) 2010. We also assessed the underlying drivers of eating out and evaluated if these were different for eating at local eateries compared to Western fast-food restaurants using 18 focus group discussions of women (130 women).ResultsParticipants reported a high eating-out frequency with 77.3% usually eating either breakfast, lunch or dinner at eateries. Main venues for eating-out included hawker centres (61.1% usually ate at least 1 of 3 daily meals at this venue) and school/workplace canteens (20.4%). A minority of participants (1.9%) reported usually eating at Western fast-food restaurants. Younger participants and those of Chinese and Malay ethnicity compared to Indians were more likely to eat at Western fast-food restaurants. Chinese and employed persons were more likely to eat at hawker centres. The ready availability of a large variety of affordable and appealing foods appeared to be a primary driver of eating out, particularly at hawker centres.ConclusionsOur findings highlight the growing importance of eating-out in an urban Asian population where local eating venues play a more dominant role compared with Western fast-food chains. Interventions focusing on improving the food quality at venues for eating out are important to improve the diet of urban Asian populations.

Association of obesity with patient-reported outcomes in patients with axial spondyloarthritis: a cross-sectional study in an urban Asian population.

To determine if obesity is associated with poorer patient-reported outcomes (PROs) in patients with axial spondyloarthritis (axSpA), we conducted a cross-sectional study using data of the PRESPOND registry from a tertiary referral center in Singapore between 2011 and 2015. Demographics, clinical, and PRO variables were collected. Patients were divided into three categories: normal (BMI<23kg/m2), overweight (23kg/m2≤BMI<27.5kg/m2) and obese (BMI≥27.5kg/m2), using Asian BMI classification. The dependent variables are Pain score, Bath Ankylosing Spondylitis Patient Global Score (BAS-G), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), and Medical Outcomes Study Short Form 36 version 2 (SF-36). Multivariate regression analyses were performed with these dependent variables and obesity categories, adjusting for confounders. Among 194 patients with axSpA, 32% are overweight while 22% are obese. We found that obese patients had significant poorer pain (β: 11.87, 95%CI 2.13, 21.60) and BAS-G scores (β: 10.18, 95%CI 1.59, 18.76) when compared to normal BMI patients. However, obesity was not associated with BASDAI (β 0.50, 95%CI -0.22, 1.22), BASFI (β 0.08, 95%CI -0.66, 0.81), HAQ (β -0.07, 95%CI -0.21, 0.06), physical component summary (β -0.02, 95%CI -4.47, 4.44), and mental component summary (β -2.85, 95%CI -7.57, 1.88) of SF-36. Obesity was associated with pain score and BAS-G but not with BASDAI, BASFI, HAQ, and SF-36. Further study is needed to examine the causal relationship between obesity and poorer PROs.

Commentary: dissecting the PNPLA3 association with liver fat and stiffness, and interaction with diet

We read the article by Shen et al. with great interest, and highlighted some of the key features of this study.1 The authors conducted a prospective cohort study and reported that the rs738409 GG variant in patatin-like phospholipase domain-containing protein 3 (PNPLA3) genotype was associated with an increased risk of non-alcoholic fatty liver disease (NAFLD) by magnetic resonance spectroscopy (MRS) of the liver, and the presence of gene effect on trait was not explained by the diet history recorded by the food frequency questionnaire. In multivariable-adjusted analyses, metabolic syndrome was a much stronger correlate of presence of hepatic steatosis than PNPLA3 genotype. Incremental net reclassification rate (although not shown) by including PNPLA3 genotype in addition to clinical risk factors of NAFLD appeared modest, and not clinically significant, when these results are seen in context of the broader themes in the field at this time. This study provides validation that PNPLA3 genotype is associated with increased risk of NAFLD in an urban Asian population, predominantly of Chinese origin, residing in Hong Kong. The investigators also found that liver stiffness measured by transient elastography did not reveal any association with PNPLA3 genotype. These data suggest that liver stiffness in NAFLD is not affected by PNPLA3 genotype, and possibly other genetic variants may be associated with hepatic fibrosis and/or liver stiffness. Previous studies have shown that the association of the GG variant and hepatic lipid content is associated with the presence of other risk factors, such as severe obesity,2 visceral adiposity,3 increased intake of sugars4 and omega-6 poly-unsaturated fatty acids.5 However, the results presented by Shen and colleagues do not find an association. Most of the prior association studies were conducted in Caucasian populations in contrast to the study by Shen et al., which is derived from a biogeo-graphically distinct population compared with previous studies. However, the association between NAFLD and various metabolic traits was consistent across all previous studies, as well as this study, suggesting some generalis-ability between cohorts.6–10 Overall, the study provides four key messages. First, it confirms the association between PNPLA3 genotype and liver fat content by MRS in a Chinese population residing in Hong Kong. Second, PNPLA3 genotype effect on trait was not found to be influenced by diet in this study. Third, presence of metabolic syndrome trumps PNPLA3 genotype in it's association with the trait (i.e., NAFLD). Fourth, PNPLA3 genotype did not influence liver stiffness. These findings underscore the need to better understand the molecular mechanisms by which the GG variant is linked to fat accumulation in the liver, and further research is warranted to unravel the physiological role of the PNPLA3 in times of starvation and caloric excess. Improved understanding of the role of PNPLA3 could open new areas of investigations and may provide novel avenues for drug development and intervention studies to reverse NAFLD.

Letter: East-West differences in the economic impact of functional dyspepsia - authors’ reply

SIRS, We thank Drs Mahadeva and Goh for their interest in our recently published study evaluating the economic impact of functional dyspepsia (FD). 2 As they correctly state, FD is highly prevalent in both the West and the East. It should come as no surprise that the economic impact (both direct costs and indirect costs) of FD will differ from country to country based on the surveyed population (rural vs. urban), variations in health care utilisation, availability of different technologies and the average income of the surveyed population. However, what is striking is the author’s own report of the high costs of FD in an urban South East Asian population – nearly $60 000 US dollars per 1000 population, compared with an estimated $80 000 per 1000 population for our urban Western population. 3 Although these costs are clearly lower than the costs we reported, they are still quite high for a region of the world where the cost of living is widely acknowledged to be lower than in the West. The very thoughtful letter by Drs Mahadeva and Goh is a reminder that in an economic climate of escalating costs and dwindling health care resource dollars, we need to devise a safe and cost-effective method of diagnosing and treating this highly prevalent disorder.

Television screen time, but not computer use and reading time, is associated with cardio-metabolic biomarkers in a multiethnic Asian population: a cross-sectional study

BackgroundRecent evidence shows that sedentary behaviour may be an independent risk factor for cardiovascular diseases, diabetes, cancers and all-cause mortality. However, results are not consistent and different types of sedentary behaviour might have different effects on health. Thus the aim of this study was to evaluate the association between television screen time, computer/reading time and cardio-metabolic biomarkers in a multiethnic urban Asian population. We also sought to understand the potential mediators of this association.MethodsThe Singapore Prospective Study Program (2004–2007), was a cross-sectional population-based study in a multiethnic population in Singapore. We studied 3305 Singaporean adults of Chinese, Malay and Indian ethnicity who did not have pre-existing diseases and conditions that could affect their physical activity. Multiple linear regression analysis was used to assess the association of television screen time and computer/reading time with cardio-metabolic biomarkers [blood pressure, lipids, glucose, adiponectin, C reactive protein and homeostasis model assessment of insulin resistance (HOMA-IR)]. Path analysis was used to examine the role of mediators of the observed association.ResultsLonger television screen time was significantly associated with higher systolic blood pressure, total cholesterol, triglycerides, C reactive protein, HOMA-IR, and lower adiponectin after adjustment for potential socio-demographic and lifestyle confounders. Dietary factors and body mass index, but not physical activity, were potential mediators that explained most of these associations between television screen time and cardio-metabolic biomarkers. The associations of television screen time with triglycerides and HOMA-IR were only partly explained by dietary factors and body mass index. No association was observed between computer/ reading time and worse levels of cardio-metabolic biomarkers.ConclusionsIn this urban Asian population, television screen time was associated with worse levels of various cardio-metabolic risk factors. This may reflect detrimental effects of television screen time on dietary habits rather than replacement of physical activity.

Impact of self-reported smoking status on health-related quality of life in Singapore

Aim To evaluate possible differences in health-related quality of life (HRQoL) according to self-reported smoking status in a multiethnic urban Asian population in Singapore.

Reliability and validity of the English (Singapore) and Chinese (Singapore) versions of the Short-Form 36 version 2 in a multi-ethnic Urban Asian population in Singapore

We aimed to evaluate the measurement properties of the Singapore English and Chinese versions of the Short-Form 36 version 2 (SF-36v2) Questionnaire, an improved version of the widely used SF-36, for assessing health-related quality of life (HRQoL) in a multi-ethnic urban Asian population in Singapore. SF-36v2 scores and data on medical history, demographic and lifestyle factors from the Singapore Prospective Study Programme were analyzed. Convergent and divergent validity, internal consistency, floor and ceiling effects, known group validity and factor structure of the SF-36v2 were assessed for the English and Chinese versions, respectively. Complete data for 4,917 participants (45.8%) out of 10,747 eligible individuals were analyzed (survey language: 4,115 English and 802 Chinese). Item-scale correlations exceeded 0.4 for all items of the English SF-36v2 and for all except one item of the Chinese SF-36v2 (bathe and dress: item-scale correlation: 0.36). In the English SF-36v2, Cronbach's alpha exceeded 0.70 for all scales. In the Chinese SF-36v2, Cronbach's alpha exceeded 0.7 on all scales except social functioning (Cronbach's alpha: 0.68). For known groups validity, respondents with chronic medical conditions expectedly reported lower SF-36v2 score on most English and Chinese SF-36v2 scales. In confirmatory factor analysis, the Singapore three-component model was favored over the United States two-component and Japan three-component models. The English and Chinese SF-36v2 are valid and reliable for assessing HRQoL among English and Chinese-speaking Singaporeans. Test-retest reliability and responsiveness of the English and Chinese SF-36v2 in Singapore remain to be evaluated.

Disease patterns of rheumatology outpatients seen in a tertiary hospital serving a multi‐ethnic, urban Asian population in Singapore

To describe the spectrum of diseases seen in an outpatient setting in the Singapore General Hospital, the largest tertiary referral centre in Singapore. In this cross-sectional study, medical records of patients scheduled for an appointment at the rheumatology specialist outpatient clinics over a 4-month period (10 August 2010-31 December 2010) were reviewed. Primary diagnoses documented by the attending physician at the latest visit were recorded. Among 4180 patients (29.5% male; mean [SD] age: 53.5 [15.1] years; 77.0% Chinese, 8.0% Malay, 8.8% Indian and 6.2% others), the spectrum of diseases seen was as follows [disease - definite n (%), probable n (%)]: Arthritis: rheumatoid arthritis - 958 (22.9%), 68 (1.6%); osteoarthritis - 452 (10.8%), 39 (0.9%); crystal arthritis - 417 (10.0%), 18 (0.4%); spondyloarthritis - 227 (5.4%), 61 (1.5%); psoriatic arthritis - 158 (3.8%), 9 (0.2%); other inflammatory arthritis - 153 (3.7%), 94 (2.2%); Connective tissues diseases: systemic lupus erythematosus - 412 (9.9%), 26 (0.6%); vasculitis - 105 (2.5%), 22 (0.5%); Sjögren's syndrome - 81 (1.9%), 32 (0.8%); overlap syndromes - 73 (1.8%); scleroderma - 50 (1.2%), 4 (0.1%); undifferentiated connective tissue diseases - 45 (1.1%), 106 (2.5%); myositis - 41 (1.0%), 12 (0.3%); antiphospholipid syndrome - 22 (0.5%), 7 (0.2%); polymyalgia rheumatica - 16 (0.4%); Others: soft tissue rheumatism - 155 (3.7%); osteoporosis - 61 (1.5%); other non-rheumatologic conditions - 189 (4.5%); other rheumatologic conditions - 67 (1.6%). Rheumatoid arthritis, osteoarthritis and crystal arthritis were the three most common rheumatological diseases seen in a tertiary referral centre serving a multi-ethnic urban Asian population in Singapore.

The Prevalence and Risk Factors of Ocular Trauma: The Singapore Indian Eye Study

Purpose: To describe the prevalence and risk factors of ocular trauma in an urban Southeast Asian population.Methods: A population-based survey of 3,400 (75.6% response rate) adults of Indian ethnicity aged 40–80 years residing in Singapore was conducted in 2007–2009. An age-stratified (10-year age group) random sampling procedure was performed to select participants. Ocular trauma was defined as any eye injury requiring medical attention and any history of ocular trauma was documented using a standardized and validated questionnaire comprising seven questions. Potential risk factors associated with ocular trauma included age, gender, socioeconomic status, occupation, housing type, alcohol consumption, smoking, diabetes mellitus, hypertension and history of falls.Results: Ocular trauma was reported in 5.1% (n = 162; 95% confidence interval [CI] 4.3–6.1%) of the study population, of whom 26.5% (n = 43) required hospitalization. A total of 42.0% (n = 68) of cases resulted from a blunt object, 36.4% (n = 59) from a sharp object, and 15.4% (n = 25) from chemical burns. After adjusting for age and sex, men had a higher prevalence of ocular trauma (7.1% vs. 3.0%, age-adjusted odds ratio [OR] 2.2, 95% CI 1.6–3.1). A history of cigarette smoking was associated with higher likelihood of ocular trauma (OR 1.6, 95% CI 1.1–2.4) but not consumption of alcohol (OR 1.0, 95% CI 0.6–1.6).Conclusions: One in twenty Indian adults in this urban Southeast Asian population had a history of ocular trauma, similar to the prevalence reported in Malays living in Singapore. Men and cigarette smokers were more likely to have incurred ocular trauma.