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UNIVERSITI PUTRA MALAYSIA
LIFESTYLE, NUTRITIONAL AND BIOCHEMICAL FACTORS ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION AMONG
PATIENTS AT SHAHID MOSTAFA KHOMEINI HOSPITAL, ILAM, IRAN
TEYMOOR YARY
FPSK(m) 2011 1
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LIFESTYLE, NUTRITIONAL AND BIOCHEMICAL FACTORS
ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION AMONG
PATIENTS AT SHAHID MOSTAFA KHOMEINI HOSPITAL, ILAM, IRAN
By
TEYMOOR YARY
Thesis submitted to the school of graduate studies, University Putra Malaysia in
fulfilment of the requirements for the degree of Master of Science
March 2011
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Abstract of thesis presented to the Senate of University Putra Malaysia in fulfilment
of the requirement for the degree of Master of Science
LIFESTYLE, NUTRITIONAL AND BIOCHEMICAL FACTORS
ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION AMONG
PATIENTS AT SHAHID MOSTAFA KHOMEINI HOSPITAL, ILAM, IRAN
By
TEYMOOR YARY
March 2011
Chairman: Firdaus Abd Rahim, MBBS
Faculty : Medicine and Health Sciences
Myocardial infarction (MI) seriously threatens public health all over the world,
especially in developing countries. Epidemiological studies have documented that
risk factors, including smoking, diet, and a person’s biochemical profile are
responsible for the development of acute myocardial infarction (AMI). This epidemic
disproportionately affects ethnic populations and has a racial correlation. According
to the Ministry of Health in Iran, each day 300 people die of AMI, affecting women
over 50 years of age and men over 32 years of age. Changes in lifestyle, the rapid
urbanization, and desperate socio-economic status have been correlated with the
occurence of AMI.
This case-control study was conducted on 120 cases of AMI and 120 control patients.
Clinical criteria, electrocardiographic criteria, and biochemical markers defined an
AMI. Control cases comprised 120 individuals who received routine health checkups
at the same hospital. Cases and controls were matched by age and sex.
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Standard questionnaires and physiological measures were used to obtain data. The
case and control groups were compared using parametric and nonparametric tests, as
required. For final analyses, a binary unconditional logistic regression analysis was
conducted to identify independent predictors for AMI in the case-control model. In
the binary logistic regression analysis, the risk factors for developing AMI were
evaluated using independent variables recognized by the American Heart Association
and documented in the literature review. These risk factors have both
epidemiological and clinical importance. The results derived revealed that
hypertension (odd ratio (OR)=3.9, 95% confidence intervals (CI) 1.4-10.9); family
history of coronary heart disease (OR=6.8, 95% CI 2.4-19.6); physical inactivity
(OR=3.0, 95% CI 1.3-6.6); and unmarried (OR=5.2, 95% CI 1.6-16.6) were
independent AMI risks. For plasma biomarkers, low-density lipoprotein (LDL)
(OR=2.9, 95% CI 1.1-7.4) and fasting blood sugar (FBS) (OR=4.3, 95% CI 1.4-13.2),
and for anthropometric parameters, only waist-hip ratio (WHR) (OR=2.6, 95% CI
1.2-5.6) were risk factors for AMI. Among nutrients variables, high saturated fat
(OR=2.7, 95% CI 1.2-6.0) was an independent risk factor for AMI. Low
consumption of total dietary fiber (TDF) (OR=8.3, 95% CI 2.0-34.6) was also a
significant independent risk factor for AMI.
In conclusion, the present study found several risk factors for AMI in this sample. It
is recommended that appropriate interventions and systematic health education
programs be implemented for the Ilamian people to reduce the incidence and
mortality rate of AMI.
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Abstrak tesis yang dikemukakan kepada Senat Universiti Putra Malaysia dalah
sebahagian daripada syarat untuk memperolehi ijazah Master Sains
CARA HIDUP, NUTRISI DAN BIOKIMIA FAKTOR YANG BERKAITAN
DENGAN INFARKSI MIOKARDIUM AKUT DI KALANGAN PESAKIT
DI SHAHID MOSTAFA KHOMEINI HOSPITAL, ILAM, IRAN
Oleh
TEYMOOR YARY
Mac 2011
Pengerusi: Firdaus Abd Rahim, MBBS
Faculti : Perubatan dan Sains Kesihatan
Infarksi miokardium (IM) merupakan satu ancaman yang serius terhadap kesihatan
masyarakat di seluruh dunia, khasnya di negara-negara membangun. Kajian
epidemiologi mendapati bahawa faktor seperti merokok, diet dan profil biokimia
seseorang itu mempengaruhi perkembangan infarksi miokardium akut (IMA).
Menurut Kementerian Kesihatan Iran, sebanyak 300 orang maut disebabkan oleh
IMA setiap hari, terutamanya di kalangan wanita berumur 50 tahun ke atas, dan
lelaki berumur 32 tahun ke atas. Perubahan cara hidup, urbanisasi dan keperluan
sosio-ekonomi yang tinggi merupakan faktor-faktor yang telah dikaitkan dengan
IMA.
Satu kajian kes kawalan telah dilakukan terhadap 120 pesakit IMA (kes) dan 120
orang yang sihat (kawalan). Kriteria klinikal, kriteria elektrokardiografi, dan ujian
biokimia dilakukan bagi proses mengenalpasti sampel kes. Seramai 120 individu
yang menerima pemeriksaan kesihatan rutin di hospital yang sama dijadikan sampel
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kawalan. Sampel kes dan sampel kawalan dipadankan berdasarkan faktor umur dan
jantina.
Borang soal selidik dan ujian fisiologi digunakan sebagai medium untuk mengumpul
data. Selain itu, ujian parametrik dan ujian bukan parametrik telah diguna pakai
dalam kajian ini untuk membuat perbandingan di antara sampel kes dan sampel
kawalan,. Bagi analisis akhir, analisis regresi logistik binari tanpa syarat dijalankan
bagi mengenalpasti prediktor bebas dalam model kes-kawalan. Di dalam analisis
regresi logistik binari, faktor risiko bagi perkembangan IMA dinilai menggunakan
pembolehubah bebas yang diakui oleh “Persatuan Jantung Amerika” dan
didokumentasikan di dalam ulasan kepustakaan. Faktor-faktor risiko ini mempunyai
kepentingan epidemiologi dan klinikal. Keputusan kajian yang diperolehi
menunjukkan bahawa hipertensi mempunyai (nisbah ods tidak terlaras (OR) = 3.9,
95% selang kepercayaan (CI) 1.4-10.9); sejarah keluarga yang mempunyai penyakit
jantung koronari, (OR= 6.8, 95% CI 2.4-19.6); tiada aktiviti fizikal, (OR= 3.0, 95%
CI 1.3-6.6); dan tidak berkahwin (OR= 5.2, 95% CI 1.6-16.6) merupakan faktor
risiko bebas bagi IMA. Bagi ujian biokimia, kepadatan lipoprotein yang rendah
(LDL) (OR= 2.9, 95% CI 1.1-7.4); paras gula dalam darah (puasa) (FBS) (OR= 4.3,
95% CI 1.4-13.2); dan bagi parameter antropometrik, hanya nisbah pinggang dan
pinggul (WHR) (OR= 2.6, 95% CI 1.2-5.6) merupakan faktor risiko bagi IMA. Di
antara pembolehubah permakanan, lemak tepu yang tinggi (OR= 2.7, 95% CI 1.2-6.0)
merupakan faktor risiko bebas bagi IMA. Pengambilan jumlah serat makanan yang
rendah (TDF) (OR= 8.3, 95% CI 2.0-34.6) juga merupakan faktor risiko bebas yang
signifikan bagi IMA.
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Kesimpulannya, terdapat beberapa faktor risiko bagi IMA di dalam sampel kajian
yang digunakan. Oleh itu, penyelesaian yang sesuai dan program pendidikan
kesihatan yang sistematik hendaklah dilaksanakan di Iran khususnya untuk rakyat
Ilamian bagi mengurangkan kejadian IMA, dan secara tidak langsung juga dapat
meminimumkan kadar kematian akibat oleh IMA.
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DEDICATION
I dedicate this thesis to unique and holy word “mother”, my family, especially to my
loving mother, I love you, thank you for your prayers, your support, and your caring
for me. Also I dedicate this thesis to my wife and her family. Furthermore, I would
like to dedicate the thesis to Poya (my nephew), who always motivated me for
studying.
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ACKNOWLEDGEMENTS
I wish to thank my supervisor committee, Dr. Firdaus Abd Rahim, Assoc. Prof. Dr.
Mirnalini Kandiah, and Dr. Wong Teck Wee, who always given their guidance to
complete this thesis. Also, I would like to express my deepest gratitude to my
supervisor (Dr. Kurosh Solaymanejad) in Iran for providing his patients for this study,
without his advice and time, the research could not have been conducted. In addition,
I thank Dr. Sayedeh Ozma Jafarpoor for providing control group.
I would like to my appreciation to the nurses and all others stuffs at the Mostafa
Hospital. Also, I wish express my sincerest appreciation to all participants in this
study for their times and cooperation, especially patients suffered from AMI; without
their willingness to share their experiences, this study would not have been possible.
I would like to express my acknowledgement to Ilam city that always is a deprived
province and Iran government never think about it. Also, I would like to thank Ilam
Medical University, especially Azim Aazami. Most importantly, I would like to
thank my mother, my wife, and her father (Dr. Javad Aazami) for their love and
exhort that maintained me during my studies. Finally, I wish to thank my friends Dr.
Yadolah Ablofathi and Dr. Javad Yaghobi for guiding me during the data analyses.
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This thesis was submitted to the Senate of Universiti Putra Malaysia and has been
accepted as fulfilment of the requirement for the degree of Master of Nutritional
Sciences. Members of the Supervisory Committee were as follows:
Firdaus Abd Rahim, PhD
Lecturer
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Chairman)
Mirnalini Kandiah, PhD
Associate Professor
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Member)
Wong Teck Wee, PhD
Lecturer
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Member)
HASANAH MOHD GHAZALI, PhD
Professor and Dean
School of Grauate Studies
University Putra Malaysia
Date:
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DECLARATION
I declare that the thesis is my original work except for quotations and citations which
have been duly acknowledged. I also declare that it has not been previously, and is
not concurrently, submitted for any other degree at Universiti Putra Malaysia or at
any other institutions.
TEYMOOR YARY
Date: 3 March 2011
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TABLE OF CONTENTS
Page
ABSTRACT ii
ABSTRAK iv
DEDICATION vii
ACKNOWLEDGEMENTS viii
APPROVAL ix
LIST OF TABLES xvi
LIST OF FIGURES xviii
LIST OF ABBREVIATIONS xix
CHAPTER
1 INTRODUCTION
1.1 Background 1
1.2 The problem statement 4
1.3 Research questions 5
1.4 Significant of the study 6
1.5 Research objectives 7
1.6 Null hypothesis 8
2 LITERATURE REVIEW
2.1 Definition of acute myocardial infarction 10
2.2 Epidemiology of heart disease 10
2.3 Non-modifiable risk factors 11
2.3.1 Family history 11
2.3.2 Age and gender 12
2.4 Modifiable risk factors 13
2.4.1 Dietary factors 13
2.4.2 Homocysteine and vitamins B 26
2.4.3 Lipoproteins 27
2.4.4 Blood pressure 30
2.4.5 Diabetes mellitus 31
2.4.6 Obesity 32
2.4.7 Body mass index (BMI) 32
2.4.8 Waist circumference (WC) and waist-to-hip ratio 33
2.4.9 Menopause status 33
2.4.10 Cigarette smoking 34
2.4.11 Physical activity 35
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2.4.12 Depression 36
2.4.13 Anxiety 37
2.4.14 Socioeconomic status (SES) and heart disease 38
2.4.15 Family income 39
3 METHODOLOGY
3.1 Study design 40
3.2 Study location 40
3.3 Sample size 42
3.4 Subjects 43
3.5 Anthropometric measurements 45
3.6 Determination of biomarkers 49
3.6.1 Lipid profile 49
3.6.2 Fasting blood sugar 51
3.7 Blood pressure 51
3.8 Questionnaires 51
3.8.1 Food frequency questionnaire 52
3.8.2 Depression questionnaire 55
3.8.3 Anxiety questionnaire 55
3.8.4 Physical activity questionnaire 56
3.8.5 Socio-demographic questionnaire 58
3.9 Data analysis 59
4 RESULTS
4.1 Socio-demographics characteristics 61
4.1.1 Gender and age 61
4.1.2 Residence 61
4.1.3 Marital status 63
4.1.4 Education status 63
4.1.5 Occupation 64
4.1.6 Household income 64
4.1.7 Household size 65
4.2 Family history of coronary artery disease 65
4.3 Nutrient intake
4.3.1 Fats intake of study subjects 66
4.3.2 Dietary fiber intake of study subjects 67
4.3.3 Water-soluble vitamins intake of study subjects 68
4.3.4 Fat-soluble vitamins intake of study subjects 69
4.3.5 Minerals intake of study subjects 69
4.4 Lifestyle factors
4.4.1 Tobacco smoking pattern of study subjects 71
4.4.3 Physical activity pattern of the subjects 73
4.5 Psychological factors
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4.5.1 Depression symptoms of study subjects 74
4.5.2 Anxiety symptoms of study subjects 74
4.6 Anthropometric measurements of study subjects 75
4.7 Blood pressure of study subjects 77
4.8 Plasma biomarkers of study subjects 78
4.9 Correlate of AMI with the risk factors 80
4.10 Risk factors for AMI using binary logistic regression 84
4.11 Results of testing of null hypotheses 87
5 DISCUSSION
5.1 Socio-demographic characteristics 90
5.1.1 Occupation 90
5.1.2 Education level 90
5.1.3 Marital status 91
5.1.4 Household size and household income 91
5.1.5 Family history of coronary heart disease 92
5.2 Nutrient intake
5.2.1 Total fats 93
5.2.2 Saturated fatty acids (SFA) 94
5.2.3 Monounsaturated fatty acids (MUFA) 95
5.2.4 Polyunsaturated fatty acids (PUFA) 95
5.2.5 Cholesterol 96
5.2.6 Dietary fiber 96
5.2.7 Vitamins 97
5.2.8 Minerals 98
5.3 Plasma biomarkers
5.3.1 Triglyceride 101
5.3.2 High density lipoprotein 102
5.3.3 Low density lipoprotein 102
5.3.4 Total cholesterol 103
5.3.5 Fasting blood sugar 103
5.4 Anthropometry 104
5.5 Blood pressure 105
5.6 Lifestyle factors 106
5.6.1 Tobacco smoking 106
5.6.2 Physical activity 107
5.7 Psychosocial factors
5.7.1 Depression 108
5.7.2 Anxiety 111
6 CONCLUSION AND RECOMMENDATION
6.1 Conclusion 113
6.2 Recommendation 114
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6.3 Limitation of the study 116
REFERENCES 117
APPENDIXES 152
BIODATA OF STUDENT 190
LIST OF PUBLICATIONS 190