Phase 2: 5 - 75 years old

MINISTRY OF HEALTHB R U N E I D A R U S S A L A M

THE R

EPOR

T : 2nd NH

AN

SS

( Phase 2 : 5 - 75 years old)

Ministry of HealthBrunei Darussalam

1

THE REPORTThe 2nd National Health

andNutritional Status Survey

(NHANSS)

2014

2

Copyright ©

Ministry of Health, Brunei Darussalam

October 2015

All rights reserved.

No part of this publication may be reproduced in any form or by any means,

electronic, mechanical, photocopy and/or otherwise without prior written permission

of the publisher.

ISBN: 978-99917-50-11-8

Published By

Ministry of Health, Brunei Darussalam

2015

3

Foreword from the Minister of Health, Brunei Darussalam

Preface from the Deputy Permanent Secretary

Acknowledgements

Project Team

List of Tables

List of Figures

Glossary

Abbreviations

Executive Summary

1.0 Background

2.0 Objectives

3.0 Method

3.1 Overview of Survey Method

3.2 Sampling Procedure and Selection

3.2.1 Selection of Sample of Segments from Frame

3.2.2 Selection of Housing Units in Selected Segments

3.2.3 Distribution of Segments Selected into 12 Replicates (or Survey Months)

3.2.4 Household Members Selection

3.2.5 Sub-Sampling Methodology for Phase 2 of 2nd NHANSS

3.2.6 Exclusion Criteria

3.3 Questionnaire Development

3.4 Database Development

3.5 Pilot Testing

3.6 Training

4.0 Promotion and Public Awareness

5.0 Data Collection

5.1 Blood Pressure

5.2 Anthropometry

5.3 Physical Activity

5.4 Dietary Assessment

5.4.1 24-Hour Dietary Recall

5.4.2 Food Frequency Questionnaire

6.0 Data Management

6.1 Data Entry and Cleaning for Database 1

6.2 Dietary Data Entry and Cleaning for Database 2

7.0 Data Analysis

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8.0 Results

8.1 Demographic Characteristics

8.1.1 Survey Population by Gender and District

8.1.2 Survey Population by Age-Groups

8.1.3 Survey Population by Residential Status

8.1.4 Survey Population by Ethnicity and Religion

8.1.5 Survey Population by Marital Status

8.2 Socioeconomic Status (Respondents Aged 18-75 Years)

8.2.1 Housing Status

8.2.2 Electricity and Piped Water Supply

8.2.3 Employment Status

8.2.4 Education Level

8.2.5 Income Level

8.2.6 Food Security

8.3 Smoking Status

8.3.1 Percentage Smoking Habits Among Respondents (19-75 Years Old)

8.3.2 Period When Smoking Commenced and Ceased

8.4 Physical Activity

8.4.1 Physical Activity at Work

8.4.2 Travel to and from Places

8.4.3 Recreational Physical Activity

8.4.4 Resting and Televison Viewing

8.5 Health Status and Illness Amongst Respondents Aged 19 Years and Above

8.5.1 History of Hypertension

8.5.2 History of Diabetes

8.5.3 History of Dyslipidaemia

8.6 Anthrophometric Measurements

8.6.1 Stunting Among the 5-19 Years Old

8.6.2 BMI-for-age Amongst the 5-19 Years Old

8.6.3 Anthropometric Measurements Amongst ≥19 Years Old

8.6.3.1 Mean Weight

8.6.3.2 Mean Height

8.6.3.3 Mean Waist Circumference

8.6.3.4 Mean Body Mass Index (BMI-kg/m2)

8.6.3.5 Body Mass Index (BMI) Categories

8.6.3.5.1 Underweight

8.6.3.5.2 Overweight

8.6.3.5.3 Obesity

8.7 Body Image

8.8 Food and Nutrient Intake

8.8.1 24-hour Dietary Recall

8.8.1.1 Energy Intake

8.8.1.2 Carbohydrate Intake

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8.8.1.3 Protein Intake

8.8.1.4 Fat Intake

8.8.1.5 Percentage Energy Contribution of Macronutrients to the Total Energy Intake

8.8.1.6 Fibre Intake

8.8.1.7 Vitamin A Intake

8.8.1.8 Calcium Intake

8.8.1.9 Iron Intake

8.8.1.10 Zinc Intake

8.8.2 Short Food Frequency Questionnaire

8.8.2.1 Fruit Intake

8.8.2.2 Vegetable Intake

8.8.2.3 Percentage of Respondents Eating 5 Servings of Fruit and/or Vegetables

8.8.2.4 Meals Not Prepared at Home

8.8.2.5 Breakfast

8.8.2.6 Types of Milk

8.8.2.7 Sugar-Sweetened Beverages/Soft Drinks

8.8.2.8 Instant Drinks

8.8.2.9 Types of Cooking Oil

8.8.2.10 Coconut Milk

8.8.2.11 Malay “Kuih”

8.8.2.12 Fast Food

8.8.2.13 “Nasi Katok”

8.8.2.14 Chicken Tail, Wing and Skin

8.8.2.15 Instant Noodles

8.8.2.16 Crisps (“Keropok”)

8.9 Use of Food Supplements

9.0 Blood Pressure and Biochemical Analyses for Age 20-75 Years Sub-groups

9.1 Blood Pressure

9.2 Diabetes

9.3 Lipids

9.4 Creatinine

9.5 Haemoglobin

10.0 Conclusion

11.0 References

12.0 Appendices

Appendix A

Appendix B

Appendix C

Appendix D

Appendix E

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6

Foreword from the Minister of HealthBrunei Darussalam

Alhamdulillah, with the blessings of Allah Subhanahu Wata’ala, it is my great pleasure to share the findings of The 2nd National Health and Nutritional Status Survey (NHANSS) 2010-2011 (Phase 2) for Brunei Darussalam. This Report provides an important insight into the health behaviours, nutritional and health status for people aged 5 to 75 years old.

The survey provides us with an extremely valuable data resource on smoking behaviour, physical activity, body mass index, dietary intake and food consumption patterns. It has a special focus on the prevalence of non-communicable diseases (NCDs) including diabetes mellitus, hypertension and hyperlipidaemia which are associated risk factors for cardiovascular diseases, the leading cause of morbidity and mortality in Brunei Darussalam.

The report from this survey will provide an updated and comprehensive information on the health and nutritional status of Brunei Darussalam.

With each additional survey conducted, the ability to analyse trends will add considerably to the usefulness of this data source. The information gathered will aid the Ministry of Health and other stakeholders to assess the effectiveness and relevance of existing programs, strategies and interventions to control and reverse the trend in NCDs. This will prove to be vital in aiding better understanding of health issues and helping policy and decision makers to formulate and review policies to improve services.

I wish to congratulate the survey team in successfully carrying out the The 2nd National Health and Nutritional Status Survey (NHANSS) 2010-2011 (Phase 2) for Brunei Darussalam and writing this comprehensive report.

My appreciation goes to the Department of Economic Planning and Development of the Prime Minister’s Office for their support including funding to conduct the survey. I would like to acknowledge the expert guidance and valuable contributions received from Consultants at The Boden Institute of Obesity Nutrition, Exercise & Eating Disorders, University of Sydney, Australia throughout the survey and for their assistance in analysing the data.

Finally, I would also like to thank the people who have spared their valuable time and contribution in participating in this survey which provides a better understanding of the status of our nation’s health.

Alhamdulillahi Rabbil ‘Alamin. Wassalatuwassalamu ‘Ala Ashrafilmursalin.

Sayyidina Muhammadin Wa ‘ala alihi wasahbihi ajmain

Pehin Orang Kaya Johan Pahlawan Dato Seri Setia Awang Haji AdananBin Begawan Pehin Siraja Khatib Dato Seri Setia Haji Awang Mohd Yusof

Minister of HealthBrunei Darussalam

6

7

Preface from the Deputy Permanent Secretary

For more than three decades Noncommunicable Diseases (NCDs) has marked its presence as the top cause of deaths in Brunei Darussalam. Current trends indicate NCDs will continue to dominate our health landscape with significant potential impacting amongst others on socio-economic development, increasing burden on health care services, escalation of health care cost and challenges to our quality of life. Therefore it is imperative that that the ongoing NCDs trends is monitored closely and objectively over set time intervals to maintain checks on key related indicators pertinent in the control and prevention of the diseases covering the spectrum from risk factors to intervention programmes and outcomes.

The publication of this Report following the completion of the Second National Health and Nutrition Status Survey – Phase 2 is much awaited, as specifically it covered a nationally representative sample of people aged 5 to 75 years capturing information on dietary habits, nutritional status and associated risk factors for NCDs. This Report is thus of high value in the surveillance of NCDs in the country particularly in identifying areas for priority action, in evaluating policy and programme interventions and tracking progress for non-communicable diseases (NCDs), as set out in the Brunei Darussalam National Multisectoral Action Plan for the Prevention and Control of NCDs 2013-2018.

Additionally, the information collected from this survey will also contribute significantly to the existing body of population data gathered from other surveys to date, hence enabling cross comparisons over time and for different target groups. Furthermore, beyond this Report, the rich field of data gathered will also offer invaluable opportunities for in-depth research and analysis allowing us to delve further, sharpen our understanding of the dynamics of NCDs in Brunei Darussalam and refine our management approaches.

In concluding, my sincerest appreciation and congratulation to the team and all involved for successfully completing the through task from planning to roll-out of the survey followed by the meticulous handling of raw data to analysis and finally the publication of this much welcomed Report. My gratitude and heartfelt thank you too goes to all respondents in the Survey for without your willingness and openness the Survey would not have been successful.

Alhamdulillahi Rabbil ‘Alamin. Wassalatuwassalamu ‘Ala Ashrafilmursalin.

Sayyidina Muhammadin Wa ‘ala alihi wasahbihi ajmain

Dr Hjh Rahmah Bte Hj Md SaidDeputy Permanent Secretary (Professional & Technical)

As Chair of National NCD Prevention and Control Strategic Planning CommitteeMinistry of HealthBrunei Darussalam

7

8

Acknowledgements

Alhamdulillahi Rabbil ‘Alamin.

Wassalatuwassalamu ‘Ala Ashrafilmursalin.

Sayyidina Muhammadin Wa ‘ala alihi wasahbihi ajmain

Alhamdulillah, this Phase 2 of the Second National Health and Nutritional Status Survey (2nd NHANSS), Brunei

Darussalam, 2010-2011 was carried out by the Ministry of Health in collaboration with the Department of

Economic Planning and Development of the Prime Minister’s Office under the 9th National Development

Plan and the Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders (BIONE) at the University of

Sydney, Australia.

The dedication and perseverance of project staff from the Community Nutrition Division and Community

Nursing Division, Department of Health Services; Medical and Health Statistics Unit of Department of Policy

and Planning, consultants from the Endocrine Unit of the Department of Internal Medicine, Raja Isteri Pengiran

Anak Saleha (RIPAS) Hospital under the Department of Medical Services, the research assistants and the

secretariat have made this survey a successful endeavour. The continuous support from Permanent Secretary

and Deputy Permanent Secretaries, Ministry of Health throughout the survey period was also highly valued.

The survey, conducted as a national project would also not have materialised without the contributions from the

following sectors of the Ministry of Health: Directorate and Administration of Department of Health Services;

Directorate of Department of Environmental Health Services, Disease Control Division; Division of Estate

Management and Development; Department of Health Care and Technology; Department of Administration

and Finance; Department of Policy and Planning, Public Relation Division; the Health Promotion Centre;

Diabetes Nurse Educators from Diabetes Centre, RIPAS Hospital; members of staff of Health Centres and

District Health Offices throughout the country and the Dietetic Unit, Department of Medical Services.

The current collaboration between BIONE and Ministry of Health, Brunei Darussalam on NHANSS 2010-

2011 was headed by Professor Ian Caterson, Professor Adrian Bauman, Associate Professor Tim Gill, Dr Anna

Rangan, Dr Sinead Boylan and Dr Jimmy Louie Chun Yu. Associate Professor Tim Gill headed the team on

technical aspects of the survey, diligently guiding us through the analysis and reporting of this survey. We

would also like to extend our appreciation to Professor Stephen Colagiuri and his team on the technical input

for the Diabetes Prevalence Sub-Study and Biochemistry Analysis.

To our family, friends and colleagues, we appreciate your tolerance and understanding throughout the

challenging times. Our heartfelt thanks goes to our respondents of the survey, as this would not be achievable

without their participation.

8

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Tables Title Page

Table 1 Distribution of Samples by Districts 29

Table 2 Arm Circumference and Cuff Size 33

Table 3 Respondents by Gender and Districts 37

Table 4 Proportions of Respondents in Each Category 37

Table 5 Age When Smoking Commenced and Ceased (≥19 years) 48

Table 6 Percentage Respondents Not Meeting Brunei Recommendations on Moderate Physical Activity for Health (

11

Figures Title Page

Figure 1 Flowchart of Data Collection Process 32

Figure 2 Residential Status 38

Figure 3 Ethnicity 38

Figure 4 Religion 39

Figure 5 Marital Status 39

Figure 6 Housing Status 18-75 Years Old 41

Figure 7 Percentage Respondents 18-75 Years Old by Employment Status 42

Figure 8 Percentage Respondents

12

Figure 24 Proportion of Total Fat Intake Obtained from Food Sources 71

Figure 25 Proportion of Total Saturated Fat Intake Obtained from Food Sources 72

Figure 26 Percentage Energy Contribution of Macronutrients to Total Energy Intake Amongst 18 Years and Below 72

Figure 27 Percentage Energy Contribution of Macronutrients to Total Energy Intake Amongst Adults 73

Figure 28 Percentage Contribution of Fibre Intake from Food Sources 74

Figure 29 Percentage Contribution of Vitamin A Intake from Food Sources 75

Figure 30 Percentage Contribution of Calcium Intake from Food Sources 76

Figure 31 Percentage Contribution of Iron Intake from Food Sources 77

Figure 32 Percentage Contribution of Zinc Intake from Food Sources 78

Figure 33 Fruit Intake 79

Figure 34 Vegetable Intake 80

Figure 35 Percentage of Respondents Eating 5 Servings of Fruit and/ or Vegetables Daily 80

Figure 36 Percentage of Respondents Having Meals Not Prepared at Home 81

Figure 37 Percentage of Respondents Having Breakfast Daily 81

Figure 38 Percentage Milk Consumption Amongst Respondents by Age-Groups 82

Figure 39 Percentage Daily Consumption of Sugar-Sweetened Beverages 83

Figure 40 Percentage Daily Consumption of Instant Drinks 83

Figure 41 Percentage of Cooking Oil Most Used by Respondents 84

Figure 42 Percentage of Weekly Usage/Consumption of Coconut Milk 84

Figure 43 Percentage of Respondents Consuming Malay ‘Kuih’ 85

Figure 44 Percentage of Respondents Consuming Fast Food 85

Figure 45 Percentage of Respondents Consuming ‘Nasi Katok’ 86

Figures Title Page

List of Figures

12

13

List of FiguresList of FiguresFigures Title Page

Figure 46 Percentage of Respondents Eating Chicken Tails, Wings or Skin 86

Figure 47 Percentage of Respondents Consuming Instant Noodles 87

Figure 48 Percentage of Respondents Eating Crisps (‘Keropok’) 87

Figure 49 Percentage of Respondents for Hypertension by Age Groups 89

Figure 50 Percentage of Respondents for Hypertension According to Gender 90

Figure 51 Percentage of Respondents with Hypertension According to Ethnicity 90

Figure 52 Percentage of Respondents According to Glucose Tolerance Status by Age Groups 91

Figure 53 Percentage of Respondents with Diabetes by Age Groups 91

Figure 54 Percentage of Respondents According to Glucose Tolerance Status by Gender 92

Figure 55 Percentage of Respondents According to Glucose Tolerance Status Amongst The Ethnic Groups 92

Figure 56 Percentage of Respondents within Age Group for Abnormal Lipid Levels 93

Figure 57 Percentage of Respondents for Abnormal Lipid Levels by Gender 93

Figure 58 Percentage of Respondents for Abnormal Lipid Levels by Ethnicity 94

Figure 59 Percentage of Respondents with Abnormal Creatinine Values by Age Groups 94

Figure 60 Percentage of Respondents with Abnormal Creatinine Values According to Gender 95

Figure 61 Percentage of Respondents with Abnormal Creatinine Values According to Ethnicity 95

Figure 62 Percentage of Respondents within Subgroup for Anaemic Status by Age Groups 96

Figure 63 Percentage of Respondents for Anaemia Status - Overall Figures 96

Figure 64 Percentage of Respondents for Anaemia According to Gender 97

Figure 65 Percentage of Respondents within Subgroup for Anaemia Status According to Ethnicity 97

13

1414

Glossary‘Nasi Katok’ Ready to eat, packaged white rice with a piece of fried chicken (normally battered) accompanied with spicy gravy

24-hour dietary recall

A type of dietary assessment method that collects information on all foods and beverages consumed in a period of 24-hour

Anthropometric Measurement

Measurement of height and weight, and waist circumference

Blood Cholesterol

Cholesterol is a waxy, fat like substance that are found in most body tissues including blood. It comes from 2 major sources, foods of animal origin or synthesised by liver. Elevated cholesterol level is associated with an increased risk for heart and blood vessel disease

Body Mass Index (BMI)

A simple index of weight-for-height that is commonly used to classify under-weight, overweight and obesity in adults. BMI is calculated by dividing weight in kilogram by height in metres squared (kg/m2)

Cerebrovascular Disease

Cerebrovascular disease refers to a group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain

Cluster or ‘Mukim’ Subdivision of a district. Equivalent English word is sub-district

Coconut MilkA milky liquid extracted from the grated flesh of a coconut, used in foods or as a beverage. It is usually white in colour and has a rich taste of milk that can be attributed to the high oil content. Most of the fat is saturated fat

Crisps or ‘Keropok’

Crunchy wafer-thin slices or finger-like products made from potato, or banana or ingredients containing a mixture of wheat, corn or rice flour. Flavourings added may include prawns, fish, mussels, squid, onions, chillies, cheese, curry powder, salt, pepper and monosodium glutamate. They are usually eaten as a snack

Cross-sectional survey

A type of survey that collects data to make inferences about a population of interest at one point in time. It is also described as snapshots of the populations about which they gather data

Current practicesSubjects are asked about recent feeding practices, usually in the previous 24 hours. This is distinct from recalled practices that occurred sometime in the past: for example, weeks or months or years ago

DiabetesA disorder of carbohydrate metabolism characterised by chronic elevated blood glucose levels due to inadequate production of insulin and/ or reduced effectiveness of insulin action

Fast Food Food designed or made or prepared for ready and quick availability for consumption

1515

Fatty AcidsFatty Acids come from animal and vegetable fats and oils. They are either saturated or unsaturated. The three main types of fatty acids in the diet are: saturated, monounsaturated and polyunsaturated

Food SecurityAccess to adequate, safe, affordable and acceptable food. In contrast, food insecurity occurs when the availability of nutritionally adequate and safe foods, or the availability to acquire such foods, is limited or uncertain

FoodWorks® professional

A nutrition analysis software program that use the AUSNUT (Food Standards Australia New Zealand’s Nutrient Database) database and it is used for nutritional analysis of the 24-hour dietary recalls

Fruit Juice The liquid extracted from fruit either as pure 100% juice or with water added, with or without added sugar

Gestational Diabetes Mellitus

Diabetes of first onset or detection during pregnancy

Glycated Haemoglobin (HbA1c)

A measurement of the average plasma glucose over the previous eight to twelve weeks. It is expressed as a percentage

Hari Raya Aidilfitri

Festive month on the tenth month of the lunar Islamic calendar which marks the end of the fasting month of Ramadhan

Health StatusDefined as information collected on a range of health indicators including overweight and obesity, self-reported history of hypertension, diabetes, dyslipidaemia and other medical conditions

Hypertension Medical term for high blood pressure. A blood pressure level of ≥140/90 mmHg is termed hypertension

Instant Drinks Drinks designed for quick preparation and are readily soluble in hot or cold water

Instant Noodles Dried precooked (often in oil) noodle block sold with flavouring powder and / or seasoning oil, usually in a separate packet

Insulin A hormone produced in the pancreas by the islets of Langerhans, which regulates the amount of glucose in the blood

LipoproteinA particle that transports cholesterol and triglycerides, two compounds essential to cell structure and metabolism. Lipoproteins are comprised of proteins (apolipoproteins), phospholipids, triglycerides and cholesterol

Malay ‘Kuih’Bite-sized snacks or dessert foods (cake, pudding, biscuits or pastries); are usually sweet but some are savoury. They are traditionally made of flour, sugar and oil or fats

Monounsaturated Fatty Acid (MUFA)

Monounsaturated fatty acids are found in nuts, vegetable oils (such as canola and olive oil) and avocadoes

1616

Non-communicable Disease (NCD)

Also known as chronic diseases and not passed from one person to person. NCDs are of long duration and generally slow progression. The four main types of NCDs are cardiovascular disease (such as heart attacks and stroke), cancers, chronic respiratory disease (such as chronic obstructed pulmonary disease and asthma) and diabetes

Nutrient

Macronutrient- Nutrients that are needed in larger quantities (e.g. protein, carbohydrate and fat)

Micronutrient- Nutrients that are needed in smaller quantities (e.g. vitamins and minerals)

Nutritional Status The general health status of the body as a result of the intake, absorption and use of nutrition and the influence of disease-related factors

Obesity Abnormal or excessive fat accumulation that presents a risk to health with a body mass index (BMI) greater than or equal to 30

Overweight Abnormal or excessive fat accumulation that presents a risk to health with a body mass index (BMI) greater than or equal to 25

Physical Activity Any bodily movement produced by skeletal muscles that requires energy expenditure

Polyunsaturated Fatty Acids (PUFA)

Differ from saturated fatty acids in its chemical structure and has been shown to have cholesterol-lowering effect. Food sources include plant-based food such as corn, soybean, sesame and sunflower oils. Other sources in-clude oily fish

RamadhanThe ninth month of the Muslim year, in which fasting is obligatory for all Muslim. Muslims all over the world abstain from eating, drinking, smoking as well as participating in anything that is ill-natured or excessive; from dawn to sunset

Recommended Nutrient Intake* (RNI)

The RNIs are essential standards against which nutrients in food eaten can be assessed for its adequacy in any given population. The RNI provides dietary recommendation for energy, protein, carbohydrates (including dietary fibre), vitamins (thiamin, riboflavin, niacin, folate, vitamin C, vitamin A, vitamin D and vitamin E) and minerals (calcium, iron, iodine, zinc and selenium)*For this survey, the RNI used is based on Malaysian RNI

Regular consumption

Food or drink consumed on a daily basis at least 1-2 servings per day

Retinol Equivalent (RE)

The recommendation for vitamin A intake is expressed as micrograms of retinol equivalents. One microgram (1 μg) of retinol equivalent equals 1 μg of retinol, or 6 μg of ß-carotene

Saturated Fatty Acid

Saturated fatty acids is a type of fat in food which mainly come animal-based foods such as high-fat cut of meat, butter, whole milk, whole milk products and cheese, and from coconut, palm and palm kernel oils. Most saturated fatty acids are solid at room temperature. Saturated fatty acids are the most cholesterol-raising components of our diet

1717

Salty SnacksThese are usually ready to eat crispy dry food made of flour, salt, monosodium glutamate, preservatives, colouring and are usually fried and may contain aritificial flavourings

Serving of Fruit One medium piece of fruit; two pieces of small fruit ; one-third cup cut fruit or one tablespoon dried fruit

Serving of Vegetable

½ cup cooked leafy and fruit vegetable or a cup of raw vegetable, salad vegetable, fresh, dried, frozen or canned vegetable (does not include vegetable juices)

Sweetened Beverages

Drinks with added sugar

Underweight

Moderate underweight in children is defined as two standard deviations below the median weight for age of the reference population. Severe underweight in children is defined as three standard deviations below the median weight for age of the reference population. In adults, a body mass index of below 18.5 is categorised as underweight

18

2ND NHANSS

AUSNUT

BIONE

BMI

CDC

CND

FFQ

GPAQ

OGTT

HbA1c

HDL

HES

HND

HUs

IMR

kcal

LDL

MOH

MUFA

NCD

PhD

PPS

PUFA

RE

RNI

SD

SPSS

U5MR

WHO

WHO STEPS

AbbreviationsThe Second National Health and Nutritional Status Survey

Food Standards Australia New Zealand’s Nutrient Database

Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders

Body Mass Index

Centre for Disease Control and Prevention

Community Nutrition Division

Food Frequency Questionnaire

Global Physical Activity Questionnaire

Oral Glucose Tolerance Test

Glycated Haemoglobin

High-density Lipoprotein Cholesterol

Household Expenditure Survey

Higher National Diploma

Housing Units

Infant Mortality Rate

Kilocalorie

Low-density Lipoprotein Cholesterol

Ministry of Health

Monounsaturated Fatty Acid

Noncommunicable Disease

Doctor of Philosophy

Probability Proportional to Size

Polyunsaturated Fatty Acids

Retinol Equivalent

Recommended Nutrient Intake

Standard Deviation

Statistical Package for Social Sciences

Under-Five Mortality Rate

World Health Organization

World Health Organization (WHO) STEPwise Approach to Surveillance

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19

ExecutiveSummary

This report presents the results from Phase 2 of the 2nd National Health and Nutritional Status Survey, Brunei Darussalam, carried out by the Ministry of Health in collaboration with Department of Economic Planning and Development, Prime Minister’s Office and Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders (BIONE), University of Sydney, Australia.

Data collection was carried out on the population aged 5 to 75 years old throughout the four districts from June 2010 till March 2011.

The health and nutritional indicators were obtained by interview using pre-tested and validated questionnaire looking into the following components :

• Demographics

• Socio-Economic Status

• Smoking Status

• Physical Activity

• History of Increased Blood Pressure

• History of Diabetes Mellitus and Dyslipidaemia

• History of Health Status

• Body Image

• Dietary Assessment through questions on Food Supplements

• Food Frequency Questionnaire

• 24-Hour Diet Recalls

• Blood Pressure measurement

• Anthropometric measurements

• Biochemical analysis

From the calculated target of 4000 participants, 2184 responded to the survey (54.6% response rate) with 67.7% from Brunei Muara, 17% from Belait, 12% Tutong and 3.3% Temburong districts. The respondents comprised of 53% females, 92.8% Brunei Darussalam Citizens and 88% of the Muslim faith. The majority of the respondents (87.2%) were of the Malay group.

Socio-Economic Status

• In this survey, 42.3% of the respondents lived in their parents’ houses and 35.6% lived in their own houses

• Amongst the 18 to 75 years old, 38.3% were government employees, 21.1% worked with the private sector while 15.7% were unemployed

• It was observed that 55.3% reached secondary level education and 10.4% achieved tertiary / higher level education as the highest level of education

• In relation to individual food security, 92.6% of respondents aged 18 to 75 years old did not report encountering food shortage and experienced financial difficulty to purchase food in the past twelve months

19

2020

Smoking Prevalence• Amongst the 19-75 age group, 35.5% of males were current smokers compared to 4% in the female population• The median age at which smoking started was 18 years for both genders• The median number of cigarette sticks smoked per day was ten for males and four for females

Physical Activity

• Only 64.5% of the respondents met the recommended National Physical Activity Guidelines of more than 150 minutes per week of physical activity of moderate intensity for health

• The median time spent on total physical activity for all respondents was 45 minutes per day

• Time spent on sport-related physical activity was at a mean of 45.9 minutes per day

• The respondents spent a mean of 258.3 minutes per day resting or being inactive and a mean of 110.4 minutes per day watching television. The total sedentary time spent on resting or being inactive and watching television was a mean of 368.4 minutes per day

Hypertension

• Within the last 12 months, 64.0% respondents reported to have had their blood pressure measured and 19.0% self-reported to be hypertensive

• Amongst the 20-75 years old age group, 33.8% were found to be hypertensive

Diabetes Mellitus

• 17.2% respondents self-reported to have diabetes of which 14.8% were on insulin injections and 78.3% were on oral hypoglycaemic medication(s)

• 5.0% of the female respondents recalled having diabetes during pregnancy

• Amongst the 20-75 years old age group, the prevalence of diabetes was 12.4%

Dyslipidaemia

• 37.1% of the respondents self-reported to have dyslipidaemia of which 76.7% were on medication(s)

• Amongst the 20-75 years old age group, the prevalence of dyslipidaemia was 73.8%

Creatinine

• Abnormal creatinine levels were seen in 2.4% of the 20-75 years old age group

Anaemia

• 85.7% were non-anaemic in the 20-75 years old age group

• Amongst those with anaemia, the female had a higher incidence at 22.5% compared with 4.6% seen in male respondents

21

Anthropometrics

• In the 5-19 years age group, 15.6% were moderately stunted and 2.3% were severely stunted

• Amongst the 5-19 years age group, using BMI-for-age, 33.5% were overweight and 18.2% were obese

• 41.6% were overweight and 23.6% were obese in the 10-14 years age group

• Amongst adults 19 years old and above, 5.1% were underweight, 33.4% were overweight and 27.1% were obese. Overall, 60.5% of this age group had BMI of more than 25kg/m2

Dietary Intake – 24-hour Dietary Recall

• The median daily energy intake ranged from 1381 to 1714 kcal in males and 957.5 to 1400 kcal in females.Across all the age groups for both genders, the energy intake was lower than the RNI

• In all age-groups, 50-55% of energy intake was derived from carbohydrates

• The median daily protein intake was 67.3 grams in males and 53.6 grams in females. Overall, 70.7% of males and 54% of females met the RNI for protein intake

• 53.3% of males and 54.6% of females derived more than 30% of their total energy from fat

• Although saturated fat contribution towards energy ranged only from 9.5-10.8% in males and 10.4-11.4% in female, 55.4% males and 58.5% females consumed higher than the recommended 10% energy from saturated fat

• The daily dietary fibre intake was low in both genders with 33.5% males and 21.3% females meeting 70% of the RNI

• The average daily Vitamin A intake was low at 362.8 RE/μg per day for males and 321.8 RE/μg for females. A total of 38.2% males and 38.3% females achieved 70% of the RNI

• Median daily calcium intake was 391.1 mg in males and 337.9 mg in females. Only 22.9% of males and 15.8% of females met 70% of the RNI

• The median daily iron consumption was 8.2 mg in males and 7.0 mg in females. Only 18.3% of females met 70% of the iron RNI as compared to 78.2% of males

• The daily zinc intake was better compared to the other micronutrients with a median daily intake of 6.5 mg in males and 5.1 g in females, with majority meeting 70% of the RNI

Dietary Intake – Food Frequency

• Low fruits and vegetables intake was reported amongst the respondents with only 8.2% who consumed the daily national recommendation of servings of fruits and/or vegetables

• Breakfast was not consumed daily by the respondents with the lowest percentage at 41.3% in males and 43% in females amongst the 15-18 years age group

• The most commonly consumed milk was sweetened condensed milk at 33.1% overall

• Palm-based oil was the most commonly used cooking oil in the household, with 77.1% of respondents reported using it most often for meal preparation. Only 17.3% used polyunsaturated oil for their cooking purposes and 3.1% used monounsaturated cooking oil

21

22

Survey team member delivering MOH formal letter to selected household

A prospective participant was informed verbally

of the survey and their random selection

22

23

Brunei Darussalam has achieved most of the health related targets set in the Millennium Development

Goals (MDGs). These include significant reductions in the under-five mortality rate (U5MR) and infant

mortality rate (IMR) where IMR has declined from 42.3 per 1000 live births in 1966 to 8.3 per 1000 live births

in 2011. The immunisation rate in this country is also high at 91% while 99.7% of births were attended by

skilled health personnel 1.

However the country is facing a rise in non-communicable diseases (NCDs) such as cancer, heart disease,

diabetes mellitus and cerebrovascular disease, which accounts for half of the total number of deaths.

Previous reports have also shown similar trends with cancer or heart disease being the leading cause of

mortality in the country 1. This is largely driven by a change in dietary and lifestyle patterns which has led

to a rise in obesity, a known risk factor for NCD. This was reflected in the 1st National Nutritional Status

Survey (NNSS) done in 1997 which showed that 32% of the population was overweight and 12% being

obese amongst adults 20 years old and above 2. The 1st NNSS also showed that 31.1% of the males were

in the ‘current smokers’ group where the highest rate was recorded among the younger males aged 20 to

29 years old (44%) 2.

The Phase 2 of the Second National Health and Nutritional Status Survey (2nd NHANSS) is a continuum

of the Phase 1 NHANSS 3. It was conducted to provide an updated and comprehensive information on

the health and nutritional status of the country. The information gathered will aid the Ministry of Health

and other stakeholders to assess the effectiveness and relevance of existing programs, strategies and

interventions to halt the rise in NCD. It will also provide a snapshot on the adequacy of the current dietary

intake of older children, adolescents, adults and elderly in the country.

Background

1

23

24

The survey was conducted to assess the health and nutritional status and the dietary habits of the

population aged 5-75 years old. The main objectives of this survey were:

1. To assess and update anthropometric data of the population and to examine their relationship

to social, dietary and health data.

2. To provide a more recent quantitative information on dietary habits, nutrient intakes and

food consumption patterns.

3. To examine the characteristics of “at risk individuals” in terms of their nutrient intake

adequacy and in relation to the recommended intake.

4. To provide baseline and/or update national data on other health status indicators such as

smoking, physical activity, NCD and biochemical measurements.

5. To assess the changes in trends in health, nutritional and dietary intake status since 1997

and, to compare it with the regional and international community.

6. To provide vital information to internal users such as physicians, dietitians, nutritionists and

health promoters and, to external users such as the food producers and regulators.

7. To evaluate and revise past and current programs, in particular those in line with NCD

prevention and control.

Objectives

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2

25

Registration of participants

Participants being interviewed by research assistants

Trained research assistant collecting blood samples

from a participant

25

26

This 2nd NHANSS Phase 2 is expected to provide information on nutrition-related of indicators of children and adults in Brunei Darussalam.

3.1 Overview of Survey Method

Phase 2 of the 2nd NHANSS was implemented from June 2010. Data collection was temporarily halted in August 2010 during the fasting month of Ramadhan and the “Hari Raya Aidilfitri” festivities as this will not be reflective of the usual daily dietary patterns. The process of data collection was resumed in October 2010 until March 2011. This survey was carried out in parallel with the Brunei Darussalam Household Expenditure Survey (HES) 2010/2011 implemented by the Department of Economic Planning and Development, Prime Minister’s Office. The 2010/2011 National HES also provided the sampling frame for the 2nd NHANSS.

The survey was a cross-sectional survey aimed at the population aged from 5-75 years old with an initial target of 4000 participants from all the districts in Brunei Darussalam.

District Health Offices, Health Centres, District Hospitals and the Community Nutrition Centre were used as survey sites. Face-to-face interviews with parents and/or caregivers (for children) and participants themselves were conducted by trained dietitians/nutritionists and research assistants using a questionnaire booklet (Appendix A). The anthropometric indices measured were the weight, height, and waist circumference. Blood pressure was also measured for all respondents using standard methodology (Appendix B) while biochemical measurements were only collected on those aged 20 years and above. The survey procedures and questionnaire were pilot tested prior to training and finalised accordingly for standardised data collection.

The questionnaire booklet was divided into sixteen sections consisting of both open- and close-ended questions. Questions provided information on demographic and socio-economic status, smoking status, physical activity, self-reporting of medical conditions (hypertension, diabetes and dyslipidaemia), health status in the last 12 months, body image, and food supplements. Anthropometric measurements and biochemistry analysis were also conducted. A food frequency questionnaire as well as a 24-hour diet recall method were used to collect information on food and beverages consumption. A second day recall was collected on at least 10% of the sample population to obtain variation in dietary intake within and between respondents.

The completed questionnaires were thoroughly inspected by principal investigators and head of data entry after the interviews.

3.2 Sampling Procedure and Selection

A sample of healthy children and adults aged from 5-75 years old who are citizens or permanent residents of Brunei Darussalam residing in the country were selected for this phase of the survey. It was initially anticipated that at least 4000 children and adults aged 5-75 years old were needed.

The respondents were sub-sampled from the Brunei Darussalam Health Expenditure Survey (HES) 2010/2011. Selection of Housing Units in the Brunei Darussalam HES 2010/2011 was done in three different steps. This involved selection of segments from the segments listings mainframe of Brunei Darussalam, the selection of housing units within the selected segments and distribution of segments to 12 survey months.

Method

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3

27

The segments listings mainframe of Brunei Darussalam is specifically stratified to accommodate three of the four objectives of Household Expenditure Survey below:

1. To collect up-to-date and comprehensive information on the expenditure and income of the population.

2. To revise the lists and weightings of goods and services of the Consumer Price Index (CPI).3. To collect information relating to calculations of Rate of Basic Requirements Needs.4. To provide additional information for National Accounts Statistics and Social Statistics.

3.2.1 Selection of Sample of Segments from Frame

Circular Systematic Sampling was used in the selection of a sample of segments from the frame.

Let the total number of segments in the hth stratum in the frame be Ah and ah the number of segments to be selected. 1) Compute the sampling interval Ih1 as follows:

Ih1 = Ah1 or 1 ah1 fh1

This is computed to the nearest whole number with decimal 0.5 rounded down. 2) Select a random number from 1 to Ah. This becomes R. 3) Compute the sequence of sampling numbers

R, R + Ih1, R + 2 Ih1, etc

until exactly ah segments have been selected. Depending on the value of R, the selection may need to be continued from the end of the list to the beginning of the list until the required number of segments has been selected.

This procedure is used to select the number of required segments separately according to the Urban and Rural Stratum.

3.2.2 Selection of Housing Units in Selected Segments

Linear Systematic Sampling with a decimal interval is used in the selection of Housing Units (HUs) numbered from 1 to Bhi from the selected segment. Compute the sampling interval Ih2 to 3 decimal places as follows:

1 fh2

fh fh1

Σah bi ah ΣAh Bi Ah

Σah bi is the total number of HUs to be in the sample and

ΣAh Bi is the number of HUs in the stratum estimated for 2010. Select a four-figure random number from 1000 to 1000 x Ih2. This becomes R.

Ih2 =

Where fh2 =

And fh = and fh1 =

28

Compute the sequence of sampling numbers

R, R + Ih2, R + 2 Ih2, etc

Each whole number part of the sampling number selects the serially numbered HUs in the segment. This procedure is continued until the end of the list of HUs in the ith segment.

3.2.3 Distribution of Segments Selected into 12 Replicates (or Survey Months)

This next step is to distribute randomly the ‘a’ segments selected for the country into 12 replicates or sub-samples using the linear systematic selection. The ‘a’ segments, with those in the urban stratum followed by those in the rural stratum, are serially numbered in the order they were selected and the sampling interval is Ir = 12. A random number is selected from 1 to 12 and this becomes R. Compute the sequence of sampling numbers:

R, R + Ir, R + 2Ir, etc

This procedure is continued until the end of the list and the first replicate is selected. Another random number different from that selected for the first replicate is used to select the second replicate. This procedure is continued until 12 replicates are selected.

3.2.4 Household Members Selection

The Brunei Darussalam HES 2010/2011 by The Department of Economic Planning and Development, Prime Minister’s Office provided the Ministry of Health 2nd NHANSS team the list of people staying in each of the selected housing unit during the survey months. Each list consisted of:

1. Address and household particulars

2. Name of head of household

3. Total number of people household and gender

4. Contact telephone number

5. Household member names

6. Smart card or identity card number and colour of each household member

7. Date of birth of each household member

8. Gender of each household member

3.2.5 Sub-Sampling Methodology for Phase 2 of 2nd NHANSS

The sample size for Phase 2 of 2nd NHANSS was taken as 1% of total population in 2008 (398,000) 4 which was rounded up to 4000 samples. Another 30% or 1200 respondents were added to the sample size to accommodate for non-responders, making it a total of 5200 respondents. A total of 1300 respondents were deducted from the total sample size (5200 respondents), as these numbers represent the sample size for first phase of 2nd NHANSS (0-5 years old). The remaining number of samples was further rounded up to 4000 samples. The samples were then distributed according to the population size of each district using the formula shown below:

District Sample size: Number of Population in District X Total Sample

Total Number Brunei Population

29

The household`s age groups were divided into two groups namely: Group A (below 20 years of age) and Group B (above 20 years of age). From each household, one child (Group A) and one adult (Group B) of opposite gender were selected. If no subject is available for selection in the Group A category, only one adult would be selected. Thus from each household two potential respondents were randomly chosen, one in the 5-19 years old group and the other in the 20-75 years old age-group. Fasting blood samples were collected from the 20-75 years old for biochemical measurements.

Formal letters from the Ministry of Health including survey pamphlets were delivered to the selected household by the survey team members. Prospective participants were informed again verbally of the survey and their random selection. Appointments were scheduled or rescheduled accordingly for participants to attend at their respective Survey Centres. Telephone calls were made to help remind the participants of their appointments three days prior to data collection. Participants and the parents/caregivers of young participants were given flexibilities to choose their survey appointment dates.

3.2.6 Exclusion Criteria

The exclusion criteria for the survey were as follows:

1. Subjects who are sick, hospitalised, convalescent, physically disabled or mentally challenged. If this was to occur, he or she will be replaced with the next person in the household close to his/her age of the same gender.

2. The selected female subject was pregnant. She will then be replaced with her sister nearest to her age living in the same household.

3.3 Questionnaire Development

Discussions on the questionnaire design and contents were initiated in December 2009. The questionnaire development was guided by Boden Institute of Obesity, Nutrition and Exercise and Eating Disorders (BIONE) of The University of Sydney, Australia. The questionnaire was developed using standard components from the 1st National Nutritional Status Survey in 1997, the WHO STEPS Manual 5, the Brunei Darussalam HES 2010/2011 6 and health and nutrition survey questionnaires from the region and international community. Amendments were made in line with current policy requirements.

Further discussion was carried out during the team’s working visit to BIONE in March 2010. The sample size, demography, physical activity, anthropometric measurements, nutrient analysis, recipes and database development were also ascertained during this visit. Following a series of thorough pilot testing, the questionnaire booklet was further refined and divided into sixteen sections.

Table 1 - Distribution of Samples by Districts

Districts Population Samples Clusters / “Mukims”

Brunei Muara 276600 2778 16

Belait 66000 663 4

Tutong 46600 458 6

Temburong 10100 101 4

Total 398300 4000 30

At the start of nutritional survey, Brunei Darussalam HES 2010/2011 by The Department of Economic Planning and Development, Prime Minister’s Office had already been initiated earlier on. From this survey, thirty clusters (“Mukims”) were first sub-sampled using Probability Proportional to Size (PPS) sampling method to carry out the Phase 2 of 2nd NHANSS. The thirty “Mukims” (Table 1) were distributed into: sixteen (16) in Brunei Muara; four (4) in Belait; six (6) in Tutong and four (4) in Temburong.

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Section A enquired on demography while section B addressed on the socio-economic status covering housing status, electricity and water supply, employment, education and income. Section C recorded current and past smoking habits. Meanwhile section D enquired on physical activity based on the WHO`s Global Physical Activity Questionnaire (GPAQ) 7. The sections E, F, G and H assessed for history of hypertension, diabetes and dyslipidaemia respectively. Participants were asked to bring their medical treatment cards if any, and a photocopy of the prescription was attached to the questionnaire. Participants’ perception of their body image was enquired in section J while food supplements consumption was recorded in Section K. Anthropometric measurements for height, weight and waist cicumference were recorded in Section L. The blood pressure was measured twice as indicated in Section M. Food intake assessment was carried out through a semi-quantitative Food Frequency questionnaire (FFQ) and 24-hour diet recall in Section N and Section O respectively. Section P was carried out only on respondents aged 20 years old and above. Biochemical test results consisting of fasting blood glucose, full blood count, fasting lipid profile, serum creatinine, HbA1c and oral glucose tolerance test (for non-diabetics only).

3.4 Database Development

The database development was managed by the Disease Control Division with the support from the Community Nutrition Division, the Statistics Unit of Research and Development Division and the Department of Policy and Planning. The master file database was created using SPSS version 15 for Windows 8, containing information on demography, socio economic status, household smoking status, physical activity, health status, body image, food supplements, food frequencies as well as anthropometric measures and blood analysis.

FoodWorks® Professional Version 2009 9 was utilized for nutritional analysis of 24-hour dietary recalls. Food and nutrient intakes were imported from FoodWorks® into a Microsoft Access database so that data could be prepared for nutrient analyses. This data was then exported to SPSS IBM Statistics 21.0. Results of nutrient intake were then merged with the master file database containing questionnaire data for further analysis.

3.5 Pilot Testing

Every step of the data collection procedures were pilot tested in three different locations including a school, university and a governmental office involving participants of various ages. This was to allow the interviewers:

• to detect any misinterpretation of questions

• to estimate the length of time to complete questionnaire for each participant

• to provide practical training for the interviewers

• to test the validity of the intervention materials

• to strengthen the questionnaire for better performance and

• to finalise the survey questions and format

3.6 Training

All members of the survey team comprising of dietitians, nutritionists, interviewers, research assistants, community health nurses and data-entry personnels attended a one-week training workshop for phase 2 from the 5th of May 2010. In addition to addressing all aspects of the survey, the workshop also covered communication skills, familiarisation of questionnaire content, interviewing techniques, anthropometric assessments and blood pressure measurements. To minimise interview bias, the interviewers received training to ensure consistent techniques. However, this does not completely eliminate recall bias by respondents as under and over reporting are commonly observed in any self reporting survey. This is frequently encountered with dietary recall or food consumption history.

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Participant being interviewed by a

community health nurse

Child participant’s blood pressure measurement being taken by a research assistant

Research assistants interviewing participants

Nursing staff checking blood sample forms

31

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Each team member was identified by a code number prior and throughout data collection. The fieldwork was conducted from 10th June 2010 until 30th March 2011 on every Monday to Thursday and Saturday with a break during the fasting month of Ramadhan and Hari Raya Aidilfitri. The flow of data collection process is shown in Figure 1. Consent was obtained from respondents aged 20 years old and above for blood samples to be taken for analysis of hemoglobin level, serum creatinine, fasting blood glucose, fasting lipids (HDL-C, LDL-C, total cholesterol and triglycerides) and glycated haemoglobin (HbA1c).

Trained research assistants conducted the interview for Section A to M while trained dietitians/nutritionists were tasked for Section N to O. Dietitians/nutritionists were also involved in the interview for Section A to M, if needed.

Each participant, upon completion of the questionnaire, received souvenirs as tokens of appreciation. Participants without transportation had transportation arranged to and fro from their home to the survey centre.

Data Collection

Promotion and Public Awareness

The public was alerted regularly about the survey prior to and throughout data collection through media channels via radio and television, television interviews and pamphlets, newspapers and, posters.

4

5

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Figure 1: Flowchart of Data Collection Process

BiochemistryRegistrationGTT

(for non-diabetics)Section P

Anthropometry& Blood Pressure

Completedquestionnaireschecked and

verified

InterviewSection A – M

Diet InterviewSection N – O

>20 years old

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Following the interviews, completed questionnaires were checked and verified by principal investigators and any errors were immediately clarified and corrected on the field. The head of data entry further verified the questionnaire before and after each data entry at the data entry center.

5.1 Blood Pressure

Participants were advised to sit in the waiting area for at least five minutes prior to each blood pressure measurements with the Blood Pressure Monitor Omron T9P. The cuff sizes were adjusted where necessary for each participant depending on their arm circumference (Table 2). Two readings of both systolic and diastolic pressure were taken and recorded in Section M of the questionnaire. The average of the two readings was calculated, recorded and entered into the database. Appendix B shows the methodology for blood pressure measurements.

5.2 Anthropometry

Anthropometry reflects both health and nutritional status and predicts performance, health and survival 10. It represents a portable, universally applicable, inexpensive and non-invasive techniques for assessing the size, proportions and composition of the human body. The anthropometry indices measured in this survey were body weight, height and waist circumference. Appendix B shows the standard operating procedure for anthropometric data collection.

5.3 Physical Activity

Questions on physical activity were adopted from WHO`s Global Physical Activity Questionnaire (GPAQ) 7. The physical activity questions comprised of three components;

• Activity At Work,

• Travel To and From Places

• Recreational Activities.

Interviewers were guided by a list of different types of physical activities based on the level of intensity which can be classified into moderate and vigorous activities (Appendix C) 11.

5.4 Dietary Assessment

This assessment measures food consumption pattern or estimates the intake of nutrients or non-nutrients. The 24-hour dietary recall and Food Frequency Questionnaire (FFQ) were selected as the dietary assessment methods for this survey.

5.4.1 24-Hour Dietary Recall

In this survey, the 24-hour dietary recall aimed to provide a complete record of all foods and drinks consumed on the previous day, from midnight to midnight. Similar to the Phase 1 of the 2nd NHANSS,

Table 2 – Arm Circumference and Cuff Size

Arm Circumference Cuff Size

A 17-22 cm Small (Children)

B 23-33 cm Adult

C 34-42 cm Large Adult

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this methodology was used for its speed and ease of implementation, cost effectiveness and, being the most feasible and appropriate in providing detailed dietary and nutrient information for our sample size 12.

Well-trained interviewers are crucial because most of the dietary information was collected by asking probing questions. All appointed dietitians and nutritionists undertook intensive training on the correct procedures for conducting 24-hour dietary recalls. All interviewers are familiar about foods and drinks available in the marketplace and about preparation practices, including prevalent regional or ethnic foods.

Multiple pass method was employed where respondents were required to adequately describe the foods and drinks, names of the foods or drinks, brand names where necessary, preparation methods, recipes, and estimated amounts consumed12. In this method, dietary intake is reviewed more than once in an effort to retrieve missed eating occasions and foods. At the end of the interview, the trained interviewer would review the records with the subject, clarify the entries and, probe for the missing foods and drinks. The young and old, male respondents and husbands were assisted in recalling their food intake by parents/caregivers, family members and wives respectively.

Actual utensils such as different sizes of plates, bowls, glasses, cups, and spoons were provided during the interview to aid the participants in estimating food portion sizes. A food model album containing pictures of commonly consumed foods with different portion sizes was also used as guide for interviewers and respondents to estimate the quantity of food consumed. A list of commonly consumed foods with portion sizes and weight was compiled in addition to the food model album. Dietary data were recorded into section O of the questionnaire booklet (Appendix A). The completed 24-hour dietary recall data were checked and verified by principal investigators upon completion of the interview on the same day.

A second 24-hour diet recall was carried out on at least 10% of the sample population within seven to fourteen days of the first recall. The purpose was to assess for any variation in the dietary intake within and between the participants. Selected participants were identified at registration and given an appointment at the end of the first diet recall interview. The second recall was scheduled for a weekday if their first recall was a weekend day and vice versa. Replacement appointments were made for second recall if participants did not turn up for their appointment.

5.4.2 Food Frequency Questionnaire

A short food frequency questionnaire (FFQ) was designed to provide qualitative and quantitative information about food consumption patterns. The FFQ was assessed by a multiple response in which respondents were asked to estimate how often a particular food or beverage was consumed. In the survey, five options were provided ranging from ‘rarely-never’, ‘x times per month’, ‘x times per week’ to ‘x times per day’ including an option for ‘Don’t Know’. Respondents were asked to choose one of these options. A total of eleven foods and beverages of particular interest in the population were incorporated in the questionnaire. This includes fruits, vegetables, sugar-sweetened beverages, instant drinks, coconut milk, Malay ‘kuih’, fried foods including fast foods, ‘nasi katok’, fat in poultry (chicken tails, wings and/or skin), instant noodles and ‘keropok’. Supplementary questions were included to ascertain the frequency of ‘meals eaten that were not prepared at home’, the frequency of breakfast, the ‘usual’ type of milk consumed and the ‘most often used’ cooking oil at home.

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Databases that had been prepared earlier for entry and analysis were:• Database 1 - for questions on Section A to N and P• Database 2 - for dietary data from 24-hour dietary recalls on Section O

The master file database was created using SPSS version 15 for Windows 8, which contains information on demography, socio-economic status, smoking status, physical activity, health status, body image, food supplements, food frequencies, anthropometric data and the biochemical results.

FoodWorks® Professional Edition (Version 2009) 9 software uses the AUSNUT database for nutritional analysis on the 24-hour dietary recalls. Results of nutrient analysis were then merged with the master file database for further analysis.

However, nutritional information on dietary recall is limited to information available in the food database. This resulted in the use of substitute ingredients to represent commonly consumed food in Brunei Darussalam and thus may affect the macro- and micro-nutrients analysis.

6.1 Data Entry and Cleaning for Database 1

These were carried out by experienced staff from the Statistics Unit and supervised by Head of the Statistics Unit of Research and Development Section, Department of Policy and Planning of the Ministry of Health.

Prior to data entry, all questionnaires were verified again. Data was then entered into the master file database 1. For the purpose of familiarisation and minimising errors, initial data entry for over 10% of the questionnaires were carried out by a pair of staff; with one person reading the written data to the other paired person entering data. This further helps in verifying the recorded data. Weekly data analysis was done to detect patterns of errors in data entry and questions interpretations to provide early feedback on corrective measures. In addition, patterns in data were also cross-checked with other similar and/or related questions to ensure consistency.

6.2 Dietary Data Entry and Cleaning for Database 2

Data of 24 hour diet recalls were entered and cleaned by dietitians/nutritionists using FoodWorks® 2009 Professional Edition (Version 9.0)9. A total of 284 local foods and recipes had been developed using foods available in the FoodWorks® 2009 Professional Edition (Version 9.0), which included those that had been used in Phase 1 of the 2nd NHANSS. Cleaned data from FoodWorks® was then converted into Microsoft Access software for final cleaning and to be merged with Database 1.

Data Management

Descriptive statistics were used to assess data from all sections of the questionnaire. A WHO macro using WHO growth standards to assess children (5-18 years old) anthropometric data by z-scores was used. The Multiple Source Method program estimated usual population intakes13 with the data from the second diet recalls. Data was analysed using SPSS version 15.0 (SPSS Inc, 2003).

Data Analysis7

6

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36

A nurse preparing to take blood sample

Procedure for collecting blood sample

Research assistants taking waist circumference

measurement from a young participant

36

37

The Brunei Darussalam 2nd NHANSS Phase 2 survey was based on a target population of 4000 respondents aged from five to seventy-five years old. A total of 2184 respondents took part in the survey with a response rate of 54.6%.

8.1 Demographic Characteristics

Demographic details were described as population by gender, districts, age-groups, residential status, ethnicity, religion and marital status.

8.1.1 Survey Population by Gender and District

There were more female (n = 1157; 53%) than male respondents (n = 1027; 47%). The respondents from Brunei Muara were the majority with 67.7%, followed by Belait (17%), Tutong (12%) and Temburong (3.3%) as shown in Table 3. This is reflective of the general population distribution4 in the country.

8.1.2 Survey Population by Age-Groups

Table 4 provides information on the age and sex distribution of the survey sample. The youngest respondent was 5.1 years old and the oldest respondent was 74.8 years old. The median age was 27.3 ±16.2 years for males and 30.0 ±16.1 years for females. The majority of the respondents were aged between 20-29 years (21.2%) and 30-39 years (20.3%).

Results

Table 3 - Respondents By Gender And Districts

District Male Female Total

n % n % n %

Brunei Muara 695 47.0 784 53.0 1479 67.7

Belait 176 47.4 195 52.6 371 17.0

Tutong 120 45.6 143 54.4 263 12.0

Temburong 36 50.7 35 49.3 71 3.3

Total 1027 47.0 1157 53.0 2184 100

Table 4 - Proportions Of Respondents In Each Category

Age (years) Male Female Total

n % n % n %

5-9 128 12.5 138 11.9 266 12.2

10-14 128 12.5 105 9.1 233 10.7

15-19 91 8.9 106 9.2 197 9.0

20-29 234 22.8 229 19.8 463 21.2

30-39 179 17.4 264 22.8 443 20.3

40-49 148 14.4 175 15.1 323 14.8

50-59 66 6.4 82 7.1 148 6.8

60+ 53 5.2 58 5.0 111 5.1

Total 1027 47.0 1157 53.0 2184 100

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8

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8.1.3 Survey Population by Residential Status

The majority of the respondents were citizens of Brunei Darussalam (92.8%) with only a small proportion of permanent residents (7.1%) as shown in Figure 2.

8.1.4 Survey Population by Ethnicity and Religion

The majority of the respondents were Malay (87.2%) followed by Chinese (7%) and Others (5.8%) as shown in Figure 3.

Figure 2 - Residential Status

92.8%

7.1% Brunei Citizen

Permanent Resident

Figure 3 - Ethnicity

87.2%

7.0% 5.8%

Malay Chinese Others

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Respondents were mostly Muslim (88%), and the remaining respondents were Buddhist (4.1%), Christians (3.3%) and of other religious faiths (4.6%) as shown in Figure 4.

8.1.5 Survey Population by Marital Status

The majority of the respondents (52.8%) were single, 43.3% were married, 2.2% were divorced and 1.7% were widowed. This is represented in Figure 5.

Figure 5 – Marital Status

52.8% 43.3%

2.2% 1.7%

Single

Married

Divorced

Widowed

Figure 4 - Religion

3.3% 4.1% 4.6%

Muslim Christian Buddhist Others

88%

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Waist circumference measurement taken from

an adult participant

Research assistant taking height measurement of a

female participant

Research assistant taking height measurement of a male participant

40

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8.2 Socio-economic Status (Respondents Aged 18-75 Years)

Socio-economic characteristics of the respondents aged 18-75 years were explored by housing status,

electricity and piped water supply to the house, employment and education level, income and, food

security or ability to buy food in the last 12 months.

8.2.1 Housing Status

In this survey, 42.3% of the respondents were living in houses belonging to their parents, while 35.6%

were living in their own houses as shown in Figure 6. In terms of respondents whose accommodation was

provided by their employers, 6.2% paid rent and 4% were provided for free. Another 8.2% lived in other

housing status such as those belonging to relatives or siblings.

8.2.2 Electricity and Piped Water Supply

Most houses occupied by the respondents were supplied with electricity (99.7%) and piped water (99.6%).

Figure 6 - Housing Status 18-75 Years Old

35.6%

4.0% 3.7%6.2%

42.3%

8.2%

Own House Rented Provided Free By

Employer

Provided By Employer With Rent

Provided Free By Parents

Others

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8.2.3 Employment Status

The employment status of respondents by gender is shown in Figure 7. Amongst the repondents with

employment, 38.3% were employed by the Brunei Government, 21.1% were in the private sector and

5.7% were self-employed. Students made up 7.4% of the respondents. In this survey, 15.7% of the

respondents were unemployed with more males (18%) than females (13.8%).

Figure 7 - Percentage Respondents 18-75 Years Old by Employment Status

18.0

44.3

24.3

6.9

6.3

0.1

13.8

33.3

18.3

7.8

21.6

5.2

0

15.7

38.3

21.1

7.4

5.7

0.1

Unemployed

Employed by Government

Employed by Private Sector

Student

Housewife

Self-Employed

Not Applicable Total

Female

Male

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The parental employment status of respondents below 18 years old is shown in Figure 8, where

similar findings were observed.

Figure 8 - Percentage Respondents

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8.2.4 Education Level

Education level of respondents by gender is represented in Figure 9. Majority of respondents had

attained secondary level education (Form 1 to 5, equivalent to current education system Year 7 to

11) with 55.3%. Tertiary education was achieved in 10.4% of the respondents and only 3.3% had n