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