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1.  Validation of a measure to assess Post-Traumatic Stress Disorder: a Sinhalese version of Impact of Event Scale 
There is paucity of measures to conduct epidemiological studies related to disasters in Sri Lanka. This study validates a Sinhalese translation of the Impact of Event Scale- 8 items version (IES-8) for use in Sri Lanka.
This cross-sectional validation study was conducted in the densely populated rural area of Tangalle in the Southern province of Sri Lanka. The English version of the IES-8 after translation procedures in to Sinhalese was administered by trained raters to a community sample of 30 survivors of tsunami aged 13 years and above. Diagnostic accuracy, reproducibility and validity of the translated IES was assessed in terms of sensitivity, specificity, predictive values, likelihood ratios, diagnostic odds ratio, inter-rater reliability, internal consistency, criterion validity and construct validity.
The cut-off score of 15 gave a fair sensitivity (77%) for screening along with other components of diagnostic accuracy. The inter-rater reliability was high (0.89). The internal consistency for the whole scale was high (0.78) with a high face and content validity. The criterion validity was high (0.83) and the construct validity demonstrated the two factor structure documented in the literature.
This study demonstrates that this Sinhalese version of the Impact of Event Scale has sound diagnostic accuracy as well as psychometric properties and makes it an ideal measure for epidemiological studies related to natural and man made disasters in Sri Lanka.
PMCID: PMC1803770  PMID: 17306023
2.  Validation of the Geriatric Depression Scale for an elderly Sri Lankan clinic population 
Indian Journal of Psychiatry  2010;52(3):254-256.
Geriatric Depression Scale (GDS) has not been validated for the elderly population in Sri Lanka.
To translate, validate, and examine the effectiveness of GDS and to suggest the optimal cut-off scores for elderly Sri Lankans attending a psychogeriatric clinic.
Materials and Methods:
The Sinhalese translation of GDS (GDS-S) was administered to people aged 55 years and above, attending a psychogeriatric outpatient clinic. The diagnostic performance of the instrument was compared against the ICD 10 diagnosis of a consultant psychiatrist, which was considered the ‘gold standard’. Receiver operating characteristic (ROC) analysis was carried out to compare the diagnostic performance of the GDS-S. Optimal cut-off scores for depression and sensitivity and the specificity of the instrument was determined.
A total of 60 subjects formed the final sample (male/female=16/44) of which 30 were depressed, while 30 were age- and sex-matched controls. The optimal cut-off score for GDS-S was 8 for differentiating non-depressed from mildly depressed, while the cut-off score for moderate depression was 10. Sensitivity and specificity of GDS-S was 73.3% for differentiating depressed from non-depressed.
GDS is culturally acceptable, easy to use, sensitive, and a valid instrument to diagnose depression and to differentiate mild from moderate depression in an elderly Sri Lankan clinic population.
PMCID: PMC2990826  PMID: 21180411
GDS; depression; Sri Lanka
3.  Development of a food frequency questionnaire for Sri Lankan adults 
Nutrition Journal  2012;11:63.
Food Frequency Questionnaires (FFQs) are commonly used in epidemiologic studies to assess long-term nutritional exposure. Because of wide variations in dietary habits in different countries, a FFQ must be developed to suit the specific population. Sri Lanka is undergoing nutritional transition and diet-related chronic diseases are emerging as an important health problem. Currently, no FFQ has been developed for Sri Lankan adults. In this study, we developed a FFQ to assess the regular dietary intake of Sri Lankan adults.
A nationally representative sample of 600 adults was selected by a multi-stage random cluster sampling technique and dietary intake was assessed by random 24-h dietary recall. Nutrient analysis of the FFQ required the selection of foods, development of recipes and application of these to cooked foods to develop a nutrient database. We constructed a comprehensive food list with the units of measurement. A stepwise regression method was used to identify foods contributing to a cumulative 90% of variance to total energy and macronutrients. In addition, a series of photographs were included.
We obtained dietary data from 482 participants and 312 different food items were recorded. Nutritionists grouped similar food items which resulted in a total of 178 items. After performing step-wise multiple regression, 93 foods explained 90% of the variance for total energy intake, carbohydrates, protein, total fat and dietary fibre. Finally, 90 food items and 12 photographs were selected.
We developed a FFQ and the related nutrient composition database for Sri Lankan adults. Culturally specific dietary tools are central to capturing the role of diet in risk for chronic disease in Sri Lanka. The next step will involve the verification of FFQ reproducibility and validity.
PMCID: PMC3496639  PMID: 22937734
Food frequency questionnaire; Development; FFQ; Sri Lanka; Adults
4.  High dietary diversity is associated with obesity in Sri Lankan adults: an evaluation of three dietary scores 
BMC Public Health  2013;13:314.
Dietary diversity is recognized as a key element of a high quality diet. However, diets that offer a greater variety of energy-dense foods could increase food intake and body weight. The aim of this study was to explore association of diet diversity with obesity in Sri Lankan adults.
Six hundred adults aged > 18 years were randomly selected by using multi-stage stratified sample. Dietary intake assessment was undertaken by a 24 hour dietary recall. Three dietary scores, Dietary Diversity Score (DDS), Dietary Diversity Score with Portions (DDSP) and Food Variety Score (FVS) were calculated. Body mass index (BMI) ≥ 25 kg.m-2 is defined as obese and Asian waist circumference cut-offs were used diagnosed abdominal obesity.
Mean of DDS for men and women were 6.23 and 6.50 (p=0.06), while DDSP was 3.26 and 3.17 respectively (p=0.24). FVS values were significantly different between men and women 9.55 and 10.24 (p=0.002). Dietary diversity among Sri Lankan adults was significantly associated with gender, residency, ethnicity, education level but not with diabetes status. As dietary scores increased, the percentage consumption was increased in most of food groups except starches. Obese and abdominal obese adults had the highest DDS compared to non obese groups (p<0.05). With increased dietary diversity the level of BMI, waist circumference and energy consumption was significantly increased in this population.
Our data suggests that dietary diversity is positively associated with several socio-demographic characteristics and obesity among Sri Lankan adults. Although high dietary diversity is widely recommended, public health messages should emphasize to improve dietary diversity in selective food items.
PMCID: PMC3626879  PMID: 23566236
Diet diversity; Dietary variety; DDS; Sri Lanka; Obesity; Adults
5.  Comparison of three instruments used in the assessment of dementia in Sri Lanka 
Indian Journal of Psychiatry  2005;47(2):109-112.
Dementia is poorly recognized even by physicians. This study compares three instruments used to assess dementia in a community setting in Sri Lanka.
Translated and culturally adapted versions of the Mini Mental State Examination (MMSE), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and Clinical Dementia Rating (CDR) were administered to 363 individuals selected by stratified random sampling in a periurban community in Sri Lanka. The results on the three instruments were compared with the independent psychiatric evaluation done on a concentrated sample of 37 individuals from the study population.
Culturally adapted MMSE, IQCODE and CDR can be used to screen dementia in Sri Lanka. IQCODE is the best among the three instruments with a sensitivity of 71.4% and a specificity of 82.6% when 3.5 is the cut-off. In addition, IQCODE is culturally acceptable, easy to administer and can be used in those with a low level of literacy as well as in those with hearing or visual impairment.
IQCODE was found to be more effective and culturally acceptable as a screening tool for dementia in Sri Lanka, compared with MMSE and CDR.
PMCID: PMC2918294  PMID: 20711293
6.  Regional comparison of dietary intakes and health related behaviors among residents in Asan 
Nutrition Research and Practice  2007;1(2):143-149.
Inadequate dietary intakes and poor health behaviors are of concern among rural residents in Korea. This study is conducted to compare dietary intakes, dietary diversity score (DDS), mean nutrient adequacy ratio (MAR) and health related behaviors by rural, factory and urban areas in Asan. A total of 930 adults (351 men and 579 women) were interviewed to assess social economic status (SES), health related behaviors and food intakes by a 24-hour recall method. Mean age was 61.5 years with men being older (64.8 years) than women (59.3 years, p<0.001). Men in the factory area were older than rural or urban men while urban women were the youngest. Education and income of urban residents were higher than other area residents. There were more current drinkers in urban area while smoking status was not different by regions. Physical activity was significantly higher in rural or factory areas, whilst urban residents exercised more often (p<0.05). Rural or factory area residents considered themselves less healthy than others while perceived stress was lower than urban residents. Energy intakes were higher in urban residents or in men, however, after SES was controlled, energy intake did not show any differences. Energy-adjusted nutrient intakes were significantly higher in the urban area (p<0.05) for most nutrients except for carbohydrate, niacin, folic acid, vitamin B6, iron and fiber. Sodium intake was higher in factory area than in other areas after SES was controlled. DDS of rural men and MAR of both men and women in the rural area were significantly lower when SES was controlled. In conclusion, dietary intakes, diversity, adequacy and perceived health were poor in the rural area, although other health behaviors such as drinking and perceived stress were better than in the urban area. In order to improve perceived health of rural residents, good nutrition and exercise education programs are recommended.
PMCID: PMC2882589  PMID: 20535400
Dietary intake; health behavior; regional comparison; rural area
7.  Zinc status and dietary quality of type 2 diabetic patients: implication of physical activity level 
The purpose of this study was to analyze the relationships among zinc status, diet quality, glycemic control and self-rated physical activity level of type 2 diabetic patients. Dietary intakes for two non-consecutive days were measured by 24-hour recall method for seventy-six diabetic patients. Fasting blood glucose and HbA1c were measured for the assessment of glycemic control. We evaluated the extent of dietary adequacy by the percentage of subjects with a dietary intake of a nutrient less than the estimated average requirement(EAR), the dietary diversity score(DDS) and the dietary variety score(DVS). Zinc status was assessed from serum levels and urinary excretion. Dietary inadequacy was serious for five nutrients: riboflavin, calcium, thiamin, zinc and vitamin C. Dietary intakes from the meat, fish, and egg food groups and the milk food group were below the recommended level. We found that subjects with high levels of physical activities had significantly higher DVS and serum zinc levels compared to others (p<0.05). Fasting blood glucose levels and HbA1c were not significantly different across self-reported physical activity levels. Therefore, we suggest that maintaining physical activity at or above a moderate level is beneficial to improving dietary quality and zinc status.
PMCID: PMC2815304  PMID: 20126364
Diabetes; zinc status; diet quality; physical activity level; glycemic control
8.  Validation of a functional screening instrument for dementia in an elderly sri lankan population: comparison of modified bristol and blessed activities of daily living scales 
BMC Research Notes  2010;3:268.
Cognitive tests have been used in population surveys as first stage screens for dementia but are biased by education. However functional ability scales are less biased by education than the cognitive scale and thus can be used in screening for dementia.
To validate Activities of Daily Living (ADL) scale appropriate for use in assessing the presence of dementia in an elderly population living in care homes in Sri Lanka.
Sinhalese version of the modified Bristol and Blessed scale was administered to subjects aged 55 years and above residing in 14 randomly selected elders' homes. Receiver Operating Characteristic (ROC) was used to determine the cut-off scores of both the scales.
Based on the ROC analysis, optimal cut off score of the modified Bristol scale was 20 with a sensitivity of 100%, specificity of 74.2% and the area under the curve 0.933(95% CI: 0.871-0.995) while the optimal cut off score of the modified Blessed scale was 10.5 with a sensitivity of 100%, specificity of 71% and the area under the curve 0.892 (95% CI: 0.816-0.967).
The findings confirm that both the scales can be used in screening for dementia in the elderly living in care homes in Sri Lanka.
PMCID: PMC2987868  PMID: 20974013
9.  Dietary Quality Indices and Biochemical Parameters Among Patients With Non Alcoholic Fatty Liver Disease (NAFLD) 
Hepatitis Monthly  2013;13(7):e10943.
Dietary intake might have important role in non-alcoholic fatty liver diseases (NAFLD). Although, there are some reports on dietary intake and anthropometrics measurements, few studies have focused on the markers of assessing whole diet like dietary quality indices.
Therefore, our aim was to determine the diet quality indices and biochemical parameters among patients with NAFLD and healthy individuals.
Patients and Methods
This case-control study was performed on 100 patients with NAFLD and 100 healthy subjects who were attending to Gastrointestinal Research Center, Baqiyatallah University, Tehran, Iran during the recent years. Usual dietary intake was assessed by three dietary records (one weekend and two week days). Healthy eating index (HEI), dietary diversity score (DDS), dietary energy density (DED), mean adequacy ratio of nutrients (MAR) were assessed according to the standard methods.
Patients with NAFLD had higher body mass index, weight and waist circumference compared to the healthy group (P < 0.05). Serum levels of liver enzymes, triglyceride, LDL, BUN, and uric acid were higher in patients with NAFLD (P < 0.05). Although patients with NAFLD had higher energy, carbohydrate and fat intake, their values for antioxidant vitamins, calcium and vitamin D were lower than healthy subjects (P < 0.05). HEI and MAR were higher among healthy group, and DED was lower among them. Nutrient adequacy ratio for calcium, vitamin D, and antioxidant micronutrients were lower in patients with NAFLD (P < 0.05).
It seems that dietary quality indices may be associated with NAFLD. Calcium, vitamin D, and antioxidant micronutrients intake might be lower among patients with NAFLD based on this case-control study. Further prospective studies should be conducted in this regard.
PMCID: PMC3776150  PMID: 24065998
Diet Therapy; Healthy People Programs; Biochemical Processes; Non-alcoholic Fatty Liver Disease
10.  Nutrient adequacy and diet quality in non-overweight and overweight Hispanic children of low socioeconomic status - the VIVA LA FAMILIA Study 
The role of diet quality and nutrient adequacy in the etiology of childhood obesity is poorly understood. The specific aims of these analyses were to 1) assess overall diet quality and nutrient adequacy, and 2) test for association between weight status and diet in children from low socioeconomic status (SES) Hispanic families at high risk for obesity.
A cross-sectional study design was used to assess dietary intake in low-SES non-overweight and overweight Hispanic children enrolled in the VIVA LA FAMILIA Study. Multiple-pass 24-h dietary recalls were recorded on two random, weekday occasions. Diet quality was evaluated according to United States (US) Dietary Guidelines. Nutrient adequacy was assessed using z-scores based on estimated average requirement (EAR) or adequate intake (AI).
The study included 1030 Hispanic children and adolescents, ages 4-19 y, in Houston, Texas who participated between November 2000 and August 2004.
Statistical analysis
STATA was used for generalized estimating equations and random effects regression.
Diet quality did not adhere to US dietary guidelines for fat, cholesterol, saturated fatty acids, fiber, added sugar and sodium. Although energy intake was significantly higher in overweight children, food sources, diet quality, macro- and micronutrient composition were similar between non-overweight and overweight children. Relative to EAR or AI, mean nutrient intakes were adequate (70-98% probability) in the non-overweight and overweight children, except for vitamins D and E, pantothenic acid, calcium and potassium for which z-scores cannot be interpreted given the uncertainty of their AI's.
While the diets of low-SES, non-overweight and overweight Hispanic children were adequate in most essential nutrients, other components of a healthy diet, which promote long-term health, were suboptimal. Knowledge of the diet of high risk Hispanic children will inform nutritional interventions and policy.
PMCID: PMC2741009  PMID: 19465183
nutrient adequacy; diet quality; dietary guidelines; childhood obesity; Hispanic population
11.  Physical activity, energy requirements, and adequacy of dietary intakes of older persons in a rural Filipino community 
Nutrition Journal  2009;8:19.
Aging is a process associated with physiological changes such as in body composition, energy expenditure and physical activity. Data on energy and nutrient intake adequacy among elderly is important for disease prevention, health maintenance and program development.
This descriptive cross-sectional study was designed to determine the energy requirements and adequacy of energy and nutrient intakes of older persons living in private households in a rural Filipino community. Study participants were generally-healthy, ambulatory, and community living elderly aged 60–100 y (n = 98), 88 of whom provided dietary information in three nonconsecutive 24-hour food-recall interviews.
There was a decrease in both physical activity and food intake with increasing years. Based on total energy expenditure and controlling for age, gender and socio-economic status, the average energy requirement for near-old (≥ 60 to < 65 y) males was 2074 kcal/d, with lower requirements, 1919 and 1699 kcal/d for the young-old (≥ 65 to < 75 y) and the old-old (≥ 75 y), respectively. Among females, the average energy requirements for the 3 age categories were 1712, 1662, and 1398 kcal/d, respectively. Actual energy intakes, however, were only ~65% adequate for all subjects as compared to energy expenditure. Protein, fat, and micronutrients (vitamins A and C, thiamin, riboflavin, iron and calcium) intakes were only ~24–51% of the recommended daily intake. Among this population, there was a weight decrease of 100 g (p = 0.012) and a BMI decrease of 0.04 kg/m2 (p = 0.003) for every 1% decrease in total caloric intake as percentage of the total energy expenditure requirements.
These community living elderly suffer from lack of both macronutrient intake as compared with energy requirements, and micronutrient intake as compared with the standard dietary recommendations. Their energy intakes are ~65% of the amounts required based on their total energy expenditure. Though their intakes decrease with increasing age, so do their energy expenditure, making their relative insufficiency of food intake stable with age.
PMCID: PMC2689250  PMID: 19409110
12.  Evaluation of nutrient intake and diet quality of gastric cancer patients in Korea 
Nutrition Research and Practice  2012;6(3):213-220.
This study was conducted to identify dietary factors that may affect the occurrence of gastric cancer in Koreans. Preoperative daily nutrition intake and diet quality of patients diagnosed with gastric cancer were evaluated. Collected data were comparatively analyzed by gender. The results were then used to prepare basic materials to aid in the creation of a desirable postoperative nutrition management program. The subjects of this study were 812 patients (562 men and 250 women) who were diagnosed with gastric cancer and admitted for surgery at Soonchunhyang University Hospital between January 2003 and December 2010. Nutrition intake and diet quality were evaluated by the 24-hr recall method, the nutrient adequacy ratio, mean adequacy ratio (MAR), nutrient density (ND), index of nutritional quality (INQ), dietary variety score (DVS), and dietary diversity score (DDS). The rate of skipping meals and eating fast, alcohol consumption, and smoking were significantly higher in males than those in females. The levels of energy, protein, fat, carbohydrate, phosphorous, sodium, potassium, vitamin B1, vitamin B2, niacin, and cholesterol consumption were significantly higher in males than those in females. Intake of fiber, zinc, vitamin A, retinol, carotene, folic acid were significantly higher in females than those in males. MAR in males was significantly higher (0.83) than that in females (0.79). INQ values were higher in females for zinc, vitamin A, vitamin B2, vitamin B6, and folic acid than those in males. The average DVS was 17.63 for females and 13.19 for males. The average DDS was 3.68 and the male's average score was 3.44, whereas the female's average score was 3.92. In conclusion, males had more dietary habit problems and poor nutritional balance than those of females. Our findings suggest that proper nutritional management and adequate dietary education for the primary prevention of gastric cancer should be emphasized in men.
PMCID: PMC3395786  PMID: 22808345
Gastric cancer; dietary habit; nutrient intake; diet quality
13.  Nutritional status and dietary intake of urban residents in Gondar, Northwest Ethiopia 
BMC Public Health  2012;12:752.
There is paucity of data on the dietary intake and nutritional status of urban Ethiopians which necessitates comprehensive nutritional assessments. Therefore, the present study was aimed at evaluating the dietary intake and nutritional status of urban residents in Northwest Ethiopia.
This cross-sectional community based nutrition survey was conducted by involving 356 participants (71.3% female and 28.7% male with mean age of 37.3 years). Subjects were selected by random sampling. Socio demographic data was collected by questionnaire. Height, weight, hip circumference and waist circumference were measured following standard procedures. Dietary intake was assessed by a food frequency questionnaire and 24-h dietary recall. The recommended dietary allowance was taken as the cut-off point for the assessment of the adequacy of individual nutrient intake.
Undernourished, overweight and obese subjects composed 12.9%, 21.3% and 5.9% of the participants, respectively. Men were taller, heavier and had higher waist to hip ratio compared to women (P < 0.05). Fish, fruits and vegetables were consumed less frequently or never at all by a large proportion of the subjects. Oil and butter were eaten daily by most of the participants. Mean energy intakes fell below the estimated energy requirements in women (1929 vs 2031 kcal/day, P = 0.05) while it was significantly higher in men participants (3001 vs 2510 kcal/day, P = 0.007). Protein intake was inadequate (<0.8 g/kg/day) in 11.2% of the participants whereas only 2.8% reported carbohydrate intake below the recommended dietary allowances (130 g/day). Inadequate intakes of calcium, retinol, thiamin, riboflavin, niacin and ascorbic acid were seen in 90.4%, 100%, 73%, 92.4%, 86.2% and 95.5% of the participants.
The overall risk of nutritional inadequacy among the study participants was high along with their poor dietary intake. Hence, more stress should be made on planning and implementing nutritional programmes in urban settings aimed at preventing or correcting micronutrient and some macronutrient deficiencies which may be useful in preventing nutrition related diseases in life.
PMCID: PMC3490783  PMID: 22958394
Urban Ethiopia; Dietary intake; Nutritional status
14.  Dietary Adequacies among South African Adults in Rural KwaZulu-Natal 
PLoS ONE  2013;8(6):e67184.
Food quality, determined by micronutrient content, is a stronger determinant of nutritional status than food quantity. Health concerns resulting from the co-existence of over-nutrition and under-nutrition in low income populations in South Africa have been fully recognized in the last two decades. This study aimed to further investigate dietary adequacy amongst adults in rural KwaZulu-Natal, by determining daily energy and nutrient intakes, and identifying the degree of satisfaction of dietary requirements.
Cross-sectional study assessing dietary adequacy from 24-hour dietary recalls of randomly selected 136 adults in Empangeni, KwaZulu-Natal, South Africa.
Results are presented for men (n = 52) and women (n = 84) 19–50 and >50 years old. Mean energy intake was greatest in women >50 years (2852 kcal/day) and exceeded Dietary Reference Intake’s for both men and women, regardless of age. Mean daily energy intake from carbohydrates was 69% for men and 67% for women, above the Dietary Reference Intake range of 45–65%. Sodium was also consumed in excess, and the Dietary Reference Intakes of vitamins A, B12, C, D, and E, calcium, zinc and pantothenic acid were not met by the majority of the population.
Despite mandatory fortification of staple South African foods, micronutrient inadequacies are evident among adults in rural South African communities. Given the excess caloric intake and the rising prevalence of obesity and other non-communicable diseases in South Africa, a focus on diet quality may be a more effective approach to influence micronutrient status than a focus on diet quantity.
PMCID: PMC3692416  PMID: 23825639
15.  The prevalence of previous self-harm amongst self-poisoning patients in Sri Lanka 
One of the most important components of suicide prevention strategies is to target people who repeat self-harm as they are a high risk group. However, there is some evidence that the incidence of repeat self-harm is lower in Asia than in the West. The objective of this study was to investigate the prevalence of previous self-harm among a consecutive series of self-harm patients presenting to hospitals in rural Sri Lanka.
Six hundred and ninety-eight self-poisoning patients presenting to medical wards at two hospitals in Sri Lanka were interviewed about their previous episodes of self-harm.
Sixty-one (8.7%, 95% CI 6.7–11%) patients reported at least one previous episode of self-harm [37 (10.7%) male, 24 (6.8%) female]; only 19 (2.7%, 95% CI 1.6–4.2%) patients had made more than one previous attempt.
The low prevalence of previous self-harm is consistent with previous Asian research and is considerably lower than that seen in the West. Explanations for these low levels of repeat self-harm require investigation. Our data indicate that a focus on the aftercare of those who attempt suicide in Sri Lanka may have a smaller impact on suicide incidence than may be possible in the West.
PMCID: PMC3092923  PMID: 20372876
Deliberate self-harm; Developing countries; Sri Lanka; Previous self-harm; Self-poisoning
16.  Intakes and adequacy of potentially important nutrients for cognitive development among 5-year-old children in the Seychelles Child Development and Nutrition Study 
Public health nutrition  2012;15(9):10.1017/S136898001200016X.
To assess the nutritional adequacy of Seychellois children in relation to nutrients reported to be important for cognitive development.
Dietary intakes were assessed by 4 d weighed food diaries and analysed using dietary analysis software (WISP version 3·0; Tinuviel Software, UK). Individual nutrient intakes were adjusted to usual intakes and, in order to investigate adequacy, were compared with the UK Estimated Average Requirements for children aged 4–6 years.
Children 5 years old were followed up as part of the Seychelles Child Development Nutrition Study (SCDNS), located in the high-fish-consuming population of Mahé, Republic of Seychelles.
Analysis was carried out on a sample of 229 children (118 boys, 111 girls).
Children consumed a diet of which fortified cereal and milk products contributed the most to nutrient intakes. The majority (≥80 %) of children met requirements for several nutrients important for child development including Fe, folate and Se. Adjusted dietary intakes of Cu, Zn, iodine, niacin and vitamin A were below the Estimated Average Requirement or Recommended Nutrient Intake. Mean adjusted energy intakes (boys 4769 kJ/d (1139·84 kcal/d), girls 4759 kJ/d (1137·43 kcal/d)) were lower than the estimated energy requirement (boys 5104 kJ/d (1220 kcal/d), girls 5042 kJ/d (1205 kcal/d)) for 88% of boys and 86% of girls.
Nutrition was adequate for most children within the SCDNS cohort. Low intakes of some nutrients (including Zn, niacin and vitamin A) could reflect nutritional database inaccuracies, but may require further investigation. The study provides valuable information on the adequacy of intakes of nutrients which could affect the growth and development of Seychellois children.
PMCID: PMC3654211  PMID: 22321870
Dietary intakes; Nutrient adequacy; Child nutrition; Cognitive development
17.  Antenatal Depression in Anuradhapura, Sri Lanka and the Factor Structure of the Sinhalese Version of Edinburgh Post Partum Depression Scale among Pregnant Women 
PLoS ONE  2013;8(7):e69708.
Mental health problems among women of reproductive age group contribute to 7% of Global Burden of Diseases of women of all ages. Purpose of this study was to determine the prevalence and correlates of antenatal depression among pregnant women in Anuradhapura, Sri Lanka, and to explore the factor structure of EPDS.
Pregnant women with gestational age of 24–36 weeks and residing in Anuradhapura district, Sri Lanka were recruited to the study using a two stage cluster sampling procedure. Sinhalese version of Edinburgh Post Partum Depression Scale (EPDS) and an interviewer administered questionnaire was use to collect data. A cut off value of 9 was used for the Sinhalese version of EPDS.
A total of 376 pregnant women were studied. Median EPDS score among pregnant women was 5 (IQR 2–8). Prevalence of antenatal depression in this study sample was 16.2% (n = 61). Thought of self harming (item number 10) was reported by 26 pregnant women (6.9%). None of the socio-demographic factors were associated with depression in this study sample. Having heart burn was significantly associated with depressive symptoms (p = 0.041). Sri Lankan version of EPDS showed a two factor solution. Anxiety was not emerged as a separate factor in this analysis.
Prevalence of antenatal depression in Anuradhapura, Sri Lanka was relatively low. Anxiety was not emerged as a separate factor in the Sinhalese version of the EPDS.
PMCID: PMC3724897  PMID: 23922781
18.  Irregular Migration as a Potential Source of Malaria Reintroduction in Sri Lanka and Use of Malaria Rapid Diagnostic Tests at Point-of-Entry Screening 
Case Reports in Medicine  2013;2013:465906.
Background. We describe an irregular migrant who returned to Sri Lanka after a failed people smuggling operation from West Africa. Results. On-arrival screening by Anti-Malaria Campaign (AMC) officers using a rapid diagnostic test (RDT) (CareStart Malaria HRP2/PLDH) indicated a negative result. On day 3 after arrival, he presented with fever and chills but was managed as dengue (which is hyperendemic in Sri Lanka). Only on day 7, diagnosis of Plasmodium falciparum malaria was made by microcopy and CareStart RDT. The initially negative RDT was ascribed to a low parasite density. Irregular migration may be an unrecognized source of malaria reintroduction. Despite some limitations in detection, RDTs form an important point-of-entry assessment. As a consequence of this case, the AMC is now focused on repeat testing and close monitoring of all irregular migrants from malaria-endemic zones. Conclusion. The present case study highlights the effective collaboration and coordination between inter-governmental agencies such as IOM and the Ministry of Health towards the goals of malaria elimination in Sri Lanka.
PMCID: PMC3703740  PMID: 23861687
19.  Derivation and validation of a risk-factor model for detection of oral potentially malignant disorders in populations with high prevalence 
British Journal of Cancer  2010;103(3):303-309.
Oral and pharyngeal cancers constitute the sixth most common type of cancer globally, with high morbidity and mortality. In many countries, most cases of oral cancer arise from long-standing, pre-existing lesions, yet advanced malignancies prevail. A new approach to early detection is needed. We aimed to validate a model for screening so that only high-risk individuals receive the clinical examination.
A community-based case–control study (n=1029) in rural Sri Lanka assessed risk factors and markers for oral potentially malignant disorders (OPMD) by administering a questionnaire followed by an oral examination. We then developed a model based on age, socioeconomic status and habits of betel-quid chewing, alcohol drinking and tobacco smoking, with weightings based on odds ratios from the multiple logistic regression. A total, single score was calculated per individual. Standard receiver-operator characteristic curves were plotted for the total score and presence of OPMD. The model was validated on a new sample of 410 subjects in a different community.
A score of 12.0 produced optimal sensitivity (95.5%), specificity (75.9%), false-positive rate (24.0%), false-negative rate (4.5%), positive predictive value (35.9%) and negative predictive value (99.2%).
This model is suitable for detection of OPMD and oral cancer in high-risk communities, for example, in Asia, the Pacific and the global diaspora therefrom. A combined risk-factor score of 12.0 was optimal for participation in oral cancer/OPMD screening in Sri Lanka. The model, or local adaptations, should have wide applicability.
PMCID: PMC2920027  PMID: 20628386
oral potentially malignant disorders; oral cancer; risk factors; screening; socioeconomic status; Sri Lanka
20.  Impact of Dairy and Sweetened Beverage Consumption on Diet and Weight of a Multiethnic Population of Head Start Mothers 
Mothers with children in Head Start play a critical role in providing healthful diets and modeling good dietary behaviors to their children, but there is little information available on their diet, especially on beverage consumption. The objective of this study was to assess the association of milk and sweetened beverage consumption with nutrient intake, dietary adequacy, and weight of a multiethnic population of Head Start mothers. Using a cross-sectional, secondary analysis, African-American (43%), Hispanic (33%), and white (24%) women (n=609) were divided into four beverage consumption groups: high milk/low sweetened beverage, high milk/high sweetened beverage, low milk/low sweetened beverage, and low milk/high sweetened beverage. Nutrient intake was determined by averaging 24-hour dietary recalls from 3 nonconsecutive days. Dietary adequacy was determined with the Mean Adequacy Ratio. Mean body mass index for the four beverage consumption groups was compared; there were no differences among the groups (overall mean±standard error=30.8±0.3). Women in the high milk/low sweetened beverage group had higher mean intakes of vitamins A, D, and B-6; riboflavin; thiamin; folate; phosphorus; calcium; iron; magnesium; and potassium (P<0.0125 for all) when compared with the other beverage consumption groups. Mean Adequacy Ratio was highest in the high milk/low sweetened beverage (71.8±0.8) and lowest in the low milk/high sweetened beverage (58.4±0.8) consumption groups (P<0.0125). Women in the high milk/low sweetened beverage group consumed more nutrient-dense foods. Overall consumption of milk was low. Consumption of high milk/low sweetened beverage was associated with improved nutrient intake, including the shortfall nutrients, ie, calcium, potassium, magnesium, and vitamin A.
PMCID: PMC2791539  PMID: 19394474
21.  Incidence of Physical Injuries in a Rural Community in Sri Lanka: Results of the First Community Survey in Sri Lanka 
Injuries account for approximately 11% of all hospital admissions in Sri Lanka. However, no published data are available with regard to the community incidence of injuries in Sri Lanka.
To determine the community incidence of major intentional and unintentional physical injuries in a rural community in Sri Lanka.
Materials and Methods:
A rural community consisting of 225 families with 1029 inhabitants was studied. Data on major injuries for a period of one year were collected retrospectively.
There were 85 major injuries in the community during the year of study. This gives a major injury incidence of 82.6 per 1000 person years. This is three times the incidence based on hospital-derived data. Animal bites being the most common cause of injury was noted in 2.3% of the population followed by falls in 1.6%, contact with objects in 1.5%, cut injuries in 1% and road trauma in 1%.
This study shows a higher incidence of major physical injuries (both intentional and unintentional) in the community than figures derived from hospital data. The prevention of injuries in a community such as the one studied here should be aimed at animal bites, falls, contacts with objects, cut injuries and road trauma.
PMCID: PMC2763689  PMID: 19876497
Community incidence; injury incidence; intentional injuries; physical injuries; Sri Lanka; unintentional injuries
22.  Food intakes and preferences of hospitalised geriatric patients 
BMC Geriatrics  2002;2:3.
A cross sectional survey was carried out on 120 hospitalised geriatric patients aged 60 and above in Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur to investigate their nutrient intakes and food preferences.
Food intakes were recorded using a one day weighed method and diet recall. Food preferences were determined using a five point hedonic score. Food wastages and factors affecting dietary adequacy were also investigated.
The findings indicated that the mean intakes of energy and all nutrients investigated except for vitamin C and fluid were below the individual requirement for energy, protein and fluid, and the Malaysian Recommendation of Dietary Allowances (RDA) for calcium, iron, vitamin A, thiamin, riboflavin, niacin and acid ascorbic. In general, subjects preferred vegetables, fruits and beans to red meat, milk and dairy products. There was a trend of women to have a higher percentage for food wastage. Females, diabetic patients, subjects who did not take snacks and subjects who were taking hospital food only, were more likely to consume an inadequate diet (p < 0.05 for all values).
Food service system in hospital should consider the food preferences among geriatric patients in order to improve the nutrient intake. In addition, the preparation of food most likely to be rejected such as meat, milk and dairy products need some improvements to increase the acceptance of these foods among geriatric patients. This is important because these foods are good sources of energy, protein and micronutrients that can promote recovery from disease or illness.
PMCID: PMC122060  PMID: 12165100
23.  The prevalence, patterns and predictors of diabetic peripheral neuropathy in a developing country 
Prevalence of diabetes mellitus (DM) has reached epidemic proportions in Sri Lanka. Presently there are studies on the community prevalence of distal peripheral neuropathy (DPN) in Sri Lanka. We describe prevalence, patterns and predictors of DPN in patients with DM in Sri Lanka. Data were collected as part of a national study on DM. In new cases DPN was assessed using the Diabetic-Neuropathy-Symptom (DNS) score, while in those with established diabetes both DNS and Toronto-Clinical-Scoring-System (TCSS) were used. A binary logistic-regression analysis was performed with ‘presence of DPN’ as the dichomatous dependent variable and other independent co-variants. The study included 528 diabetic patients (191-new cases), with a mean age of 55.0 ± 12.4 years and 37.3% were males, while 18% were from urban areas. Prevalence of DPN according to DNS score among all patients, patients with already established diabetes and newly diagnosed patients were 48.1%, 59.1% and 28.8% respectively. Prevalence of DPN in those with established DM as assessed by TCSS was 24% and the majority had mild DPN (16.6%). The remainder of the abstract is based on subjects with established DM. The prevalence of DPN in males and female was 20.0% and 26.4% respectively. The mean age of those with and without DPN was 62.1 ± 10.8 and 55.1 ± 10.8 years respectively (p < 0.001). The majority of those with DPN were from rural-areas (75.3%) and earned a monthly income < Sri Lankan Rupees 12,000 (87.6%). In the binary logistic-regression presence of foot ulcers (OR:10.4; 95%CI 1.8–16.7), female gender (OR:6.7; 95%CI 2.0–9.8) and smoking (OR:5.9; 95%CI 1.4–9.7) were the strongest predictors followed by insulin treatment (OR:4.3; 95%CI 1.3–6.9), diabetic retinopathy (OR:2.7; 95%CI 1.3–5.4), treatment with sulphonylureas (OR:1.8; 95%CI 1.1–3.2), increasing height (OR:1.8; 95%CI 1.2–2.4), rural residence (OR:1.8; 95%CI 1.1–2.5), higher levels of triglycerides (OR:1.6; 95%CI 1.2–2.0) and longer duration of DM (OR:1.2; 95%CI 1.1–1.3). There is a high prevalence of DPN among Sri Lankan adults with diabetes. The study defines the impact of previously known risk factors for development of DPN and identifies several new potential risk factors in an ethnically different large subpopulation with DM.
PMCID: PMC3408375  PMID: 22642973
Diabetes mellitus; Distal peripheral Neuropathy; Prevalence, Sri Lanka; Developing country
24.  Dietary quality and adequacy among Aboriginal alcohol consumers in the Northwest Territories, Canada 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.17341.
The present study aimed to assess dietary adequacy and quality among Inuvialuit alcohol consumers and non-consumers in the Northwest Territories (NWT), Canada.
Study design
Cross-sectional study.
A validated quantitative food frequency questionnaire was administered to individuals (n =216) of randomly selected households in 3 NWT communities to capture dietary intake and alcohol consumption over a 30-day recall period. The daily energy and nutrient intake, dietary adequacy and the top food sources of energy and selected nutrients were determined by alcohol consumption status.
Energy intake was higher among all alcohol consumers regardless of gender. Male alcohol consumers had lower nutrient intake density (per 4,184 kJ) of protein, cholesterol and several micronutrients (p≤0.05), and female alcohol consumers had lower intake density of saturated fat (p≤0.01), thiamine, folate and sodium (p≤0.05). Among all men and women, 70–100% had inadequate intakes of dietary fibre, vitamin E and potassium. Non-nutrient-dense foods contributed similar amounts and traditional foods (TF) contributed 3% less to energy comparing alcohol consumers to non-consumers.
Nutrient inadequacies are prevalent among Aboriginal populations in the Canadian Arctic and may be exacerbated by alcohol consumption due to alcohol's effects on dietary intake, nutrient transport and metabolism. Adult Inuvialuit who consumed alcohol had increased caloric intake and consumed similar amounts of non-nutrient-dense foods and less nutrient-dense TF. Fewer dietary inadequacies were observed among alcohol consumers than non-consumers, which might be due to the increase in overall food intake among alcohol consumers; however, further exploration of volume and pattern of drinking might help explain this result.
PMCID: PMC3417643  PMID: 22456041
NWT; Aboriginal; dietary adequacy; alcohol; chronic disease
25.  The Mediterranean Diet and Nutritional Adequacy: A Review 
Nutrients  2014;6(1):231-248.
The Mediterranean dietary pattern, through a healthy profile of fat intake, low proportion of carbohydrate, low glycemic index, high content of dietary fiber, antioxidant compounds, and anti-inflammatory effects, reduces the risk of certain pathologies, such as cancer or Cardiovascular Disease (CVD). Nutritional adequacy is the comparison between the nutrient requirement and the intake of a certain individual or population. In population groups, the prevalence of nutrient inadequacy can be assessed by the probability approach or using the Estimated Average Requirement (EAR) cut-point method. However, dietary patterns can also be used as they have moderate to good validity to assess adequate intakes of some nutrients. The objective of this study was to review the available evidence on the Nutritional Adequacy of the Mediterranean Diet. The inclusion of foods typical of the Mediterranean diet and greater adherence to this healthy pattern was related to a better nutrient profile, both in children and adults, with a lower prevalence of individuals showing inadequate intakes of micronutrients. Therefore, the Mediterranean diet could be used in public health nutrition policies in order to prevent micronutrient deficiencies in the most vulnerable population groups.
PMCID: PMC3916858  PMID: 24394536
Mediterranean diet; dietary patterns; nutrient adequacy; requirements; micronutrient intake

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