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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 3  |  Page : 220-226  

Whole-grain consumption and its determinants in Malaysian medical students: A cross-sectional study


1 Lecturer, Department of Clinical Skills, School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
2 Senior Lecturer, Department of Public Health, School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
3 Senior Lecturer, Department of Internal Medicine, School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
4 Senior Lecturer, Department of Clinical Pharmacology, School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
5 Associate Professor, Department of Family Medicine, School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Selangor, Malaysia
6 Project Manager, Department of Clinical Operations, Ecron Acunova, Bengaluru, Karnataka, India

Date of Web Publication20-Sep-2019

Correspondence Address:
Sapna S Patil
Department of Public Health, School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, No. 1, Jalan Taylor's, Subang Jaya 47500, Selangor
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_278_18

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   Abstract 


Background: Whole-grain consumption is associated with several health benefits. Little is known, however, about whole-grain consumption patterns in medical students in Malaysia. Objectives: The study was conducted to assess whole-grain intake pattern and factors influencing intake among Malaysian medical students. Methods: A cross-sectional study investigating whole-grain intake among 151 medical students in a private medical university in Malaysia was conducted from January to June 2018. A self-administered questionnaire was used to assess sociodemographic variables, the whole-grain intake pattern and the knowledge and attitudes toward whole-grain intake. Data were analyzed using IBM SPSS software. Chi-square test and multivariable logistic regression were used. Results: The prevalence of reported whole-grain intake in the past 3 months was 51%. Chinese ethnicity, readiness to adhere to Malaysian food pyramid, and self-preparation of food, and eating at home were significantly associated with whole-grain consumption. However, the primary determinants of food choice such as education, knowledge, and affordability did not seem to influence whole-grain consumption. Whole-grain consumption is relatively low among Malaysian medical students. Cultural background and self-belief influence this practice despite being from the medical fraternity. Conclusions: Efforts are needed to bridge the knowledge–practice gap by assessing the barriers to whole-grain consumption to design effective initiatives to promote an increase in whole-grain consumption.

Keywords: Medical students, practice, whole-grain consumption


How to cite this article:
Subramanian S, Patil SS, Ponnusamy S, Hasamnis AA, Loh KY, Santosh N. Whole-grain consumption and its determinants in Malaysian medical students: A cross-sectional study. Indian J Public Health 2019;63:220-6

How to cite this URL:
Subramanian S, Patil SS, Ponnusamy S, Hasamnis AA, Loh KY, Santosh N. Whole-grain consumption and its determinants in Malaysian medical students: A cross-sectional study. Indian J Public Health [serial online] 2019 [cited 2020 Dec 4];63:220-6. Available from: https://www.ijph.in/text.asp?2019/63/3/220/267213




   Introduction Top


A whole grain is defined as consisting of the intact, ground, cracked, or flaked kernel after removal of inedible parts such as the hull and husk.[1],[2] The principal anatomical components, namely the endosperm, germ, and bran are to be present in the same relative proportions as they exist in the intact kernel. Small losses of components, around <2% of the germ or <10% of the bran, which may occur through processing methods consistent with safety and quality, are allowed.

A significant body of research indicates that whole-grain consumption has been associated with greater nutrient intakes and enhanced dietary quality.[3],[4] Observational studies involving large populations have consistently shown an inverse relationship between whole-grain intake and disease risk, with health benefits proportional to the amount of whole-grain consumed.[5]

Consumption of 2–3 servings per day (~48 g) of whole grains may reduce the risk of cardiovascular disorders (CVD), Type 2 diabetes mellitus (T2DM), overweight, and obesity. This dietary practice has shown to lower the risk of certain cancers also. The current evidence shows that 3–5 servings of the whole grains per day reduces not only the risk of ischemic heart diseases and CVD, but also causes 21%–30% reduction in risk of T2DM compared to those who rarely or never consume whole grains.[6],[7],[8] It is proposed that whole grains also aid in the maintenance of glucose and insulin homeostasis, lowering of serum cholesterol and low-density lipoprotein cholesterol concentration, and reducing inflammation and oxidative stress.[5]

Whole grains and their products form the base of the Malaysian food pyramid. Whole grains are included in one of the food groups that form the main constituent of daily diet with recommendations of 4–8 servings per day, as recommended by the Malaysian dietary guidelines of 2010.[2] As tomorrow's doctors, it is crucial for medical students to have sound knowledge of healthy lifestyles and practice optimal dietary habits to maintain their own health and well-being.

There is lack of published evidence regarding the pattern of whole-grain consumption among medical students in Malaysia. Very few studies have been conducted among medical students to evaluate the dietary pattern, lifestyle, factors affecting eating habits, attitude on nutrition intake, obesity indices, and relationship between dietary habits and prevalence of fatigue.[9],[10],[11],[12] However, many studies have been conducted to explore whole-grain intake, its likeability, and association with body mass index (BMI), among university students and school children.[13],[14],[15],[16]

Nonetheless, a number of studies have evaluated the nutritional knowledge, eating habits, and obesity indices of university students in general.[17],[18],[19],[20],[21]

The purpose of this study was to find out the whole-grain consumption pattern among medical students and determine the factors influencing the practice of whole-grain consumption.


   Materials and Methods Top


Study design

A cross-sectional study was conducted from January to March 2018 in a private university in Malaysia, among medical students from both preclinical and clinical phases of the course. The study was approved by the Human Ethics Committee of the University (Reference No. HEC 2017/032). Written, informed consent was obtained from the students who volunteered to participate in the study. The sample size calculated, using the Krejcie and Morgan's formula[22] for a population of 328, the population proportional of 0.5, at a confidence level of 95% with an estimation error of 0.05, was 178 of which 151 students completed the study giving a response rate of 84.8%. Confidentiality of collected information and anonymity of the participants was maintained throughout the conduct of the study.

Operational definitions

  • Preclinical phase – Defined as students who were in 1st year (1st and 2nd Semester) and 2nd Year (3rd and 4th Semester)
  • Clinical phase – Defined as students who were in 3rd year (5th and 6th Semester), 4th Year (7th and 8th Semester), and year 5 (9th and 10th Semester)
  • Breakfast consumers – Defined as the respondents who took breakfast every day or >3 times/week
  • Breakfast skippers – Defined as the respondents who took breakfast <3 times/week and those who never had their breakfast.


Study instrument

We used a self-administered questionnaire comprising two sections. The questionnaire was circulated online using Google forms to ensure the completeness of the information.

Section 1 included information on sociodemographic variables such as age, gender, ethnicity, phase in the MBBS program, parents' level of education, monthly household income, and living arrangement. In this section, students were also asked to report their height (in centimeters) and current weight (in kilograms), based on which their BMI was calculated.

Section 2 comprised information regarding breakfast-related habits, dietary habits with reference to the Malaysian food pyramid, whole-grain consumption, its patterns and questions pertaining to assessing the students' knowledge (both perceptual and actual), and attitude toward whole grains. The assessment of the perceptual knowledge was based on the level of confidence in the topic of whole grains answered as “Yes” and “No.” Actual knowledge was tested by asking questions on whole-grain anatomy, their benefits, and food items containing whole grains.

Statistical analysis

The IBM Statistical Package for Social Sciences (SPSS, Inc. Chicago, IL, USA) version 22.0 was used for data analysis. The BMI was calculated as weight in kilograms divided by height in square meters (kg/m2). Based on the WHO BMI cutoffs for the Asian population, a BMI <18.5 kg/m2 was categorized as underweight, 18.5–22.9 kg/m2 as the normal range, 23.0–27.4 kg/m2 as preobese, and 27.5 kg/m2 or more as obese. The relationship between whole-grain consumption and factors influencing it was assessed using the Chi-square test. All reported P values were two-tailed, and P ≤ 0.05 was considered statistically significant. Multivariable logistic regression analysis was performed to determine the predictors of the practice of whole-grain consumption.


   Results Top


Sociodemographic characteristics

Of the 151 respondents, 68.9% (104) majority were in the age group of 21–23 years with 102 (67.5%) females and 49 (32.5%) males. Majority were Malays (70, 46.4%), followed by Chinese (51, 33.8%), Indians (15, 9.9%), and other ethnic groups (15, 9.9%). Thirty-one students (20.5%) were from preclinical phase and 120 (79.5%) from the clinical phase. About 53% (80) of the participants' mothers and 64.9% (98) of the participants' fathers had attained tertiary education. Fifty-nine percent (89) participants reported that their monthly household income was above 5000 RM and 60.3% (91) of them were living with their friends.

Whole-grain consumption and its pattern

The prevalence of reported whole-grain consumption in the past 3 months was 51% (77).

Of the 77 participants who reported that they consumed whole grains, the proportion of daily whole-grain consumers was 13% (10). About 26% (20) ate whole grains >3 times a month, 23.3% (18) took >3 times/week, 22% (17) had <3 times/week, and 15.6% (12) ate <3 times a month.

Assessment of the type of whole-grain consumed in the past 3 months revealed that 44.1% (34) consumed oatmeal, 35.1% (27) took whole-grain/wholemeal bread, 10.4% (8) took brown rice, and the rest 10.3% (8) ate either biscuits or bars enriched with whole grains such as granola bar.

Comparison between sociodemographic factors and whole-grain consumption

The practice of whole-grain consumption was significantly higher among the Chinese students (33, 42.9%) than other ethnic groups such as Malay (25, 32.5%), Indian (10, 12.9%), and others (9, 11.7%). On the other hand, the practice of consuming nonwhole-grain foods was highest among Malay (45, 60.8%) and lower among other ethnic groups such as Chinese (18, 24.3%), Indian (5, 6.8%), and others (6,8.1%). However, the factors such as phase of MBBS program, parental education, household income, and living arrangement did not reveal any statistically significant association with the practice of whole-grain consumption [Table 1].
Table 1: Comparison of the sociodemographic characteristics with the practice of whole-grain consumption

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Comparison between nutritional characteristics and whole-grain consumption

[Table 2] depicts the relationship between the various nutritional characteristics of the participants with the practice of whole-grain consumption. Regular breakfast consumers (67, 87.1%) had a significantly higher whole-grain consumption compared to the breakfast skippers (10, 12.9%). Of the 118 breakfast consumers, the proportion of whole-grain consumers who prepared and consumed their breakfast at home (42, 62.7%) were significantly higher than the nonwhole-grain consumers who did the same (21, 41.2%). Comparison of BMI and whole-grain consumption revealed that respondents with normal BMI were found to be high in whole-grain consumption (43, 55.8%) than nonwhole-grain consumers (30, 40.5%). The data showed that a significantly greater percentage of the ones who were underweight did not seem to consume whole grains (19, 25.7%) compared with the ones who consumed whole grains (6, 7.8%).
Table 2: Comparison of the nutritional characteristics with the practice of whole-grain consumption

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Beliefs and attitudes toward whole-grain consumption

Statistically significant differences were found in the attitude of the whole-grain consumers and the nonwhole-grain consumers to adherence to food group in the Malaysian food pyramid, among the (P = 0.004, 95% confidence interval [CI] = 0.16–0.72).

A significantly higher proportion of whole-grain consumers (65, 84.4%) expressed that they were likely to include whole grains in their regular diet as compared to the nonwhole-grain consumers (52, 70.3%). Even though majority of the respondents who were not whole-grain consumers (60, 81.1%) expressed more willingness to encourage their family and friends toward whole-grain consumption, the difference was not statistically significant [Table 3].
Table 3: Association of the students' beliefs and attitudes with the practice of whole-grain consumption

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Determinants of whole-grain consumption

Table 4 shows the multivariable logistic regression analysis of factors influencing the practice of whole-grain consumption. The logistic regression model was statistically significant, χ2 (13) = 171.65, P<.001. The model explained 67.7% (Cox and Snell R2) to 90.3% (Nagelkerke R2) of the variance in whole-grain consumption and correctly classified 92.8% of cases. Sensitivity was 93.6%, specificity was 91.9%, positive predictive value was 92.4%, and negative predictive value was 93.2%. Of the predictor variables analyzed, only three were statistically significant: ethnicity (P < 0.01, 95% CI = 1.12–2.30), breakfast habits (P < 0.01, 95% CI = 1.39–3.63), and source of breakfast consumed (P < 0.01, 95% CI = 0.31–0.90) [Table 4]. Regular breakfast consumers had 2.24 times higher odds to consume whole grains than breakfast skippers. Taking breakfast outside home was associated with a decreased likelihood of whole-grain consumption.
Table 4: Multivariable logistic regression analysis of factors predicting whole-grain consumption

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   Discussion Top


The prevalence of whole-grain consumption among medical students was 51%, which is slightly less compared to prevalence (60%) of whole-grain consumers among medical students in Karachi as reported by Nisar et al.[23] However, a study conducted among university students of Nebraska by Rose et al.[14] found that 86% of students reported eating whole grains which is high compared to our results.

Among the whole-grain consumers, the main sources of whole grains were oatmeal and wholemeal bread; as these food items were ready to eat food and required less preparation time and could be easily consumed at home. These findings were similar to those obtained by Rose et al.[14]

Of the 151 respondents, 48% were in the normal weight category of BMI, while rest were either preobese/obese (35.1%) or underweight (16.6%). Our results are similar to those reported in a study conducted by Boo et al.[10] in which they found that only slightly more than half (55.0%) of the students were in the normal weight category, while the rest were either overweight/obese (30.0%) or underweight (15.0%).

To evaluate the factors that influence whole grains as food choice in this study population (medical students), it is discussed under different determinants of food choices below.

Economic determinants

One of the primary determinants of the food choice is cost of the food, and the affordability depends mainly on the income and socioeconomic status. In this study, the affordability, socioeconomic status, and parental education were assessed which did not seem to influence whole-grain consumption, although the influence of cost of the food was not assessed in this study.

Accessibility to shops is another important physical factor influencing food choice, which is dependent on resources such as transport and geographical location. The study conducted by Rose et al.[14] attributed the high percentage of whole-grain consumption to the dining centers within the campus that served mainly whole-grain foods. A similar finding was reported another study that increases the whole-grain consumption is influenced by the dining centers in the campus conducted by Bisanz and Stanek Krogstrand[13] The present study included a preclinical group of students who had easy access to a variety of shops, supermarket and food outlets that served whole grains and a clinical group located at a suburban area that had food outlets serving food which included local, traditional food, and less of whole-grain and few shops/supermarkets that were far away. However, no influence of accessibility on the practice of whole-grain consumption was found.

Physical determinants

Kearney et al. proved that level of education to influence the dietary behavior during adulthood.[24] This study showed no significant influence of parents' education on the practice of whole-grain consumption in their children. Although the study included the students from different level of the MBBS program, the data showed no significant influence of the respondent's level of education on their practice of whole-grain consumption. Hence, the present study showed that there was no influence on the level of education (self and parental) with the practice of whole-grain consumption.

Cooking skills, method involved and preparation time, are the important physical determinants of food choice. This study showed that respondents who prepared and had food at home were more likely to consume whole grains. The observation of the different choice of whole grains consumed by the students (oatmeals 44.1% [34], 35%[27] whole-grain/wholemeal bread, 10.3%[8] brown rice, and the rest 10.3%[8] consuming either biscuits or bars enriched with whole grains such as granola bar). This finding helps us understand that the preferred foods were those requiring less cooking time or instant ready to cook food. Lappalainen et al. reported lack of time as a frequent attitude of not following nutritional advice, particularly by the young and well educated.[25] They also addressed that the issue of lack of time is met with a shift in the fruit and vegetable market, from loose to prepacked, prepared, and ready to cook products.

Social determinants

The present study revealed a significant relationship between the practice of whole-grain consumption and the ethnic or cultural background. Chinese students were the highest among the whole-grain consumers and Malay were the highest in the nonwhole-grain consumer group. This showed the influence of the cultural background and tradition on the type of food consumed. According to a review of the European Food Information Council, 2006, social determinants such as culture, family, peers, and meal patterns influence the eating patterns of an individual.[26]

Social factors impact an individual's or a group's eating behavior directly (buying food) or indirectly (learning from peer's behavior), either consciously (transfer of belief), or subconsciously.[27] Family is widely recognized as being significant in food decisions. Research shows the shaping of food choices taking place in the home. Because family and friends can be a source of encouragement in making and sustaining dietary change, adopting dietary strategies which are acceptable to them may benefit the individual while also having an effect on the eating habits of others.[28] However, in this study, no significant influence of the living arrangements (alone, with family, or with peers) with the practice of whole-grain consumption.

Behavioral determinants

It was found that even though the students had good nutritional knowledge about the basic information on whole grain, the common whole grains available and its health benefits, it did not influence them to consume whole grains. The findings of the present study were similar to those in the study conducted by de Almeida et al., which suggested that nutritional knowledge and good dietary habits are not strongly correlated.[29]

A significant proportion of the respondents in this study who reported that they adhere to the food groups in the Malaysian pyramid were more likely to be whole-grain consumers. In this study, it was found to have a significantly positive attitude among majority of them who did not consume whole grains at present and expressed their willingness to include whole grains in their regular diet while a significant percentage still remained unchanged. It was reported that if people believe that their diets are already healthy it may be unreasonable to expect them to alter their diets, or to consider nutrition/healthy eating as a highly important factor while choosing their food.[30] Although these consumers have a higher probability of having a healthier diet than those who recognize their diet is in need of improvement, they are still far short of the generally accepted public health nutrition goals.

Limitations

The small sample size and lack of generalization of the study findings are limitations of the study.


   Conclusions Top


This study revealed that almost half of the medical students were whole-grain consumers, and only a small percentage consumed whole grains every day. Even though there are many factors that influence the food choice, a striking influence of ethnic background, cooking skills and method, self-perception to adhere to food groups in the Malaysian food pyramid was found.

Further, this study stresses the consistent increase in the status of underweight among the medical schools over the past decade. Nonetheless, the study would like to put forth a hypothetical fact of consumption of more nonwhole-grain foods can project population with underweight and low BMI, which gives scope to further research.

Finally, dynamic approaches need to be formulated that would encourage the medical students to have regular whole grains in their food and lead a healthier life. In order to achieve this goal, a multi-dimensional and multisectoral approach needs to adopt that should involve the education system to include whole grains as an important component of nutrition and its basic knowledge and health benefits emphasized not only in colleges but also at school level as well.

However, more detailed studies need to be conducted to investigate the biological, and psychological, motivating, and hindering factors that influence whole-grain consumption among medical students.

Acknowledgment

The authors would like to thank Sister Norisah Ab Latif and Encik Muhammad Hafizuddin Mohamed Hatta for their assistance in the collection of data and all the students of the School of Medicine, who participated in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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