Phataraphon Markmee*, Sarai Inbou, and Nattanan Changpouk

BODY MASS INDEX AND FACTORS RELATIONSHIP WITH BODY MASS INDEX IN WORKFORCE AGE WITH AT LEAST ONE OF RISKS OF DIABETES MILLITUS, HYPERTENSION AND STROKE IN BANGRAKAM DISTRICT, PHITSANULOK, THAILAND Phataraphon Markmee*, Sarai Inbou, and Nattanan Changpouk Sirindhorn College of Public Health, Phitsanulok Province Praboromrajchanok Institute for Health Workforce Development Ministry of Public Health, Thailand *e-mail : pmarkmee@gmail.com Abstract Workforce age with 35-59 of age is the first of risk of Diabetes mellitus, Hypertension and Stroke. Multi health risks of these diseases should provide information to prepare for health promoting and prevention in risk reduction. Body mass index is the second of risk of these diseases. The objective of this cross-sectional study was to ascertain factors relationship with nutritional status (Body Mass Index: BMI) of 357 objects in Bangrakam District, Phitsanulok Province. Data were collected between November and December, 2015. Samples were selected by multi-stage sampling. Standardized Questionnaires were consisted of 5 parts: socio-demographics, dietary intake, exercise and movement, stress, and body mass index. Data analysis was used multiple regression statistic to examine factors association with nutrition status. The result found that most of objects were male (51.8%), married status (68.3%), average income < 10000 baht (63%) and average age was 45. Nutrition status was found that they had overweight or obese about 26.9%. Factors predicted nutrition status (BMI) were direct relative with at least one of diabetes, hypertension or stroke, person with cholesterol, number of meals > 4 meals per day, cooking method and oil-based dietary behavior. This result recommends that authorities who provide health promoting in risk reduction of diabetes, hypertension, and stroke by body mass index controlling should promote daily food intake especially number of meals per day and oil-based dietary behavior. Keywords : working age, body mass index (BMI), stress, diabetes mellitus, hypertension Introduction : The nutritional status of the population measured like the one shown progressive in developing countries, especially in the economic, social health. Good nutrition will promote public health, with the health and preventing disease and reduce the use of medical services. The long life and healthy life ready to become a key resource in developing countries. Surveillance diet of the people in no overweight standards and malnutrition in individual groups are the heart of human resource development. Because improper nutrition is the causes and risk factors for various diseases. It also has a direct impact on the efficiency and quality of life in the nation. (Division of Nutrition, 1999) A group of middle-aged adults as a group are likely to be very overweight. Since the last increase cells of the body begin to deteriorate slowly. The body's hormone secretion is reduced. As a result, the metabolic rate of the cells reduced by the rate of energy metabolism that requires basic Basal Metabolic Rate (BMR) (LeMone & Burke, 1996; Potter & Perry, 2001). The structure and function of various organs of the body decline whether bone or 50

muscle (Payne & Hahn, 1995; Williams, 1993), make the muscle strength decrease, have restricted the movement of joints (Choo medical doctor, 2538), then the movement of the body slows down. The body has to use less energy in their daily lives. In addition, the deterioration of pancreatic cells, the body prone resists more insulin. Blood sugar levels rise to be transformed into fat accumulate in various parts of the body (Ntitipis Bahadur, 2538; Bray, 1997). The World Health Organization (WHO, 2005) indicated that in the year 2009 around the world have died from chronic diseases, 35 million people, which was about two times that of those who died of the disease at all, and increased 17 percent in the year 2015 WHO estimated in 2015 around 700 million people were obese, overweight million in 2030, aiming to expand the health department organization without hitting a learning organization without a master effects of obesity and overweight in Thailand pressure, diabetes, cardiovascular disease risk factors, especially obesity is an epidemic that is universal worldwide by lack of exercise, smoking, drinking and stress (WHO, 1995). Obese were associated with respiratory disorders during sleep. Gallbladder Disease, mental disorders and stress urinary incontinence are an epidemic that needs to be taken care of in a timely manner (Arthur, 2005) and from the National Health and Nutrition Survey in Thailand by the Thailand national health examination four times from 2008 to 2009 of the population aged 15 years and over Thailand showed a BMI equal to and greater than 25 kg / m 2 8.4% male and 40.7% female had waist over standard in male 18.6%, female 45.0%, patients with diabetes, high blood pressure, and high blood cholesterol causes the deaths of millions of people of Thailand. The main cause of diabetes and hypertension is genetic and behavioral. Today we will see how to proceed with this measure, however, another issue presenting the specific problem is, under the circumstances at the time found that the diabetes prevalence rate in the country. At about 7 percent, meaning the 100 people aged 35 years and over has at least seven people with diabetes. Report of Public Health Thailand by physical examination Source: Report of the Public Health Thailand by physical examination of 2008-2009. The disease, hypertension and diabetes in the downtown district, was found in 2012 in the whole Province with the screening of the population aged 35 and over found a higher risk of developing diabetes of 2.73 and is susceptible to disease, high blood pressure of 16.44 and the follow-up group Pre. - DM 1149 in the year 2011 the number of people that have been diagnosed by a physician as a diabetic of 22 new cases (1.91 percent), followed by the group Pre - HT in 2011 of 6157 people found. was diagnosed by doctors as patients with high blood pressure, a new 135 (2.19 per cent) and in 2012 patients with diabetes, the registered number of 4732 patients (1729 patients per hundred thousand population ratio. ) and patients with hypertension, the registered number of 7987 cases (incidence rate per thousand population 2,919) (Phitsanulok Provincial Public Health Office, 2556). In current environment, the subject and the media has begun to influence the lives of people much higher up and offer a new form of the ubiquitous fast food, junk food diet. But they considered the nutritional value of food and two types that have lower nutritional value (Obcheuy gold, 2541: 95-96). In the current situation risk factors include increasing daily. The food is not proportional consuming; high amounts of alcohol, lack of sufficient exercise change the way a paleontologist, sit, lie. Consumption threshold Stress tends to increase the intensity up, that will open the free market. Age of information is leisure through the television screen. Changing a society uses mechanical and the nature of work to be done repeatedly. These causes Bang Rakam district residents dietary habits changed from the original. Dietary habits are associated with things such as dietary habits popular food choices. A prohibition on the consumption of food and consumer habits, Because of this, suggesting that the diets of people in the country are a major problem should be corrected. 51

The population is aging, with a focus on family especially those aged 35 and over who have the overweight. The second factor is that the patient is at increased risk of hypertension, diabetes and stroke. Information about nutrition and factors that contribute to the risk of increasing will promote health and prevent disease on correctly with problems and needs. Health authorities should understand the issues and data discovery to guide health promotion in reducing the incidence of new cases; treat effectively reduces symptoms and complications. The purpose of the research was to study nutrition and factors association with dietary factors relation to the nutritional status of working age who are at risk for diabetes, hypertension and stroke in Nong Kula sub-district, Bang Rakam district of Phitsanulok. Methodology : This cross-sectional study research aims to study the personal factors, dietary factors, exercise factors movement exerts, and stress factors that influence the nutritional status of the working-age population working age group; aged 35-59 years in Bang Rakam district of Phitsanulok province. Populations were 5,190 working age group aged 35-59 years, 357 samples size were calculated using OpenEpi Version 3, SSpropor, Confidence level 95%, population size 5190 and selected by simple random sampling. Research tools consist of interviewed questionnaires adopted from Tawatchai Keawuan (2010) a stress questionnaires used Suanprung Department of Mental Health, (2002) the first part of questions inclded gender, age, religion, marital status, educational level, professional main income of a family member suffers parents, any smoking, drinking alcohol. The second part questions were factors of diet affects nutrition including dietary habits, consuming foods that provide nutrients such as carbohydrates, protein and fat. Protecting the rights group in this study, researcher had the right to escort the sample studied by letter of authorization approved ethical committee for approval and permission of the Graduate School Director Health Promotion Hospital Ban Phai. The study reported the purpose of education for example, every point for cooperation in education by participating voluntarily without coercion. Simultaneously, it was explained that the group had the right not to provide information without being able to withdraw from the study at any time if needed without affecting the samples. The samples were kept secret by the use of the code name. The data acquired was used in this study only and presented an overview of the data. The samples had useful knowledge factors associated with obesity. The study provided welcome guidance or counseling as appropriate. Data analysis General information and health information were used descriptive statistical analysis such as frequency, percentage, mean, standard deviation. The relationship of risk factors association nutrition statistics was used Multiple Regression Analysis. Result : The study sample consisted of 357 people found that the majority of females than males (51.8 and 48.2 percent), average age was 44.7 most of them had aged between 35-42 years (43.4 percent), followed by ages 43-50 years (33.1 % ) mostly Buddhist (100 percent), married (68.3 percent), education, elementary education (percentage 50.7), most farmers (36.1 percent), followed by, workers (33.1 percent), family monthly income of less than 5,000 baht per month (32.2 percent), followed by revenues of between 5,000-10,000 per month (30.8 percent) lived mostly midsize family (65.5 percent) table. 1 Table 1: Demographic characteristic (n=357) 52

Characteristic Number (%) Gender Male 172 48.2 Female 185 51.8 Age Groups (Year) 35 42 155 43.4 43 50 118 33.1 51-59 84 23.5 Mean =44.72, SD =7.14, Min = 35, Max=59 Marital Status Married 244 68.3 Single 54 17.9 Widow/Divorced/ Separate 49 13.7 Educational Level No education 11 3.1 Primary School 181 50.7 Secondary School 82 23.0 High School 55 15.4 Diploma 12 3.4 Bachelor Degree or higher 16 4.5 Occupation Agriculture 129 36.1 Government officials 9 2.5 Solder/Police 2 0.6 Private business 70 19.6 Labor 124 34.7 Other such housewife/no work 23 6.4 Family monthly income (bath) < 5,000 115 32.2 5,001 10,000 110 30.8 10,001 15,000 90 25.2 > 15,000 40 11.8 Household member (person ) 1-4 234 65.5 5 or more 123 34.5 According to health status, most of subjects had no chronic disease (82.9%) and found had hypertension about 11.8%, followed by diabetes (6.7%). Most of them had never smoked and never drunk (63.6 percent) shown in table 2. Table 2: Number and percentage of health status (n=357) 53

Health Status Number (%) Have chronic disease No 296 82.9 Yes 61 17.1 Current chronic disease Diabetes 24 6.7 Hypertension 42 11.8 Heart disease 17 4.8 Other diseases 4 1.1 Direct relative have diabetes, hypertension or stroke No 226 63.3 Yes 131 36.7 Smoking Never smoke 266 74.5 Ever smoke 46 12.9 Current smoke 45 12.6 Drinking Never drink 227 63.3 Ever drink 59 16.5 Current drinking 71 19.9 Positive rating factors defined as 0 negative factors (risk) as 1. Dietary habits daily in the past week was measured number of meals per day if they ate one meal or eating two meals or eat three meals, the score was 0 and more than three meals was 1that was risk level. The second part; most meals eaten include breakfast, lunch for 0 points and dinner for one score that risk level. The third was the taste of the food eaten offered in the majority of medium roast flavor, spicy, sour, salty, sweet and risk level was greasy or sweet or salty. The fourth was family and practice cooking method divided into 6 method ; multi-methods, boil, fried, puff, grill, and stream, risk level was define as puff or grill. Overall dietary behavior was total points from the 0-4 score of 4 behaviors and 3 of 4 risk levels was overall risk level. The result found that most of subjects had 3 meals per day, and had normal level 91.0%. Most meal eaten of subjects had dinner (6.19%) with risk level. The taste of the food eaten, most of them had medium roast (42.0%). However, risk Level (greasy or sweet or salty) had 31.9%. Cooking Method, they had risk level about 22.1%. Finally, overall risk level was 12.8% shown table 3. Table 3 : Dietary habits daily in the past week (n=357) 54

Characteristics Number (%) Number of meals per day 1 2 0.6 2 22 6.2 3 301 84.3 >3 32 9.0 Normal Level 325 91.0 Risk Level ( more than 3 meals) 32 9.0 Most meals eaten Breakfast 61 17.1 Lunch 75 22.0 Dinner 221 61.9 Normal Level 138 38.7 Risk Level (dinner) 219 61.6 The taste of the food eaten Medium roast 150 42.0 Spicy 93 26.10 Salty 63 17.60 Sweet 53 14.80 Sour 45 12.6 Greasy 21 5.9 Normal Level 243 68.1 Risk Level (greasy or sweet or salty) 114 31.9 Cooking Method Multi-methods 173 48.50 Boil 52 14.6 Fried 52 14.6 Puff 50 14.0 Grill 43 12.0 Steam 18 5.0 Normal Level 278 77.9 Risk Level (puff or grill) 79 22.1 Overall Dietary behavior Normal Level 308 86.2 Risk Level (three of four in risk level) 49 12.8 Dietary factors that provide nutrients such as carbohydrates during the past weeks consisted the consumption of starchy foods: bread, rice, corn, rice noodles, instant noodles, potatoes, taro, and risk level define as 5 8 points. Dietary sugar consists of 7 sugar foods: fruits such as durian, longan, jackfruit with sweet custard or fruit, desserts such as ice cream, cake etc., sparkling water, finished juice, tea, sweet coffee, and energy drinks such as Red Bull risk level define as 4-7 points. Protein dietary behavior dietary intake of had 14 protein food questions in each section are as follows: score 0 and 1.Eat a 0 rating Eating one to rate would be sum of the scores from 0-14 points to break the score. Dietary intake of protein to normal levels the score 0-7 for 0 points and risk level had 8 14points. Fat Dietary Behavior dietary intake of had 6 fat food questions in each section are as follows: score 0 and 1.Eat a 0 rating eating one to rate would be sum of the scores from 0-6 points to break the score. Dietary intake of fat to normal levels the score 0-3 for 0 points and risk level had 4 6 points. Oil- 55

based Dietary Behavior dietary intake of had 12 oil-based food questions in each section are as follows: score 0 and 1.Eat a 0 rating eating one to rate would be sum of the scores from 0-12 points to break the score. Dietary intake of fat to normal levels the score 0-6 for 0 points and risk level had 7 12 points. Most of risk levels were sugar dietary behavior, starchy dietary behavior (Carbohydrate), and oil-based dietary behavior respectively in table 4. Table 4: Risk levels of dietary behaviors daily in the past week by food class (n=357) Characteristics Number (%) Starchy Dietary Behavior Normal Level 178 49.9 Risk Level 179 50.1 Sugar Dietary Behavior Normal Level 172 48.2 Risk Level 185 51.8 Fat Dietary Behavior Normal Level 300 84.0 Risk Level 57 16.0 Protein Dietary Behavior Normal Level 184 51.5 Risk Level 173 48.5 Oil-based Dietary Behavior Normal Level 196 54.9 Risk Level 161 45.1 Most of subjects had exercise (73.4%). Movement consist of 5 activities: (1) craped home or sweep home or dish washer, (2) washing or car wash, (3) cleaning house, (4) walking to work place, and (5) working for yourself on a farm or in the garden. All activities measured 4 Rekert Scale; never = 1 point, rarely = 1 point, often = 0 point, always = 0 point. To normal levels the score was 0-3 points and risk level 4 5 points. The result shows that most of subjects had normal level both exercise and movement in table 5. Table 5: Risk levels of exercise and movement daily in the past week (n=357) Characteristics Number (%) Exercise Normal Level 262 73.4 Risk Level 95 26.6 Movement Normal Level 106 29.7 Risk Level 251 7.3 This study was designed to measure stress by using Suanproung Stress Test-20, SPST-20 (Department of Mental Health, 2015) measured in six months in any event happened to samples including 5 scales: stress score 1 rating means not feel stressed, stress 56

score two points means little stress, stress score three points means moderate stress, stress score four points means a lot of stress, and stress score 5 points means that the most stressful, and interpretation of test stress Suanprung series with 20 points, including a maximum of 100 points by the sum to be divided into four levels: the 0-23 less stressful score 24-41 points a moderate strain 46-61 strain is high, and62 points to severe stress. This study found that more than 50% had height and severe level and average score of stress was about 43 points shown in table 5. Table 5: Number and percentage of stress level (n=357) The body mass index (BMI) is a value derived from the mass (weight) and height of an individual. The BMI is defined as the body mass divided by the square of the body height, and is universally expressed in units of kg/m2, resulting from mass in kilograms and height in meters, then categorized into five levels ; Underweight (< 18.50 kg/m 2 ), Normal Range (18.51-2300 kg/m 2 ), Overweight At Risk Overweight(23.00-25.00 kg/m 2 ), Overweight Moderately Obese(25.00-30.00 kg/m 2 ), and Overweight Severely Obese (> 30.01 kg/m 2 ), (Japan Society for the Study of Obesity,2000). The result showed that higher level was normal range (39%), however more than 45% had over weight that was a risk levels in table 6. Table 6: Levels of body mass index (n=357) Stress Number (%) Mild stress ( 0 23 points) 22 6.2 Moderate stress( 24 41 points) 137 38.4 Height stress ( 42 61 points) 179 50.1 Severe stress ( > 62 points) 19 5.3 Mean =42.82, SD =13.08, Min = 20, Max =92 Body Mass Index (BMI) Number (%) Underweight 59 16.5 Normal Range 141 39.5 Overweight At Risk Overweight 62 17.4 Overweight Moderately Obese 72 20.2 Overweight Severely Obese 23 6.4 Mean =22.88, SD =4.71, Min = 15.44, Max =49.22 Multiple regression analysis was used to predict factors association with body mass index. The model show that factors association with body mass index were at least one of direct relative have diabetes, hypertension or stroke (p- value < 0.001), have chronic disease with High Cholesterol (p- value < 0.001), Number of meals per day with > 4 meals per day (p- value = 0.002), cooking method (p- value = 0.004) and oil-based dietary behavior (p- value < 0.001) in table 7. Table 7: Factors association with body mass index (n=357) Predictors B S.E. Beta P-value 57

Direct relative have diabetes, hypertension or stroke At least one of direct relative 2.339 0.479 0.240 < 0.001 Have chronic disease With High Cholesterol 4.069 1.069 0.184 < 0.001 Number of meals per day > 4 meals per day 2.536 0.807 0.154 0.002 Cooking Method Risk level 1.650 0.563 0.146 0.004 Oil-based Dietary Behavior Risk level -1.732 0.466-0.183 < 0.001 Constant 22.017 0.357 < 0.001 R 2 =.199; SEE = 4.242; F = 17.432; Sig. of F < 0.001 Discussion and Conclusion : The objectives of this cross-sectional study were to study nutrition and factors association with dietary factors relation to the nutritional status of working age who are at risk for diabetes, hypertension and stroke in Nong Kula sub-district, Bang Rakam district of Phitsanulok, sample consisted of 357 subjects selected by simple random sampling. The study found that the majority of females than males, average age was 44.7 most of them had aged between 35-42 years, all of them were Buddhist, most of them were married, education at primary school, most occupation were farmers, family monthly income of less than 5,000 baht per month, lived mostly midsize family (65.5 percent). According to health status, most of subjects had no chronic disease (82.9%) and found had hypertension about 11.8%, followed by diabetes (6.7%). Most of them had never smoked and never drunk (63.6 percent). Overall dietary behavior was total points from the 0-4 score of 4 behaviors and 3 of 4 risk levels was overall risk level. Most of subjects had 3 meals per day, and had normal level 91.0%. Most meal eaten of subjects had dinner (6.19%) with risk level. The taste of the food eaten, most of them had medium roast (42.0%). However, risk Level (greasy or sweet or salty) had 31.9%. Cooking Method, they had risk level about 22.1%. Finally, overall risk level was 12.8%. Most of risk levels of dietary behaviors daily in the past week by food class were sugar dietary behavior, starchy dietary behavior (Carbohydrate), and oil-based dietary behavior respectively. More than 50% of subjects had height and severe level and average score of stress was about 43 points. Body mass index higher level was normal range (39%), however more than 45% had over weight that was a risk levels. Factors association with body mass index were at least one of direct relative have diabetes, hypertension or stroke, have chronic disease with High Cholesterol, number of meals per day with > 4 meals per day, cooking method and oil-based dietary behavior. The model could predict 19.9%. The study found that nutritional status of the sample had overweight and obese BMI harm (43.0 percent), which must be taken care of and resolved urgently. Because overweight level has associated with many diseases. In addition to obesity, then system also affects the body's various systems, such as problems with heart disease, which includes stroke and heart. hypertension, diabetes, cholesterol. Dietary habits and excessive carbohydrate noodles success including tea, coffee and sugar in large quantities on a daily basis should take into account the amount of rice and flour to consumers because if the body has excess demand. It will be transformed to fat stored as body parts. When accumulated more cause obesity the 58

rice is the staple food, starchy foods are interspersed with some meals along with other foods rich in 5 groups and proper proportions sufficient quantities. It is conduct leading to better nutrition and health, healthy. The diet consists of plenty of fat to fry or fried pork, fried chicken, fried fish, such as the introduction of lean meat, cooking pork belly, pork leg, pork mostly. As a result, the body has more energy than necessary. The samples have a habit of eating that sweet taste foods containing coconut milk. This is consistent with the Kachin girl (2551). The sample is moving to exert very little overweight, which resulted in a significant way. Exercise every day, each 30 minutes of exercise frequency represents the number of times each week to exercise to increase physical fitness and exercise. The durability of lungs and heart exercise 3-5 days a week and have done so consistently. Exercise is beneficial to both physical health and mental health. The collection benefits of exercise are many. The health benefits of exercise helps improve muscle strength, improved balance, strength improved. (National Bureau of Statistics, 2004). Limitation, this study had done in one of sub-district of Bangrakam district, Phitsanulok province that cannot represent overall district. Some of questionnaires were self-reported in the past week might have some error. Otherwise, researchers try to collect data carefully to get success information from subjects. Recommendation 1. Health authorities should promote dietary intake education that might effects body mass index to the risk of hypertension, diabetes, and stroke to the risk groups. 2. Future research should develop intervention model and test effective of model to reduce the risk of hypertension, diabetes, and stroke to the risk groups. Reference 1. Department of Mental Health, (2016). Suanproung Stress Test-20, SPST-20. http://www.dmh.go.th/test/stress/ 2. Ministry of Health, Labor and Welfare. (2015). Obesity Homepage(in Japanese).. Retrieved 2013-05-25. http://www.mhlw.go.jp/topics/bukyoku/kenkou/seikatu/himan/about.html 3. Department of Mental Health.(2015) Nutrition and Stress. Retrieved 2015-12-03 www.dmh.go.th/news/view.asp 59