The identified ‘high sugar, high fibre, high energy density and low fat’ DP in this study showed 35% variations in all response variables linked to adiposity and was associated with higher odds of having elevated TC, LDL-C levels and dyslipideamia in adolescents aged 13 years.
Although similar technique of DP assessment (RRR) and response variables were employed, DP identified in this study differed from the DPs characterised in a previous study among the UK children namely the Avon Longitudinal Study of Parents and Children (ALSPAC) (12). In the ALSPAC study, two DPs namely the ‘high energy density, high sugar, high fat and low fibre’ DP and ‘non-energy density, high sugar, low fat’ DP were identified. Nevertheless, both the DPs identified in the current study as well as in the ALSPAC study were characterised mainly by foods high in sugarand therefore suggesting major role of sugar an adolescent’s diet, at least in the studies from these two countries.
The identified DP in this study was characterised by high consumption of SSB, fruit and sweet with lower consumption of cereal and cereal-based dishes, as well as, meat and meat dishes. This is in line with a review on added sugar intake among Malaysian adolescents whereby a high frequency of sugary foods and beverages intake for breakfast and during snacking times was reported (38). The common sweetened foods and beverages frequently consumed (more than twice a week) by Malaysian adolescents include carbonated drinks, fruit juices, caffeinated and chocolate drinks, biscuits, candies, ice cream and cakes (39). On the other hand, a higher SSB intake among Malaysian adolescents aged 13 years in Kuala Lumpur was found to be associated with increased levels of FBG, TG, insulin and HOMA-IR and decreased HDL-C level (40). The excessive intake of sugar (sucrose, fructose, high fructose corn syrup) can directly affect the regulation of lipid and carbohydrate metabolism or it can affect the metabolism indirectly by promoting continuous positive energy balance and gradual weight gain over the long term (41).
The findings from this study were in line with a recent evidence that have evaluated the effect of dietary sugar on cardiometabolic risk in adults, based on systematic review and meta-analyses of 39 randomised controlled trials (42). It was demonstrated that the replacement of fat intake with refined carbohydrate was associated with elevated blood lipids and blood pressure, which consequently increased the risk of cardiovascular diseases (42,43). Although it is quite natural to experience peaks in TC and LDL-C levels during adolescence, it was suggested that elevated LDL-C concentrations among adolescents aged 12 to 18 years was a significant predictor for 38% of dyslipidaemia cases in adulthood after 20 years of follow-up (44). While saturated fatty acids was hypothesised to be associated with the development of heart disease in early 1970s, decades later, refined carbohydrates (added sugar and SSB) have been also linked to the risk of heart disease due to its large consumption (45,46).
The positive correlation observed between the identified DP and higher fruit intakes contradicted findings from the Western countries (9,12,47). Nevertheless, this correlation is consistent with the pattern of fruit intakes in other studies conducted among the Malaysian adolescents (48,49). For instance, a cross-sectional study among 1307 Malaysian children aged 1 to 6 years old in the South East Asian Nutrition Surveys (SEANUTS Malaysia) reported that fruit intakes significantly increases as the children gets older (49). In the same SEANUTS Malaysia study, a total of 1773 children aged between 7 to 9 years reported to have achieved 14% of the recommended daily fruit intake (2 servings), while children aged between 10 and 12 years consumed 20% as per the recommendation (48). In Malaysia, few type of fruits are commonly eaten as a fried item e.g. banana or jackfruit fritters, therefore an increase in the consumption of fruits in this study could be due to the misconception of fried fruits as a healthy dietary intake (39). Another cross-sectional study in 454 adolescents aged 12 to 19 years in Kelantan, Malaysia also reported that older adolescents were more likely to choose healthy foods such as fruits, vegetables and dairy products compared to their younger counterparts (50).
Fruits are known to be rich in fibre content and are perceived as a healthy snack by all age groups including adolescents (51). Evidence suggested that an increase fibre intake may provide protection against cardiometabolic risk factors in adults (52). Although the DP identified in this study was characterised by the favourable aspect of high fibre intake from fruits, it was mainly characterised by tropical fruits available in Malaysia such as papaya, guava, pear, starfruit, mango, banana, lanzones, durian, jackfruit and rambutan, which are high in fructose (sugar) as compared to non-tropical fruits such as apples and oranges (53,54). A lower correlation coefficient between percentage of energy from total fat and the identified DP in this study may be due to the compensation of low dietary fat intakes with high free sugar intakes.
Although the selection of the response variables used in this study were linked to obesity, the identified DP was not associated with overweight or obesity and abdominal obesity. This finding contradicted the results suggested in the ALSPAC study (10). However, the lack of significant associations seen in the current could be due to the use of BMI and WC instead of fat mass to measure adiposity (9). Another potential explanation for the lack of association could be due the cross-sectional design of this study. Similar to this study, lack of an association between a DP characterised by high intakes of sugar, sweets, peanuts butter, jam and margarine and obesity was also reported in adolescents aged 12 to 19 years in Kelantan, Malaysia (50). The lack of observed association between the identified DP and obesity could also due to the reduction in the final sample size. The small sample size might have reduced the power to produce any significant associations in this study. Nonetheless, no significant differences were reported (data not shown) in the anthropometric outcomes and cardiometabolic biomarkers, as well as socio-economic characteristics, particularly maternal education and school location between the total participants and the 336 adolescents (with both valid dietary data and biomarkers data) who were included in the multivariate analysis. The present study also reported no significant association between the identified DP and cardiometabolic risk factors specific to any gender, even though, the males were reported to have a higher mean FBS level and a lower mean TC, HDL-C and LDL-C levels compared to females. This could be due to differences in the timing of puberty among the study adolescents (55,56).
It is important to note that this study was the first to examine relationships between empirical DPs and cardiometabolic risk factors among Malaysian adolescents. Furthermore, the application of RRR, a-priori method to derive a specific DP and the ability to control for dietary misreporting were also the strengths of this study. Despite these study strengths, there are a few limitations worth mentioning. Firstly, this cross-sectional study was subjected to the possibility of finding significant associations by chance alone. Besides, the findings from this study could not be generalised due to limited coverage of the study location, whereby the study was focused only in the southern region of Peninsular Malaysia. Another limitation of the study is the biases inherent to the dietary assessment method. However, this limitation was minimised by using nutrient densities e.g. DED, fibre density and %E fat and sugar as response variables so that errors linked to the dietary assessment method could be reduced (57). While the food items listed in the FFQ of this study and the study conducted among Raine adolescents were different, it was suggested that an identification of Raine DPs using a FFQ was similar to those characterised using a food record (47). Furthermore, the reduced sample size of the available valid dietary data for the RRR analysis could have influenced the strength of relationships between the identified DP and biochemical parameters. However, this is an unavoidable issue particularly among adolescents and that at this large scale of a study.
In conclusion, a DP characterised by food intakes high in free sugars and energy density was associated with elevated lipid profiles, particularly cholesterol and LDL-C levels among adolescents aged 13 years in Malaysia. Further longitudinal studies are recommended to strengthen the role of a dietary pattern explained by food intakes high in sugar, fibre and energy density in the development of cardiometabolic risk factors in young people.