Open Access

Energy and nutrient intakes among Sri Lankan adults

  • Ranil Jayawardena1, 2Email author,
  • Shalika Thennakoon2,
  • Nuala Byrne1,
  • Mario Soares3,
  • Prasad Katulanda1 and
  • Andrew Hills4
International Archives of Medicine20147:34

DOI: 10.1186/1755-7682-7-34

Received: 5 April 2014

Accepted: 5 July 2014

Published: 11 July 2014

Abstract

Introduction

The epidemic of nutrition related non-communicable diseases such as type 2 diabetes mellitus and obesity has reached to epidemic portion in the Sri Lanka. However, to date, detailed data on food consumption in the Sri Lankan population is limited. The aim of this study is to identify energy and major nutrient intake among Sri Lankan adults.

Methods

A nationally-representative sample of adults was selected using a multi-stage random cluster sampling technique.

Results

Data from 463 participants (166 Males, 297 Females) were analyzed. Total energy intake was significantly higher in males (1913 ± 567 kcal/d) than females (1514 ± 458 kcal/d). However, there was no significant gender differences in the percentage of energy from carbohydrate (Male: 72.8 ± 6.4%, Female: 73.9 ± 6.7%), fat (Male: 19.9 ± 6.1%, Female: 18.5 ± 5.7%) and proteins (Male: 10.6 ± 2.1%, Female: 10.9 ± 5.6%).

Conclusion

The present study provides the first national estimates of energy and nutrient intake of the Sri Lankan adult population.

Keywords

Dietary survey Nutrition survey Energy intake Sri Lanka Adults

Introduction

The epidemic of nutrition related non-communicable diseases (NCDs) such as type 2 diabetes mellitus, obesity, Cardio Vascular Diseases (CVDs) and certain cancers are continuing to challenge the health sectors in Asia [1]. Sri Lanka is a low-middle income South Asian country with a population of 20 million. Despite Sri Lanka’s relatively good health status, during the last two decades NCDs have become a more prominent health issue in the country [2]. A quarter of Sri Lankan adults suffer from metabolic syndrome [3]. According to Sri Lanka Diabetes and Cardiovascular Study (SLDCS), the prevalence of diabetes among Sri Lankan adults was nearly 11% and one fifth of adults in Sri Lanka have diabetes or pre-diabetes while one third of those with diabetes are undiagnosed [4]. Premarathna et al., have also reported that there was an increase in the incidences of hospitalization of Sri Lankan adults by 36%, 40% and 29% due to diabetes mellitus, hypertensive disease and ischemic heart disease, respectively, in 2010 compared to 2005 [5]. In Sri Lanka, diet-related chronic diseases currently account for 18.3% of all deaths and 16.7% of hospital expenditure [1]. There is a significant health burden due to NCDs and this will be a challenge to the health sector in a developing country like Sri Lanka.

Some methods to assess the quantity and quality of dietary intake include prospective food records (with weighed or estimated food portions), retrospective 24-hour recalls (24 HDR), and food frequency questionnaires (FFQs) [6]. The 24HDR which is less time consuming and has a low respondent burden, is the method used to gather the quantitative estimate of all foods and beverages that an individual has consumed in the previous 24 hours at a population level. Several national dietary surveys have used 24 HDR and it is known to be acceptable for gathering dietary information on a given day at the population level [7, 8].

National diet and nutrition surveys provide valuable information on a possible partial explanation for the eople’s health status and disease risk [9]. Assessment of the dietary and nutritional status of the population is essential to monitor the ongoing nutrition transition in a country [6]. As a developing country, no studies have been carried out to investigate the information on the diet of Sri Lankans and their nutritional status at a national level. Since Sri Lanka is a multi cultural country, peoples’ foods and dietary habits at a national level should be assessed with a representative sample of Sri Lankan adults, which will be more useful to implement health policies and to initiate many interventions. By keeping this view in mind, the current dietary survey was carried out to assess the intakes of energy, macro-nutrients and selected other nutrients with respect to socio demographic characteristics and the nutritional status of Sri Lankan adults.

Methodology

Study sampling and the subjects

The eligible respondents of this study were healthy Sri Lankan adults aged ≥ 18 years recruited from a sub sample of a Sri Lanka Diabetes and Cardiovascular Study [4]. In this study, a total of 600 subjects were randomly selected representing all nine provinces. This sample population was then stratified for area of residence and ethnicity. Description of sample selection is published elsewhere [10]. Written informed consent for participation in the study was obtained and ethical approval for this study was taken from the Ethical Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka.

Measurements

Socio-demographic variables

The selected subjects were initially contacted via telephone or a postal notice by the study team and the information regarding the study was provided in order to obtain their willingness to participate in the study. On the study day, the purpose of the study was briefly explained to the subjects and the information sheets of the study were also given out. Written consent was obtained from each volunteer prior to data collection. Socio-demographic details and diabetes status were obtained by using an interviewer-administered questionnaire and body weight and height were measured using a standard method. Areas of residence, ethnicities, and education levels were categorized according to Sri Lankan governmental standards [11]. Body mass index (BMI) was calculated by weight (in kilograms) divided by height squared (in meters) and several cut-offs were presented as recommended by WHO experts for Asian populations [12].

Dietary assessment

Dietary data were obtained from a 24 HDR method. The subjects were asked to recall all foods and beverages, consumed over the previous 24-hour period. Respondents were probed for the types of foods and food preparation methods. For uncommon mixed meals, the details of recipes and preparation methods were collected at the time of taking the 24 HDR. Dietary recalls were collected by two trained nutritionists who had received uniform training and adhered to the standard operating procedure (SOP). As dietary assessment aids, the standard household measurements such as plate, bowl, cup, glass, and different spoons etc. and food photograph atlases were used to facilitate the quantification of portion sizes. One medium sized coconut spoon of rice was taken as 100 g, a full plate as 400 g, one cup of liquid as 150 ml, one glass of liquid as 200 ml, a table spoon as 15 g and a tea spoon was taken as 5 g. For different curries, weights of average respective amounts were taken. Household measurements were clarified by demonstration of the real utensils and the food portion size photographs. When subjects recalled some food amount in grams, that information was directly entered. Further details of dietary assessment were published previously [10].

Data analysis

All foods recorded in 24 HDR were converted into grams and then, the intake of total energy, macro nutrients (Carbohydrate, Protein and Fat), sodium and dietary fiber were analyzed using NutriSurvey 2007 (EBISpro, Germany) which was modified for Sri Lankan food recipes. As no updated nutritional database has been gathered for some Sri Lankan food, we used the US Department of Agriculture (USDA) nutrient database [13] as our standard to estimate nutrient content in addition to local and regional food composition databases [14, 15]. Due to the absence of energy and nutrient information on local mixed cooked dishes, we used a cookery book [16]. All the recipes were accepted after checking for face validity by consulting local housewives and nutritionists. According to recipes, ingredients were weighed to the nearest 1 g for edible portions of the foods. Then food items were cooked accordingly and the end product was weighed. Nutritional composition of the final meal was calculated by entering nutritional values and the weights of individual ingredients to the spreadsheet. The sum of each nutrient was computed and standardized to 100 g of final product. We also excluded participants whose reported daily energy intake was not between 800 and 4200 kcal to identify under- and over-reporters of food intake [17].

Statistical analysis

All data were doubly entered and rechecked in Microsoft Excel 2007. Data sorting and cleaning were carried out before data analysis. Data on energy, macro-nutrients and some selected nutrient intakes were transferred from the NutriSurvey 2007 to the Minitab version 15.0 for statistical analysis. Nutrient intake distributions are presented as mean ± SE, median, 25th and 75th percentiles to characterize population intake levels for socio-demographic characteristics (gender, ethnicity, age groups, and educational levels) and BMI categories. One-way ANOVA and t-test were used to examine the differences in mean intakes energy and nutrients intakes. P value < 0.05 was considered statistically significant.

Results

Socio-demographic profile

From 600 subjects, 491 (81.8%) participated and 28 of subjects under-reported their energy intake. So, a total of 463 (77.2%) was included for the analysis. Socio demographic profiles and BMI categories of the subjects are presented in Table  1. The majority of the subjects were from rural areas (59.7%) and 33% of the population were from urban areas followed by the estate sector (tea plantation area) 7.3%. The majority were women (n = 297). By ethnic groups, Sinhalese (78%), Sri Lankan Tamil (9%), Indian Tamil (7%), and Muslim (6%) in this survey. Adults between the age of 41 and 50 years formed the biggest group (25.27%) while the smallest group was the youngest adults aged between 18-30 yrs (13.17%). It was significant that a majority of the study population (39%) had received formal education up to Ordinary Level. The next largest group was adults (25%) who had studied up to Advanced Level.
Table 1

Socio-demographic characteristics of the survey population

Characteristics

Total (n = 463)

Men (n = 166)

Women (n = 297)

n

%

n

%

n

%

Area of residence

      

  Urban

153

33.0

45

26.5

108

36.4

  Rural

276

59.6

102

61.4

174

58.6

  Estate

34

7.4

19

11.5

15

5.0

Age group (yrs)

      

  18-29

61

13.2

27

16.3

34

12.7

  30-39

84

18.1

23

13.8

61

22.8

  40-49

117

25.3

38

22.9

79

29.6

  50-59

106

22. 9

40

20.1

66

24.7

  >60

95

20.5

38

22.9

57

21.4

Ethnicity

      

  Sinhala

360

77.7

118

71.0

242

82.5

  Muslim

27

5.8

8

4.8

19

6.4

  Sri Lankan Tamil

42

9.1

20

12.1

22

7.4

  Indian Tamil

34

7.3

20

12.1

14

4.7

Educational level

      

  No schooling

27

58.3

11

6.6

16

5.4

  Up to 5 years

113

24.4

43

25.9

70

23.6

  Up to O/L

182

39.3

59

35.5

123

41.4

  Up to A/L

116

25.1

46

27.7

70

23.6

  Graduate

25

5.4

07

4.2

18

6.1

BMI category

      

  ≤ 18.5 kg.m-2

64

13.8

29

17.5

35

11.8

  > 18.5 - ≤ 22.9 kg.m-2

163

35.2

75

45.2

88

29.6

  > 23 - ≤ 24.99 kg.m-2

76

16.4

21

12.6

55

18.5

  > 25 - ≤ 27.5 kg.m-2

95

20.5

32

19.3

63

21.1

  ≥ 27.5 kg.m-2

65

14.1

09

5.4

56

18.9

Energy intake

Table  2 represents the distribution of energy intake of Sri Lankan adults. The mean energy intake of men was significantly higher (1912.7 kcal/d) than that of women (1513.6 kcal/d) (p < 0.05). People living in the estate sector have a significant lower energy intake compared to both the urban and rural subjects (p < 0.05). Muslims had the highest intake of daily energy (1748.8 kcal) while Indian Tamils had the lowest (1437.7 Kcal/d) which statistically significant for both men and women (p < 0.05). Energy consumption of both gender groups declined gradually with their age. Energy intake increased gradually with educational level. According to BMI categories, lower energy levels were reported in both extremes and no distinct pattern was seen.
Table 2

Energy intake (kcal) of Sri Lankan adults by socio-demographic characteristics

Characteristics

All subjects (n =463)

Men (n = 166)

Women (n = 297)

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

   

25

75

   

25

75

   

25

75

Area of residence

  Urban

1669

45

1594

1217

2005

1910

89

1899

1522

2218

1569

50

1453

1158

1885

  Rural

1677

32

1590

1304

1994

1975

57

1926

1518

2300

1502

32

1462

1193

1728

  Estate

1439

61

1468

1114

1690

1581

72

1635

1294

1847

1258

87

1340

973

1470

Ethnicity

  Sinhala

1669

28

1256

1589

1977

1947

51

1901

1518

2247

1533

30

1447

1173

1790

  Muslim

1749

84

1435

1647

2156

1949

173

1984

1458

2324

1664

91

1626

1401

2026

  Sri Lankan Tamil

1671

100

1189

1526

2091

2061

161

2094

1660

2352

1317

62

1334

1071

1523

  Indian Tamil

1438

61

1468

1114

1690

1546

77

1634

1225

1833

1283

90

1354

993

1472

Age group (years)

  18-30

1832

75

1942

1297

2301

2166

95

2064

1942

2392

1567

91

1385

1108

2052

  31-40

1808

64

1661

1403

2059

2250

148

1777

1633

2726

1641

56

1596

1346

1892

  41-50

1634

46

1545

1268

1906

1810

89

1848

1418

2099

1549

51

1507

1197

1821

  51-60

1614

49

1544

1233

1905

1859

70

1639

1595

2037

1465

60

1361

1134

1701

  >61

1487

47

1394

1138

1747

1688

84

2155

1305

2094

1353

48

1257

1068

1626

Educational level

  No schooling

1287

73

1202

905

1589

1442

115

1484

1123

1792

1181

89

1117

882

1469

  Up to 5 years

1556

39

1528

1233

1831

1748

69

1715

1380

1992

1438

42

1451

1138

1655

  Up to O/L

1677

40

1788

1299

2468

1970

77

1873

1493

2356

1536

41

1473

1194

1787

  Up to A/L

1823

55

1763

1378

2183

2058

89

2086

1590

2292

1668

65

1583

1224

2008

  Graduate

1594

102

1470

1226

2000

2221

119

2234

1977

2543

1350

78

1265

1065

1635

BMI category

  ≤ 18.5 kgm-2

1548

64

1409

1173

1799

1782

113

1637

1288

2151

1354

54

1325

1135

1466

  >18.5 - ≤ 22.9 kgm2

1731

45

1642

1296

2064

1946

66

1886

1522

2290

1548

56

1439

1113

1907

  >23 - ≤ 24.9 kgm-2

1666

60

1570

1294

1857

1910

118

1817

1493

2083

1532

62

1466

1233

1724

  > 25 - ≤ 27.5 kgm-2

1674

52

1677

1285

1977

1988

99

1987

1650

2324

1556

56

1579

1224

1790

  ≥ 27.5 kgm-2

1541

54

1520

1169

1871

1851

147

1892

1569

2103

1491

56

1430

1138

1728

Carbohydrate intake

The mean daily carbohydrate intake was shown in Table  3. The total mean carbohydrate intake of Sri Lankan adults was approximately 304.4 g (71.2% of total energy from Carbohydrates as shown in Figure  1). By strata, rural adults had a higher intake of carbohydrate (307.7 g) than their estate counterparts (270.3 g). Mean carbohydrate intake was highest in Sinhalese (308.7 g) and lowest in Indian Tamils (269.9 g). Male adults’ carbohydrate intake (352.4 g/day) was significantly higher than that of women (277.5 g/day). Carbohydrate intake declined with age.
Table 3

Carbohydrate intake (g) of Sri Lankan adults by socio-demographic characteristics

Characteristics

All subjects (n =463)

Men (n = 166)

Women (n = 297)

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

   

25

75

   

25

75

   

25

75

Area of residence

  Urban

305.9

8.7

290.7

217.5

373.5

343.5

16.3

346.7

262.8

414.1

290.4

10.0

259.1

259.1

349.1

  Rural

307.7

6.2

292.3

233.0

365.7

367.1

11.4

353.9

285.3

425.6

272.8

5.88

262.1

262.1

324.7

  Estate

270.3

11.8

266.6

213.0

320.6

295.0

13.7

309.5

237.2

345.4

239.0

17.7

237.2

237.2

262.7

Ethnicity

  Sinhala

308.7

5.6

292.3

229.7

368.0

363.1

10.3

346.8

289.3

427.7

282.2

5.9

262.0

214.3

330.8

  Muslim

298.0

13.9

299.9

245.2

348.4

316.8

30.7

282.8

247.3

404.6

290.0

15.1

299.9

245.2

348.4

  Sri Lankan Tamil

298.9

17.7

269.9

203.4

375.1

367.9

27.3

369.6

315.9

402.0

236.1

12.6

226.8

199.6

267.2

  Indian Tamil

269.9

11.9

266.6

213.0

320.6

288.0

14.7

300.6

233.8

341.5

244.2

18.1

237.7

196.2

270.8

Age group (years)

  18-30

338.9

15.1

340.2

233.7

425.8

401.9

19.0

400.7

345.5

440.1

289.0

18.6

247.7

206.0

392.2

  31-40

305.0

10.8

299.5

252.8

344.1

423.6

28.6

395.8

309.5

477.8

305.0

10.8

299.5

252.8

344.1

  41-50

298.7

8.6

294.6

232.8

352.1

330.4

17.1

316.3

252.4

381.3

283.4

9.4

272.6

226.9

333.3

  51-60

291.9

9.4

273.5

225.5

348.5

339.1

13.2

329.0

275.1

398.1

263.2

11.4

235.4

198.2

321.7

  >61

273.8

9.1

261.0

203.9

324.8

310.2

16.4

306.6

233.7

371.9

249.5

9.35

239.0

201.4

390.4

Educational level

  No schooling

242.9

13.5

235.7

174.2

305.5

270.9

21.1

259.2

211.4

318.2

223.6

16.4

216.2

160.6

258.0

  Up to 5 years

286.4

7.8

276.4

228.9

331.6

323.8

14.3

317.6

244.5

386.8

263.5

7.9

261.3

216.1

307.1

  Up to O/L

309.3

7.7

290.8

233.2

364.8

366.8

15.5

345.5

290.9

415.5

281.8

7.4

262.6

221.1

329.5

  Up to A/L

332.5

11.1

323.1

243.7

399.0

373.1

16.9

374.7

300.3

427.9

305.9

13.8

279.6

216.0

360.8

  Graduate

284.8

18.5

239.0

203.6

343.1

399.2

22.5

401.6

323.0

440.4

240.3

13.5

232.2

200.0

293.1

BMI category

  ≤ 18.5 kgm-2

292.0

13.3

254.2

220.1

329.8

342.6

23.5

323.7

237.5

401.9

250.1

10.3

238.2

205.7

268.8

  >18.5 - ≤ 22.9 kgm2

318.1

8.7

301.6

230.5

376.3

356.3

12.5

335.8

291.5

418.3

285.5

11.0

258.5

213.2

349.5

  >23 - ≤ 24.9 kgm-2

305.2

12.1

275.1

236.2

349.9

350.5

22.6

346.7

266.6

401.7

280.2

12.8

258.5

213.2

349.5

  > 25 - ≤ 27.5 kgm-2

303.4

9.8

301.9

236.3

356.3

363.2

20.3

368.0

291.3

426.0

280.9

9.8

283.1

214.9

331.7

  ≥ 27.5 kgm-2

282.4

10.4

264.6

221.4

334.1

325.8

28.2

317.6

263.4

378.0

275.5

11.0

262.8

211.1

329.4

Figure 1

Percentage energy contribution from macronutrients according to gender, ethnicity and area of residance, BMI, educational level and age group.

Protein intake

Sri Lankan adults recorded a mean daily protein intake of 44.6 g whilst men’s intake (52.8 g) was significantly higher than women’s intake (40.0 g). As shown in Table  4, rural (42.9 g/day) and estate (43.7 g/day) adults had similar daily intakes of protein. However, by ethnicity, mean protein intake was significantly higher in Muslims (52.2 g) compared others. Youngest group by age also consumed significantly more protein than others but only for men.
Table 4

Protien intake (g) of Sri Lankan adults by socio-demographic characteristics

Characteristics

All subjects (n =463)

Men (n = 166)

Women (n = 297)

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

   

25

75

   

25

75

   

25

75

Area of residence

  Urban

47.8

3.6

41.0

31.8

53.3

62.7

11.6

47.7

37.8

67.1

41.6

1.4

38.8

29.7

50.5

  Rural

42.9

0.9

39.8

32.5

50.7

48.7

1.6

45.6

35.6

57.9

39.5

1.0

37.6

29.9

46.2

  Estate

43.7

2.4

42.1

32.6

54.9

50.4

3.1

53.0

38.8

61.9

35.1

2.2

33.8

27.3

44.4

Ethnicity

  Sinhala

44.2

1.6

39.8

32.1

50.5

52.6

4.5

35.6

35.6

57.1

40.1

0.9

37.5

29.7

47.6

  Muslim

52.2

2.6

49.9

40.9

61.3

58.6

5.1

47.3

47.3

70.1

49.4

2.9

47.7

40.2

60.8

  Sri Lankan Tamil

44.1

3.2

38.8

29.8

52.8

54.8

5.5

38.6

38.6

65.1

34.4

1.8

34.0

27.9

39.6

  Indian Tamil

43.4

2.5

42.1

32.6

54.9

48.9

3.3

38.2

38.2

61.0

35.3

2.5

33.9

27.3

44.4

Age group (yrs)

  18-30

57.4

8.6

46.8

34.3

60.6

74.9

18.8

52.3

43.8

74.9

43.4

2.6

41.0

31.8

53.9

  31-40

47.6

2.0

42.9

34.5

52.6

59.5

4.8

53.3

41.5

72.5

43.1

2.0

40.4

32.6

47.0

  41-50

42.6

1.2

41.0

32.7

50.5

46.5

2.3

44.9

35.5

54.3

40.8

1.4

49.9

37.9

69.8

  51-60

41.9

1.5

38.1

29.6

50.8

48.4

2.5

48.2

37.0

56.2

38.0

1.7

34.6

27.3

46.2

  >61

39.1

1.4

34.4

29.9

45.4

43.7

2.5

40.2

32.2

54.9

36.0

1.6

33.5

28.6

41.0

Educational level

  No schooling

33.1

2.0

33.8

25.3

38.3

67.7

22.1

52.3

43.8

74.9

31.9

2.7

32.4

24.2

41.1

  Up to 5 years

41.9

1.4

38.8

30.5

49.3

59.5

4.8

53.3

41.5

72.5

38.8

1.5

37.7

28.6

44.7

  Up to O/L

42.7

1.1

39.6

32.4

50.5

46.5

2.3

44.9

35.5

54.3

39.4

1.1

36.4

30.0

46.3

  Up to A/L

52.9

4.7

45.5

35.7

56.5

48.4

2.5

48.2

37.0

56.3

44.4

1.8

40.8

32.7

53.8

  Graduate

44.24

3.5

40.2

32.2

57.5

43.7

2.5

40.2

32.2

54.9

39.4

4.1

34.3

29.5

41.9

BMI Category

  ≤ 18.5 kgm-2

41.6

1.2

39.9

31.8

46.6

45.8

2.9

43.0

35.6

52.4

38.1

2.3

34.1

29.6

43.2

  >18.5 - ≤ 22.9 kgm2

47.6

3.4

41.0

32.5

53.3

55.6

7.0

46.0

36.2

59.1

40.6

1.6

37.8

29.4

50.3

  >23 - ≤ 24.9 kgm-2

44.6

2.0

41.1

32.7

49.3

52.8

3.9

47.7

35.6

59.0

40.0

1.8

34.1

29.6

43.2

  > 25 - ≤ 27.5 kgm-2

43.8

1.5

39.9

32.6

54.4

52.6

2.8

53.2

41.9

64.4

40.5

1.7

37.9

30.5

48.7

  ≥ 27.5 kgm-2

41.1

1.7

37.7

29.5

48.3

52.1

6.2

56.3

33.3

70.8

39.3

1.7

36.5

29.0

46.3

Fat intake

Estimated daily mean fat intake of Sri Lankan adults was 35 g. A more or less similar fat consumption was noted for rural and urban residents (Table  5) whereas estate people had significantly lower intake of fat (24.76 g; p < 0.05). The youngest age group recorded the highest fat intake (37.7 g) while the lowest intake was observed in the oldest age group (30.8 g). By ethnic groups, Muslims had the highest fat intake (44.7 g) whilst the Indian Tamils had the lowest (24 g) which is significantly lower than Muslims (p < 0.05). With education level, fat consumption was increased particularly among men. Adults with normal BMI and BMI > 25 - ≤ 27.5 kgm-2 had a higher fat intake than other BMI categories.
Table 5

Fat intake (g) of Sri Lankan adults by socio-demographic characteristics

Characteristics

All subjects (n =463)

Men (n = 166)

Women (n = 297)

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

   

25

75

   

25

75

   

25

75

Area of residence

  Urban

35.3

1.3

31.3

23.8

43.2

42.8

2.98

37.1

27.6

58.2

32.2

1.3

29.8

22.8

38.5

  Rural

36.1

0.9

34.2

23.8

43.8

41.9

1.70

39.1

29.6

50.2

32.7

1.1

30.2

21.6

40.6

  Estate

24.8

1.8

22.3

17.0

34.8

27.3

2.39

22.8

17.9

35.4

21.6

2.6

18.7

14.6

26.4

Ethnicity

  Sinhala

34.8

0.8

32.4

23.0

42.6

40.4

1.53

37.6

28.7

49.8

32.1

0.9

29.8

21.5

39.6

  Muslim

44.7

4.0

37.9

29.4

61.3

57.0

8.68

55.4

37.5

78.6

39.6

3.8

36.4

25.0

54.6

  Sri Lankan Tamil

39.0

2.9

32.8

25.6

52.0

48.2

4.67

46.0

30.2

62.9

30.6

2.4

28.6

22.1

35.4

  Indian Tamil

24.9

1.8

22.3

17.2

34.8

26.8

2.32

22.3

17.4

35.3

22.2

2.7

21.2

15.7

26.9

Age group (years)

  18-30

37.7

2.2

36.3

24.8

44.9

45.0

3.58

39.1

33.8

60.4

32.0

2.2

30.8

22.6

41.7

  31-40

36.6

1.8

33.9

24.6

44.3

45.4

4.48

40.1

29.5

60.9

33.2

1.7

29.6

24.2

42.2

  41-50

35.4

1.6

31.8

24.1

41.9

40.5

2.96

37.7

28.0

53.2

33.0

1.8

30.8

21.6

39.0

  51-60

35.6

1.6

32.8

22.7

45.0

38.8

2.82

34.3

24.0

49.7

33.6

1.8

32.4

22.1

39.2

  >61

30.8

1.4

27.4

20.7

39.6

36.1

2.39

34.2

23.7

46.8

27.3

1.7

24.4

19.0

33.0

Educational level

  No schooling

23.6

2.1

20.5

16.4

30.8

26.6

3.34

22.8

17.9

32.8

21.4

2.6

19.5

13.6

29.0

  Up to 5 years

32.1

1.2

39.2

23.2

29.9

34.9

1.84

35.4

24.9

42.0

30.4

1.5

29.0

22.3

36.6

  Up to O/L

35.0

1.2

31.7

22.1

44.8

40.3

2.30

38.0

25.3

52.2

32.5

1.3

29.0

20.7

41.0

  Up to A/L

39.6

1.6

36.4

26.7

46.0

46.0

3.05

39.4

31.9

60.8

35.4

1.7

34.6

24.3

42.8

  Graduate

39.3

3.9

34.2

23.8

58.5

61.6

5.25

60.9

56.6

76.1

30.6

3.2

35.4

21.8

28.4

BMI category

  ≤ 18.5 kgm-2

28.8

1.8

24.2

17.3

35.6

33.3

3.04

28.0

19.6

43.8

25.1

2.0

22.6

16.4

30.6

  >18.5 - ≤ 22.9 kgm2

37.2

1.4

34.8

23.7

46.7

42.6

2.16

38.8

29.2

51.8

32.3

1.5

30.0

22.1

40.9

  >23 - ≤ 24.9 kgm-2

34.2

1.6

32.5

25.4

39.5

39.0

3.52

33.7

26.9

57.5

32.0

1.5

32.6

25.6

38.0

  > 25 - ≤ 27.5 kgm-2

36.8

1.6

35.8

24.1

45.5

42.2

3.06

38.3

29.6

53.3

34.8

1.9

32.8

22.2

44.8

  ≥ 27.5 kgm-2

34.0

2.0

28.7

24.0

40.0

44.9

7.02

37.8

26.4

66.2

32.3

2.0

28.6

22.4

39.3

Energy contribution from macro nutrients

As a whole, 71.2% energy come from carbohydrates among Sri Lankan adults, 10.8% from protein and 18.9% from fat. Comparisons of the percentage of energy derived from macronutrients according to socio demographic profile and BMI categories were shown in Figure  1. By ethnic distribution, Muslims had more energy from fat (22.3%) while Indian Tamils had the lowest amount of fat (15.5%) and highest intake of carbohydrates (75%). The percentage of calories from protein were relatively higher among the graduates. In contrast, adults who did not receive a formal education had a higher percentage of energy from carbohydrates compared to other groups. There was no difference in energy distribution between diabetic and non-diabetic subjects.

Dietary fiber

The daily mean dietary fiber intake of Sri Lankan adults was 18.1 g (men: 21.3 g; women: 16.3 g; p < 0.05). By area of residence, estate adults had a higher dietary fiber intake (20.6 g) than their urban and rural counterparts (Table  6). Mean dietary fiber intake was highest in Indian Tamils (20.6 g) and lowest in Sinhalese (17.6 g) (p < 0.05). Dietary fiber intake increased with educational level and a similar trend was observed for women as men. Daily dietary fiber intake was always higher among men than women with different socio demographic characteristics. Adults aged > 60 years had the lowest intake of fiber.
Table 6

Dietary fiber intake (g) of Sri Lankan adults by socio demographic characteristics

Characteristics

All subjects (n =463)

Men (n = 166)

Women (n = 297)

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

   

25

75

   

25

75

   

25

75

Area of residence

  Urban

18.1

0.7

16.2

12.2

22.6

19.7

1.4

17.0

13.8

25.5

17.5

0.8

15.4

11.9

21.0

  Rural

17.7

0.5

16.6

12.2

21.3

21.3

0.8

18.6

15.6

26.8

15.6

0.5

15.1

11.1

19.0

  Estate

20.6

1.9

17.7

12.8

28.7

24.9

2.8

22.3

14.6

33.1

15.2

1.5

16.7

8.8

19.5

Ethnicity

  Sinhala

17.7

0.4

16.4

12.1

21.4

20.2

0.8

17.8

14.1

24.9

16.4

0.5

15.6

11.3

19.7

  Muslim

18.8

1.4

18.0

12.8

24.4

22.4

2.3

22.7

16.7

24.8

17.2

1.7

15.3

12.1

19.5

  Sri Lankan Tamil

18.8

1.3

17.4

12.4

26.4

23.8

2.0

26.4

15.6

31.8

14.3

1.0

13.6

11.1

18.6

  Indian Tamil

20.6

1.9

17.6

12.8

28.7

24.5

2.6

20.8

15.2

32.7

15.0

1.6

15.5

8.7

19.9

Age group (years)

  18-30

18.1

1.0

16.9

11.7

22.3

21.6

1.7

21.0

14.2

26.5

15.3

1.1

14.4

10.7

19.2

  31-40

18.6

0.9

17.1

13.0

22.1

22.8

1.8

20.9

17.0

27.1

17.0

0.9

16.4

12.2

20.0

  41-50

18.2

0.7

17.0

13.4

22.0

19.9

1.5

17.4

14.0

25.5

17.4

0.8

16.4

12.9

20.5

  51-60

18.8

0.9

16.5

12.0

25.4

23.4

1.6

20.4

15.6

31.3

16.0

1.0

14.4

10.1

19.6

  >61

16.6

0.8

15.6

10.5

20.4

19.3

1.4

18.3

14.8

23.7

14.8

1.0

13.0

9.2

18.8

Educational level

  No Schooling

15.6

1.2

19.1

10.5

17.0

17.0

2.2

17.2

10.5

22.1

14.6

1.4

15.9

10.1

18.9

  Up to 5 years

17.6

0.8

15.4

11.8

20.4

21.9

1.7

18.3

14.1

29.1

15.0

0.8

13.6

10.8

18.8

  Up to O/L

17.6

0.6

16.3

12.2

21.0

20.5

1.1

17.4

14.1

26.8

16.2

0.6

15.6

11.4

19.6

  Up to A/L

19.9

0.8

18.4

13.9

25.3

22.3

1.3

21.0

15.8

26.9

18.2

1.1

17.7

12.8

22.1

  Graduate

17.8

1.6

18.0

10.6

23.0

24.2

2.7

23.3

22.4

27.1

15.3

1.7

13.6

9.8

20.1

BMI category

  ≤ 18.5 kgm-2

16.9

0.9

15.8

11.9

21.2

18.8

1.4

17.2

13.8

23.4

15.4

1.0

14.3

10.6

19.4

  >18.5 - ≤ 22.9 kgm-2

19.1

0.7

17.1

13.0

22.6

23.0

1.1

20.9

15.6

27.4

15.8

0.8

14.6

11.5

18.8

  >23 - ≤ 24.9 kgm-2

17.3

1.0

16.2

11.2

22.0

19.1

1.8

16.7

13.2

26.8

16.4

1.1

13.8

10.8

20.8

  > 25 - ≤ 27.5 kgm-2

18.2

0.7

17.0

13.6

22.4

20.6

1.4

17.2

15.8

26.6

17.4

0.8

16.4

13.1

20.9

  ≥ 27.5 kgm-2

17.2

1.2

15.5

9.3

20.4

23.6

4.4

21.2

11.9

33.2

17.3

0.8

16.4

13.0

20.6

Sodium

Daily mean sodium intake was 3.26 g and 2.51 g for men and women, respectively (p < 0.05). Dietary sodium intake of Sri Lankan adults according to demographic and BMI categories is shown in Table  7. Mean sodium intake of rural adults was 2.89 g, followed by urban adults (2.73 g). The Estate sector had the lowest intake (2.48 g). Muslims and Sri Lankan Tamils had a higher intake of sodium than Sinhalese and Indian Tamils. With aging, sodium intake declined and the youngest age group recorded the highest intake (3.04 g).
Table 7

Sodium intake (mg) of Sri Lankan adults by socio-demographic characteristics

Characteristics

All subjects (n =463)

Men (n = 166)

Women (n = 297)

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

Mean

±SE

Median

Percentiles

   

25

75

   

25

75

   

25

75

Area of residence

  Urban

2729

102

2509

1835

3411

3100

196

3003

1952

3893

2574

116

2362

1711

3242

  Rural

2890

81

2582

2025

3507

3396

155

3190

2448

4211

2605

84

2374

1870

3143

  Estate

2477

156

2378

1800

3072

2889

184

2665

2377

3502

1954

200

2036

1359

2350

Ethnicity

  Sinhala

2769

61

2523

1934

3391

3155

107

2969

2228

3877

2580

70

2372

1825

3225

  Muslim

3012

301

2610

1941

3910

2983

345

3256

2085

3760

3023

407

2469

1612

4023

  Sri Lankan Tamil

3306

333

2797

1954

4487

4400

588

4492

2624

5463

2311

176

2189

1803

2859

  Indian Tamil

2488

154

2378

1800

3072

2831

184

2598

2144

3467

1997

209

2096

1440

2363

Age group (years)

  18-30

3045

145

3071

2186

3519

3436

238

3179

2536

4258

2736

162

2873

1915

3441

  31-40

2940

144

2532

2048

3667

3883

311

3856

2379

4669

2584

135

2390

1903

2985

  41-50

2778

99

2536

2048

3667

2976

173

2655

2163

3833

2683

120

2480

2023

3245

  51-60

2832

162

2448

1817

3441

3188

307

2560

2013

3924

2616

180

2211

1678.

3299

  >61

2564

114

2363

1652

3265

3108

187

3106

2290

3822

2201

123

2003

1577

2511

Educational level

  No schooling

2290

193

2157

1359

2954

2923

279

2530

2200

3562

1855

206

1740

1203

2302

  Up to 5 years

2697

114

2403

1847

3351

2984

169

2772

2198

3813

2521

148

2188

1684

3032

  Up to O/L

2825

104

2500

1944

3461

3353

233

3200

2057

3910

2571

99

2371

1903

3031

  Up to A/L

2971

113

2715

2122

3437

3300

187

2999

2479

4385

2755

136

2645

1937

3249

  Graduate

3046

269

3126

1739

3910

4384

447

4432

3562

5215

2526

241

2663

1506

3408

BMI category

  ≤ 18.5 kgm-2

2580

147

2296

1649

3383

3124

252

2927

2052

4219

2129

129

2054

1541

2793

  >18.5 - ≤ 22.9 kgm2

3029

114

2665

2069

3622

3464

192

3231

2509

4111

2659

121

2449

1879

3261

  >23 - ≤ 24.9 kgm-2

2775

150

2486

1914

3241

2896

232

2536

1958

3716

2708

196

2443

1858

3211

  > 25 - ≤ 27.5 kgm-2

2756

120

2509

1974

3405

3179

119

3213

2278

4126

2596

143

2257

1800

3240

  ≥ 27.5 kgm-2

2615

133

2351

1769

3502

3286

435

3810

2099

4306

2507

135

2255

1660

3287

Discussion

Although national dietary and nutrition surveys have a number of important functions and can provide much valuable information, Sri Lanka had never conducted a national food consumption survey before, probably due to lack of human and financial resources. This is the first attempt to report energy and macronutrients intakes in a fairly representative sample over the island using updated food composition data. Subject distribution of ethnic groups, area of residence and educational levels closely mirror the national statistics [11].

Differences in calorie consumption were seen according to demographic and BMI categories. Men consume larger portions of foods and are expected to obtain a higher amount of energy than their female counterparts [18]. The intake of energy by Sri Lankan men was found to be higher than that of women by about 350 kcals. Similar differences were reported among Malaysian adults [19] and in Britain the difference was nearly 700 kcal [20]. When compared to people living in urban and rural areas, estate workers are getting the least energy. Lower mean energy intake was reported among Malaysian estate workers [21]. The decline in calorie consumption with age was probably due to reduction in physical activity levels and poor appetite, particularly in older adults. Different energy intakes in ethnic groups may represent their cultural eating habits. For instance, Muslim people tend to have a higher energy intake and eat more fat rich food items compared to Indian Tamils. Up to A/L by education level, energy consumption was gradually increased, this is probably associated with increased purchasing power with higher education status; however, graduate groups may be also aware of health issues associated with excess energy. In developed countries, calorie consumption is inversely associated with education levels [22]. Except for the very obese category, consumption of total energy intake was steadily rising with BMI categories. Under-reporting of food intake by obese subjects is well documented [23].

The total daily intake of protein in Sri Lankan adults is almost half that of the US adults and, among Americans 2/3 of all protein, is derived from animal sources [24]. In contrast, plant sources (rice and pulses) are the main contributors of protein among Sri Lankan adults [10, 25]. American men consume over 100 gms of fat daily and for women it is 65 g [26]. Corresponding values for Sri Lankans are 40.5 grams and 31.9 grams. In addition to the amount of fat, the type of fat is crucial for development of diet-related chronic diseases such as cardiovascular disease. Although, sub types of fat are not reported in this analysis, the main lipid source in Sri Lankan diet is coconut milk/oil which is high in saturated fatty acids [27]. Therefore, it is important to conduct further studies to explore the coconut consumption and associated cardiovascular disease risk in this population.

Energy-providing macronutrient proportions could vary in different populations. According to the ranges of population nutrient intake goals recommended by WHO, the percentage of energy from total carbohydrates, fats and proteins should be 55-75%, 15-30% and 10-15%, respectively [28]. British adults consume less than fifty percent of energy (men: 47.7%; women: 48.5%) from carbohydrates, whilst fat intake contributes 35.8% and 34.9% of total energy for men and women respectively. The contribution of protein as an energy source is 16.5% for both sexes [20]. In contrast to western countries, Malaysians get nearly 60% of their energy from carbohydrates, 14% of energy from protein and the rest from fats [19]. In contrast to western countries and some Asian countries, Sri Lankan adults consume proportionally more carbohydrates (>71% of energy) and less fat (<19% of energy) and proteins (<11%). The prevalence of diabetes in Sri Lanka is 11% and one fifth of adults are suffering from diabetes despite low levels of obesity (BMI > 30 = 3.7%). Since the study is cross-sectional in nature, we cannot conclude the association between the relatively larger contribution of energy from carbohydrate and higher prevalence of diabetes/dysglycemia among Sri Lankan adults, in spite of carbohydrates contributing over 70% of energy for both diabetics and non-diabetics. Longitudinal studies assessing the prospective risk of developing diabetes and the proportion of energy derived from macronutrients are needed to fully elucidate an association. A high intake of carbohydrate may lead to hyperinsulinaemia, high serum TAG and low HDL-cholesterol levels and chronic consumption of large carbohydrate meals may cause postprandial hyperglycaemia and hypertriacylglycerolaemia and eventually develop insulin resistance and diabetes [29].

A generous intake of dietary fiber reduces risk of developing many diseases including coronary heart disease, stroke, hypertension, diabetes, obesity, and certain gastrointestinal disorders as well as improving metabolic parameters and immune functions [30]. The definition, method of measuring fiber and recommendations varies in different countries. The backbone of our food composition data is based on USDA. According to US guidelines, the current recommendation is to consume 14 g per every 1000 kcals, therefore using the energy guideline of 2000 kcal/day for women and 2600 kcal/day for men, the recommended daily dietary fiber intake is 28 g/day for adult women and 36 g/day for adult men [31]. Although Sri Lankan adults consume fewer energy compared to US adults, their dietary fiber intake is insufficient according to their calorie intake.

Epidemiological, clinical and animal-experimental evidence showed a direct relationship between dietary electrolyte consumption and blood pressure [32]. Furthermore, clinical trials show that a reduction in salt (NaCl) intake reduces BP levels in normotensive and hypertensive populations and prevents the development of hypertension [32]. Recommended Na intake is maximum of 2.3 g/day [32]. Our findings showed most Sri Lankan adults exceed current recommendations. The high consumption of Sodium may be associated with the epidemic of hypertension (Men: 18.8%; Women: 19.3%) among Sri Lankan adults [33].

This study has several limitations. Sri Lanka has over 20 million inhabitants. Therefore, diet records of a sample of 463 subjects may not represent the eating patterns of the whole population. However, a well-conducted UK NDNS [20] measured the dietary records of 1724 respondents and achieved a lower response rate of 47%. Considering available resources, the high response rate and satisfactory representation of demographic parameters, we believe this is a reasonable sample size. Secondly, 24HDR may not be the best tool to determine habitual diet, because of the non-representative diet and recall bias. However, we selected random 24HDR, which were evenly distributed within weekdays and weekends. Random 24HDR in a large sample has been used in other national surveys in other countries [7]. Thirdly, our findings were limited to energy and selected major macronutrients due to sub quality nutritional information on sub categories of macronutrients and micronutrients of Sri Lankan mixed dishes (Additional file 1). Another limitation is that despite of reports of high alcohol consumption among Sri Lankan men [34], alcohol intake was under-reported in our study (<0.5%). In this survey, low energy reporters (<800 kcal/day) were excluded, therefore exclusion will have biased the data towards higher intakes. Lastly, we did not attempt to correlate energy intake and its adequacy to this population as calorie recommendations may vary with several factors such as gender, age, body weight, body composition and physical activity level.

Acknowledging the limitations of the survey, the present study provides the first national estimates of energy and nutrient intake of the Sri Lanka adult population. It is evident that consumption of high levels of carbohydrate, fat mainly from saturated sources, low protein, low dietary fiber and high levels of sodium may have detrimental effects on health and be related to the current epidemic of NCDs. Unfortunately, current food-based dietary guidelines are based on limited research [25]. Therefore, well-designed and nationally representative studies are needed to explore the association between diet and chronic disease among Sri Lankan adults. Moreover, regular diet and nutrition surveys should be carried out to obtain information on dietary patterns and nutrient intakes and, ideally, periodical monitoring is needed to identify the changing trends in food intake and to assess public responses to dietary recommendations.

Declarations

Acknowledgements

The authors would like to acknowledge Miss Fathima Shakira and other members in the Diabetes Research Unit, Colombo, for their contribution in arranging logistics for the study.

Authors’ Affiliations

(1)
Institute of Health and Biomedical Innovation, Faculty of Health, Queensland University of Technology
(2)
Diabetes Research Unit, Faculty of Medicine, University of Colombo
(3)
Curtin Health Innovation Research Institute, School of Public Health, Faculty of Health Sciences, Curtin University
(4)
Centre for Nutrition and Exercise, Mater Research Institute–The University of Queensland

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© Jayawardena et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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