Factors influencing Aflatoxin M1 levels in breast milk and urine among lactating mothers in Kuala Lumpur, Malaysia

Consumption of food contaminated with aflatoxin may severely impact public health because it is a known carcinogen that can affect all organs. The most potent and toxic mycotoxin is aflatoxin B1 (AFB1), while aflatoxin M1 (AFM1) is the metabolite of AFB1 of liver metabolism, where it can be detected in the urine. Breast milk, which provides an essential source of nutrients for infants, may contain AFM1 due to ingestion of AFB1-contaminated food. The main objective of this study is to determine the association between mother's socio demographic and socio economic, knowledge on aflatoxin, dietary intake, physical activity, and body weight statuses with the level of aflatoxin M1 levels in breast milk and urine. The present study was a cross-sectional study conducted among nursing mothers residing in Kuala Lumpur. The data collection was conducted from January 2019 until June 2019. The maternal and child health clinics in Titiwangsa and Cheras districts were randomly chosen as the sampling sites within Kuala Lumpur. This study’s inclusion criterion includes mothers who live in Kuala Lumpur, 18 years old or older, and breastfeeding her infant for more than three months. Mothers were provided with a set of questionnaires to assess their socio demographic and economic status, knowledge on aflatoxin, dietary intake within 3 days, physical activity for the past 7 days, and weight status. The mothers were only asked about their socio-demographic, income, and knowledge on aflatoxin during the recruitment. The arrangement home visits were done for biological samples collection and anthropometric (weight and height) measurements. Five to ten ml of breastmilk samples were collected in a 15 ml falcon tube, while morning urine was collected in a 60 ml urine container. The level of aflatoxin M1 in the samples was analysed using ELISA. The data were analysed using SPSS version 22.0. The significant predictors of AFM1 in breast milk and urine were determined using binary logistic regression. Based on the result, two hundred and fifty-six (n=256) mothers were recruited with a mean age of 30.62 ± 4.25 years old. The majority of the mothers were of Malay ethnicity (89.8%) with tertiary education (71.1%). Most mothers earned more than RM 1500 per month (58.6%) based on the income. In terms of household income, more than half of the mothers reported having a monthly income of more than RM 3500 (60.2%). AFM1 was detected respectively in 68% and 14.8% of urine and breast milk collected. Bivariate analyses show no significant correlation between the level of aflatoxin M1 in breast milk and urine (p>0.05). Besides, there was no significant association between the level of AFM1 in breast milk (p>0.05) with mother's socio demographic and economic statuses, knowledge on aflatoxin, dietary intake, physical activity level, and weight statuses. On the other hand, the consumption of milk and dairy products was significantly associated with AFM1 in urine (r=-0.199, p=0.001). In addition, being sedentary was linearly associated with the occurrence of AFM1 in urine (r=-0.141, p=0.02). Aflatoxin M1 in urine was also shown to be significant with the mother's weight status (r= 0.162, p=0.009). However, multivariate analysis showed that the both predictors of mother's household income (OR=0.254, CI= 0.033-1.943) and weight status (OR=1.020, CI=0.946-1.099) were not significant with AFM1 in breast milk. Besides that, nut and legume-based items intake was an important significant predictor of AFM1 in urine (OR=0.997, CI=0.994-0.999, p= 0.011). Additionally, the consumption of milk and dairy-based products are significantly determining by the AFM1 levels in urine (OR=0.999, CI= 0.994-0.999, p=0.012). In conclusion, the current study indicates that none of the factors such as socio demographic and economic, knowledge on aflatoxin, dietary intake, physical activity, and weight status may influence the level of AFM1 in breast milk. However, the intake of nuts and legumes and milk and dairy based products were significantly associated with the occurrence of AFM1 in urine. Additional research is recommended in the future to substantiate these findings. Additionally, it is recommended that future research to monitor the AFM1 level among infants through the analysis of urine. Moreover, other biological specimens should be collected such as blood and serum to determine long-term aflatoxin exposure.

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