Clinical Nutrition

Objective: To explore socio-economic differences in 'Nutritional Care Potential' (NCP) of housewives belonging to three distinctively different income groups living in urban areas of Karachi. Methods: Data was collected from families living in small, medium and large sized houses located in the authorized urban residential areas of Karachi. A total of 180 housewives (60 each for low, middle and high income groups) were interviewed. Trained data collectors visited the households, interviewed the housewives about family's socio-demographic characteristics and their own nutritional knowledge, health locus of control and decision making. Results: The total NCP scores increased with income level (Low = 14.8+5.6; Middle 16.58+5.5; High = 17.28+5.3) but the difference was statistically significant only between low and high income groups (t-test P = 0.015). The mean nutrition knowledge score of low income group was lower (mean score = 11.7+4.1) and significantly different from both middle (mean score = 13.5+3.4 t-text P = 0.013) and high income group (mean score = 14.2+4.0, t-test P = 0.001). All the three income groups had firmer belief in internal health locus of control (mean score less than one out of a total of 4). Though, the mean score was highest for the high income group and lowest for the middle income group but the difference were not statistically significant. There were no marked differences in decision making power of the three groups.

Madam, Dyslipidemia is a major problem in diabetes. It occurs more commonly in Type-II diabetes alongwith obesity and serum lipid abnormalities are characterized by decreased HDL cholesterol and elevated total triglyceride levels, whereas total cholesterol and LDL cholesterol levels in patients with this type of diabetes do not differ from those in nondiabetic subjects. The risk of coronary heart disease (CHD) death and serious nonfatal CHD events markedly increased in diabetic patients relative to nondiabetic subjects 1-3 . Furthermore, clinically manifest CHD has a worse prognosis in diabetic patients than in nondiabetic subjects 4,5 . Among the various classes of lipid lowering drugs 3-hydroxy-3methyl glutaryl coenzyme A (HMG-Co-A) reductase inhibitors (statins) are considered as the drug of first choice. In order to assess the efficacy of one such drug in our local population, a prospective study was done to evaluate the positive effect of Simvastatin 20 milligrams on diabetic dyslipidemia. Adults with diabetic dyslipidemia aged 30 years and above were eligible to participate in this study. Known diabetics with LDL >130 or LDL / HDL ratio >4.5 were recruited. Of the patients visiting out-patient-department or cholesterol camps at Baqai Institute of Diabetology and Endocrinology, the first forty subjects who fulfilled the inclusion criteria were selected for this study. Before starting medication HbA le and lipid profile was done to assess glycaemic control and extent of dyslipidemia respectively. Lipid profile included the measurement of high density lipoproteins -cholesterol(HDL-C), low density lipoproteins -cholesterol (LDL-C), total blood cholesterol (TB-C) and triglycerides (TG). All the subjects were given Simvastatin 20 milligrams daily for an average of 6 weeks. Lipid profile was done at the end of the study to re-assess the improvement in lipid levels. Height, body weight and blood pressure of all the patients was also recorded. Obesity was assessed by calculating Body Mass Index (BMI). Subjects having B.MI greater than 25 Kg/rn 2 were considered obese. Those having blood pressure greater than 140/90 rnmHg were considered hypertensive. Out of the 40 patients recruited for this study half were males. The mean age of subjects was 52 years. The results of the lipid profile after giving medications for an average of around 6 weeks was that LDL-cholesterol decreased by 18%, cholesterol decreased by 13%, triglycerides decreased by 27% while HDL-cholesterol increased by 22%. The results suggest that Simvastatin is effective for lowering lipid profile in diabetic dyslipidemias in our local population. These results are also supported by similar studies 6 done previously in which Simvastatin decreased levels of total blood cholesterol, LDL-C and triglycerides while it increased the level of HDL-C.

To assess the differences in fasting blood glucose, insulin and lipids of children having family history of diabetes or heart disease in first or second degree relative compared with a control group. Questionnaire was given to collect demographic data and to assess the dietary habits and family history of these children. Demographic data, anthropometric measurements and blood samples for fasting blood glucose, insulin and lipids of children from 4 schools was taken. The samples of ninety nine children were collected and sent to Baqai Institute of Diabetology and Endocrinology, Karachi to assess their biochemical parameters. Children having positive family history for diabetes had slightly mean values for BMI as compared to the controls but the differences were not statistically significant. Overweight risk children (>85 th Percentile of BMI for age) did not differ significantly in terms of various risk indicators however those who had a positive family history of diabetes had significantly higher percentage of abnormal Total Cholesterol, LDL-C, Insulin and low HDL. Diabetes and CVD risks in children having positive family history are probably mediated through increased weight. Thus information about family history augmented by body mass index could be used as an important screening tool for determining the risk status of children.

Observations on associations between fatness and metabolic risks among South-East Asian adults have resulted in devising lower thresholds of body mass index (BMI) for them. Metabolic abnormalities, including type 2 diabetes, are now also appearing in children and are associated with obesity. There has not been much work done to identify indicators of metabolic risks among South Asian children. This study was undertaken to observe the relationship among fatness, blood lipids, and insulin resistance in Pakistani children. Fatness, lipids, and insulin resistance were assessed in 92 middle-class Pakistani school children aged 8-10 years. Height, weight, waist, hips, mid-arm circumference, and triceps skinfold, measured in school, were used for calculating various indicators of fatness, i.e. BMI, waist hip ratio (WHR), and arm-fat percentage. Fasting blood samples were analyzed for total lipids, triglycerides (TG), total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL), glucose and insulin levels. Homeostasis model assessment (HOMA) index was calculated to assess insulin resistance. Two separate multiple regression models of various risk indicators (family history, sex, BMI, WHR, arm-fat percentage) showed that only arm-fat percentage had a significant positive association both with insulin levels (b=2.04, p=0.044) and LDL (b=2.11, p=0.037). Only five children were overweight (BMI-for-age>85th percentile according to National Center for Health Statistics 2000 reference). Neither overweight children nor those who were in the uppermost tercile of BMI-for-age differed significantly from other children in terms of presence of higher-than-desirable values of lipids or insulin. However, compared to those in the lowest tercile, children who were in the uppermost tercile of armfat percentage had a significantly higher frequency of high blood cholesterol (40% vs 67%, p=0.027), high LDL (33.3% vs 61.3%, p=0.026), and markedly higher proportion above average insulin levels (16.7% vs 35.5%, p=0.083). Arm-fat percentage could be developed as a practical tool for determining the risk status of children. However, further cross-sectional assessments are needed to ascertain accurate relationships among arm-fat percentage, lipid profiles, and insulin resistance in larger and varied groups of children.

Dietary trends have been found to be related with metabolic syndrome in various studies. To identify dietary patterns and study associations between the dietary patterns of subjects with high and low risk of metabolic syndrome in a Karachi based community. A group of 871 men and women were selected randomly from 532 households. Data about consumption of specific foods was available for 867 adults. Participants completed a health and lifestyle questionnaire and 363 subjects provided fasting blood samples for glucose and lipids. Dietary intake was assessed by a questionnaire to identify consumption of 33 specific food items and the dietary patterns categorized into 6 food groups was assessed by cluster analysis. Five dietary patterns were identified through cluster analysis. Cluster 1 had the lowest proportion of persons with metabolic syndrome i.e. 42.7% while cluster 2 had the highest percentage of metabolic syndrome subjects (56.3%) (p = 0.09). Consumption of fat and caloric dense foods was significantly higher among highest risk group (cluster 2) compared to lowest risk group (cluster 1) (p = 0.0001). The consumption of food groups containing fruit, milk and meat was also more than twice in high risk compared to low risk group (p = 0.0001). Even within the same population there are marked differences in dietary patterns and these apparently contribute to the risk of developing metabolic syndrome. Dietary pattern studies will help elucidate links between diet and disease and contribute to developing healthy eating guidelines.

Background: This study was carried out to assess the association of glycemic control and hypertension with chronic complications in type 2 diabetic subjects attending a tertiary care centre in Karachi, Pakistan. Methods: This was a cross sectional analytical study. First visit of type 2 diabetic subjects to the outpatient department of Baqai Institute of Diabetology and Endocrinology, from September 1996 to December 2001, were analyzed for this study. Socio-demographic attributes and clinical profiles were obtained from the computerized records of these patients retrospectively. Odds ratio with 95% confidence interval were reported for independent variables associated with outcome variables. Results: Records of 2199 subjects (48.5% males, 51.5% females) were analyzed. Mean age of the male and female subjects was 52.2 and 50.6 years respectively. Hypertriglyceridemia [OR: 1.74; 95% CI (1.18-2.57)] and diabetic foot ulcers [OR: 2.32; 95% CI (1.14-4.01)] were significantly associated with poor glycemic control according to HbA1c. Whereas hypertriglyceridemia [OR: 2.39; 95% CI (1.42 -4.03)] and hypertension [OR: 1.65; 95% CI (1.13-2.41)] were significantly associated with poor glycemic control according to FPG. Obesity [OR: 1.44; 95% CI(1.18-1.75)], Retinopathy [OR: 1.95; 95% CI(1.49-2.53)], nephropathy [OR: 1.99; 95% CI(1.45-2.75)],neuropathy [OR:1.40; 95% CI(1.15-1.71)] and presence of coronary arterial disease [OR:1.33; 95% CI(1.02-1.72) were found to be significantly associated with systolic blood pressure. Obesity [OR:2.07; 95% CI(1.69-2.54)], hyperglycemia [OR: 1.40; 95% CI(1.04-1.90)] and nephropathy [OR: 1.92; 95% CI(1.39 -2.64)]

Changes in diet and activity are supposed to be responsible for the increased prevalence of urbanization related diseases. By comparing determinants of food choice among rural and urban south Asians we can assess the impact of urbanization on food selection process and this information can help in planning nutrition education strategies. This study was conducted to compare the determinants of food choice for South Asian children at different levels of urbanization.Among South Asian groups relative impact of m ales on family food choice and that of parents on children's food choice was more pronounced than it was among British Caucasians (BrC) but the influence decreased with urbanization rank (UR). With urbanization children's likeness for fatty snacks increased significantly. Gender bias in food choice was higher among all south Asian groups as compared to BrC but decreased with urbanization rank. Determinants of food selection for children differ with urbanization status. Influences of children's own preferences increase with UR. Influence of male family members on family food choice and gender bias in food preference decreases with UR.

Food habits and nutrient density of diets of six groups of rural and urban school children aged 10-12 years were compared. Data were collected from three-day food records. In the UK, data were collected during October-November 1994 and in Pakistan during April-May 1995. Based on the apparent level of urbanism, the six groups were arbitrarily assigned urbanization rank 1-6. Patterns of their food and intake of nutrients were different from each other in various aspects and were not always associated with the apparent level of urbanism of the group. With urbanization, the intake of fat and sugar increased steadily. The intake of carbohydrate, fibre, riboflavin, and vitamin E decreased with urbanization. The intake of vitamin C, vitamin B 12 , and folates was higher among group 4, 5, and 6 than other groups. Due to various factors, in terms of micronutrient density, diets of various urban groups could have more differences than similarities. While these differences point toward the need for comprehensive nutrition education and community nutrition surveys, they also indicate the possibility of having healthy diets in urban settings.

Objective: To study the socio-economic differences in height and body mass index (BMI) in urban areas of Karachi. Design: A comparative study was undertaken to compare the heights and BMIs of adults and children belonging to three distinctively different income groups living in urban areas of Karachi. Setting: Data was collected from families living in small, medium and large houses located in the authorised urban residential areas of Karachi. Subjects: A total of 600 families, 200 from each income group, were included in the study. Anthropometric measurements of 1296 females and 1197 males of different ages were taken. Methods: All the housewives were interviewed to collect socio-demographic information. Height and weight of all the available family members were measured. In order to determine the socio-economic difference in height status, the mean height in cm of adults was compared. For children (2 ± 17 y) means of height-for-age Z-scores determined on the basis of NCHS reference values were compared. For studying the weight status the BMI of all the respondents was calculated and they were grouped into categories of under-, normal or overweight according to the NCHS recommended cut-off points. For adult men and women BMI values`18.5 kgam 2 indicated underweight and b 25 kgam 2 indicated overweight. Among children, those having BMI values below the 5th percentile of the NHANES III reference values were categorised as underweight and those above the 95th percentile were termed overweight. Results: Height status improved with income level among adults and children of both sexes. Among males the difference in weight status was signi®cant only among 2 to 18-y-olds (P`0.05 in each case). The rate of overweight among 2 to 18-y-old males was signi®cantly higher (P 0.004) at the middle-income level (15%) as compared to low or high income. The rate of underweight was signi®cantly higher (P 0.025) at the low-income level among 2 to 18-y-old males (31%, 21% and 22% at low-, middle-and high-income levels, respectively). Among females, rates of underweight were not signi®cantly different at any age. Rates of overweight increased signi®cantly (P 0.048) with income level among 41 to 60-y-old women (38%, 53% and 60% at low-, middleand high-income levels, respectively). Conclusion: Chronic undernutrition as indicated by de®cit in height decreased with increasing income level. Socio-economic differences in weight status were not uniform among various age ± sex groups. The in¯uence of increasing af¯uence is likely to be seen both in the form of increased obesity among older females and underweight among children. Differing patterns of association between income and weight status among male and female children need to studied further with more accurate birth records, so as to further clarify the situation. In terms of prevention of nutrition-related disorders both problems of under-and over-nutrition need to be addressed. Sponsorship: Financial support for this project was provided by ISFE, Switzerland.

Rationale: Patients admitted for upper gastrointestinal (UGI) resection for malignancy are often malnourished secondary to anorexia, taste changes, dysphagia and increased energy expenditure. The aim of this study was to determine the incidence of malnutrition and identify any causal factors, in patients on admission to hospital for resection for UGI malignancy. Methods: Design: Prospective study of consecutive patients referred for resectional surgery. Setting: Regional cancer network serving a population of 1.3 million. Nutritional status was assessed by dietary history, anthropometric methods, and serologic measurements on patients when diagnosed, on admission for resection and then again the day prior to surgery. Results: Ninety six patients entered into this study. On admission, the incidence of malnutrition varied depending on the criterion used; 36 patients (38%) were malnourished as classified by a weight loss of more than 10% of their body weight in the previous 3 months; 14 patients (17%) if NRI was used; Pre-illness BMI was 27 (SD 4.5); Pre-operative BMI was 25.4 (SD 4.8), indicating that BMI is not a useful parameter of nutritional status in this patient group. Five patients (5.2%) had a BMI less than 18 on admission for surgery.