Effect of Intervention in Subjects with High Risk of Diabetes Mellitus in Pakistan

Aims. To observe the rate of conversion from impaired glucose tolerance (IGT) to diabetes following lifestyle modification (LSM) or a combination of lifestyle and metformin compared to a control population with 18-month followup. Methods. Forty screening camps were organized, which 5000 people attended. Around 2300 persons filled the questionnaire and 1825 subjects were identified as high risk. Of 1739 subjects who took the oral glucose tolerance test, 317 subjects were identified as IGT. The 317 IGT subjects were randomized into three groups: control group was given standard medical advice, LSM group was given intensive lifestyle modification advice, while LSM + drug group was given intensive lifestyle advice and metformin 500 mg twice daily. Results. At the end, 273 subjects completed the study, giving a compliance rate of 86%. Total of 47 incident cases of diabetes were diagnosed (overall incidence was 4 cases per 1000 person-months with the incidence of 8.6 cases in control group, 2.5 cases in the LSM, and 2.3 cases in the LSM + drug groups). Conclusions. Study showed that lifestyle intervention had a major impact in preventing diabetes among IGT subjects in this region. Adding drug did not show any improved results. We recommend lifestyle advice and followup should be incorporated in primary health care

Relationship among Fatness, Blood Lipids, and Insulin Resistance in Pakistani 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 skin-fold, 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) andLDL (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 arm-fat 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

Refinement of arsenic attributable health risks in rural Pakistan using population specific dietary intake values

Background: Previous risk assessment studies have often utilised generic consumption or intake values when evaluating ingestion exposure pathways. If these values do not accurately reflect the country or scenario in question, the resulting risk assessment will not provide a meaningful representation of cancer risks in that particular country/scenario. Objectives: This study sought to determine water and food intake parameters for one region in South Asia, rural Pakistan, and assess the role population specific intake parameters play in cancer risk assessment. Methods: A questionnaire was developed to collect data on sociodemographic features and 24-hour water and food consumption patterns from a rural community. The impact of dietary differences on cancer susceptibility linked to arsenic exposure was evaluated by calculating cancer risks using the data collected in the current study against standard water and food intake levels for the USA, Europe and Asia. A probabilistic cancer risk was performed for each set of intake values of this study. Results: Average daily total water intake based on drinking direct plain water and indirect water from food and beverages was found to be 3.5 L day-1 (95% CI: 3.38, 3.57) exceeding the US Environmental Protection Agency’s default (2.5 L day-1) and World Health Organization’s recommended intake value (2 L day-1). Average daily rice intake (469 g day-1) was found to be lower than in India and Bangladesh whereas wheat intake (402 g day−1) was higher than intake reported for USA, Europe and Asian sub-regions. Consequently, arsenic-associated cumulative cancer risks determined for daily water intake was found to be 17 in children of 3-6 years (95% CI: 0.0014, 0.0017), 14 in children of age 6-16 years (95% CI: 0.001, 0.0011) and 6 in adults of 16-67 years (95% CI: 0.0006, 0.0006) in a population size of 10000. This is higher than the risks estimated using the US Environmental Protection Agency and World Health Organization’s default recommended water intake levels. Rice intake data showed early life cumulative cancer risks of 15 in 10000 for children of 3-6 years (95% CI: 0.0012, 0.0015), 14 in children of 6-16 years (95% CI: 0.0011, 0.0014) and later life risk of 8 in adults (95% CI: 0.0008, 0.0008) in a population of 10000. This is lower than cancer risks in countries with higher rice intake and elevated arsenic levels (Bangladesh and India). Cumulative cancer risk from arsenic exposure showed the relative risk contribution from total water to be51%, from rice to be44% and wheat intake 5%. Conclusions: The study demonstrates the need to use population specific dietary information for risk assessment and risk management studies. Probabilistic risk assessment concluded the importance of dietary intake in estimating cancer risk, along with arsenic concentrations in water or food and age of exposed rural population

Metabolic Syndrome and Insulin Resistance in Pakistan: a population based study in adults 25 years and above in Karachi

Abstract Background : Sedentary lifestyle along with easy access to fast foods have resulted in a global epidemic of diabetes with a prediction that it will rise from the current estimate of 190 million to 324 million in 2025. WHO predicts that 170% increase of diabetes will be in the developing countries. Type 2 diabetes (T2DM) has become one of the major causes of premature illness and death and cardiovascular disease (CVD) will be responsible for up to 80% of these deaths. So it seems that at the moment we are faced with the twin pandemic of T2DM and CVD and the brunt of this would be borne by the developing countries. The clustering of central obesity, dyslipidaemia, hypertension, and hyperglycaemia known as metabolic syndrome has been associated with a 2-3 fold increase in T2DM and CVD. It is recognized that the features of the metabolic syndrome can be present 10 years preceding T2DM and CVD. The prevalence rates of metabolic syndrome appear varied using the WHO, EGIR, AACE, ATP III and IDF definitions. Therefore it is needed to study the suitability of metabolic syndrome definitions in this population. Objective: To estimate the prevalence of metabolic syndrome in adults aged 25 years and above from an urban population of Karachi. Methods: The survey was conducted from July to December 2004 by generating a computerized random sample of 500 households from houses in Lyari Town using a Geographical Imaging System (GIS). The survey activities were divided into two phases—the household interview and blood sample collection. Field work entailed visits to the selected household by a field team (medical students and health worker), introduction to the purpose of the research study, consent, interviews and physical measurements. In the 532 households visited 867 adults > 25 years old consented to take part in the survey out of which 363 gave blood samples. Results: Prevalence of Diabetes was 9.4% while 5.6% had impaired fasting glucose (Abnormal glucose tolerance 15%). Prevalence of metabolic syndrome was found to be 49% by modified ATP III, 34.8% by IDF, 16.9% by AACE, 15.2% by EGIR and 7.4% by WHO definition. Insulin resistance defined by 75th percentile of HOMA-IR was measured as 1.94. Conclusion: Inclusion of modified waist circumference and BMI cutoffs may help to predict metabolic syndrome more precisely as incorporated in modified ATP III and IDF definition. The rising prevalence of obesity and metabolic syndrome has received increased attention in recent years as both place individuals at risk for T2DM and CVD. Thus epidemiological and intervention trial studies which support lifestyle changes as the main modifiable risk factor in the treatment of individual components of the metabolic syndrome can then be initiated. Key Words: Prevalence, Metabolic Syndrome, IDF Definition, Diabetes, Pakistan, WHO, Modified ATP II

Risk factors for Type 2 Diabetes Mellitus : Metabolic Syndrome, Insulin Resistance and Primary Prevention

Aims: The purpose of the study was to identify the extent of metabolic syndrome on the basis of ATP III and IDF definition in subjects aged 25 years and above from an urban population of Karachi. Also to see the association of risk factors related to diabetes and metabolic syndrome in this population. And finally to prove the hypothesis of intervention effect on the onset of type 2 diabetes in a high risk urban population and evaluate the rate of conversion of IGT to diabetes by these interventions in this population. Methods: The epidemiological survey was designed to see the prevalence of metabolic syndrome and its risk factors among 500 randomly selected households in Lyari, an urban area within Karachi city in 2004 . We generated a computerized random sample of the households from among the 85,520 households in Lyari Town. There were 11 union councils in Lyari Town where the samples were taken and each union council had equal opportunity to be represented in the sample selection. We expected approximately 1000 adult men and women 25 years and above in the households selected in Lyari Town. If members of a household that had been selected refused to consent to household interviews, we knocked on the third door to the right of that house and seeked consent there. Out of the 85,520 households, 532 households were randomly selected and 867 adults 􀑈25 years old consented to take part in the survey; 363 of these subjects gave blood samples. The second study was a primary prevention trial which was started in the city of Karachi in 2006. It was a prospective randomized clinical trial (RCT) to assess the effect of intervention for 18 months on high risk subjects. Nearly 2000 suspected high risk cases identified by a questionnaire were to be invited to participate. Considering 30% IGT cases in high risk individuals around 600 were expected to have IGT based on OGTT. The IGT cases were then randomly allocated on three different arms, two preventive groups and one control group, all with 200 participants (one of the preventive arms included metformin 500mg twice daily). An estimated 5000 people attended the diabetes prevention lectures and visited the screening camps and around 2300 people filled in the high risk questionnaire only 1825 were identified as high risk. Of these 1739 high risk subjects undertook a standardized oral glucose tolerance test (OGTT) and 317 subjects were identified as having impaired glucose tolerance (IGT group) and were randomized into the three groups. Results: The prevalence of diabetes was 9.4%, whereas 5.6% had impaired fasting glucose (abnormal glucose tolerance 15%). The prevalence of metabolic syndrome according to the IDF definition and modified ATP III criteria was 34.8% and 49%, respectively. Inclusion of modified waist circumference and specific body mass index (BMI) cut offs for Asians might have helped in this increased prevalence of the metabolic syndrome. Dietary data about specific food items was available for 867 adults. Participants also 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 calorie 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. Insulin Resistance (IR) was defined at 75th percentile cut off of insulin levels (9.25 U/mL) and HOMA-IR (1.82). The 25th percentile cut off was used for defining IR in QUICKI (0.347) and McAuley Index (6.77). In the second study which was the primary prevention trial 273 subjects out of 317 subjects completed the study giving a compliance rate of 86%. A total of 47 incident cases of diabetes were diagnosed during the study. The overall incidence of diabetes was 4 cases per 1000 person-months with the incidence of diabetes as 8.6 cases in the control group, 2.5 cases in the Life Style Modification (LSM) group and 2.3 cases per 1000 person-months in the LSM+drug group. Conclusion: In the first study we observed high prevalence of metabolic syndrome irrespective of the definition applied in this urban population. This may call for immediate action such as preventive measures to halt the accelerating risk of diabetes and CVD which is leading to a possible unparalleled rise in the cost of health care and human suffering. To initiate a preventive program we need to make dietary changes within the population and we found marked differences in dietary patterns which were apparently contribute to the risk of developing metabolic syndrome in the same population. Dietary pattern studies will help elucidate links between diet and disease and contribute to developing healthy eating guidelines. A common approach towards managing subjects with metabolic risk factors which could help physicians would be able to identify IR cases earlier and defining IR reference values identified from simple indirect methods would be of value in such cases. However larger population based studies are needed to further define and validate the cutoff values defined for insulin resistance in our population. The primary prevention study was initiated after we had some baseline information from our first epidemiological study and it showed that lifestyle intervention had a major impact in preventing diabetes among IGT subjects in this region. However, addition of drug in the intervention did not show any improved results. Resource constrain societies are challenged with the additional burden of diabetes cost on their already ailing economy and such lifestyle intervention approach would be of benefit in such communities. Therefore, we recommend that lifestyle modification advice and follow-up should be incorporated in primary health care

Effects of 16 genetic variants on fasting glucose and type 2 diabetes in South Asians : ADCY5 and GLIS3 variants may predispose to type 2 diabetes

Background: The Meta-Analysis of Glucose and Insulin related traits Consortium (MAGIC) recently identified 16 loci robustly associated with fasting glucose, some of which were also associated with type 2 diabetes. The purpose of our study was to explore the role of these variants in South Asian populations of Punjabi ancestry, originating predominantly from the District of Mirpur, Pakistan. Methodology/Principal Findings: Sixteen single nucleotide polymorphisms (SNPs) were genotyped in 1678 subjects with type 2 diabetes and 1584 normoglycaemic controls from two Punjabi populations; one resident in the UK and one indigenous to the District of Mirpur. In the normoglycaemic controls investigated for fasting glucose associations, 12 of 16 SNPs displayed b values with the same direction of effect as that seen in European studies, although only the SLC30A8 rs11558471 SNP was nominally associated with fasting glucose (b = 0.063 [95% CI: 0.013, 0.113] p = 0.015). Of interest, the MTNR1B rs10830963 SNP displayed a negative b value for fasting glucose in our study; this effect size was significantly lower than that seen in Europeans (p = 1.2961024). In addition to previously reported type 2 diabetes risk variants in TCF7L2 and SLC30A8, SNPs in ADCY5 (rs11708067) and GLIS3 (rs7034200) displayed evidence for association with type 2 diabetes, with odds ratios of 1.23 (95% CI: 1.09, 1.39; p = 9.161024) and 1.16 (95% CI: 1.05, 1.29; p = 3.4961023) respectively. Conclusions/Significance: Although only the SLC30A8 rs11558471 SNP was nominally associated with fasting glucose in our study, the finding that 12 out of 16 SNPs displayed a direction of effect consistent with European studies suggests that a number of these variants may contribute to fasting glucose variation in individuals of South Asian ancestry. We also provide evidence for the first time in South Asians that alleles of SNPs in GLIS3 and ADCY5 may confer risk of type 2 diabetes

Enlèvement d’Hélène

Céramique à figures noires. H. 53 cm ; D. 30,2 cm ; L. 35 cmAutre aventure de Thésée : l’enlèvement d’Hélène. En effet, bien avant que Pâris ne vienne ravir la plus belle femme du monde, Thésée avait été séduit par Hélène dans sa jeunesse et l’avait emmenée de force en Attique, avant qu’elle ne soit délivrée en son absence par ses frères Castor et Pollux, les cavaliers jumeaux. Cet épisode reste assez obscur, faute de sources littéraires concordantes, mais il est bien attesté dans les images dès la fin du 6e siècle av. J.-C. Sur cette hydrie, Thésée et deux compagnons en armes surgissent de la gauche, reculant devant des adversaires hors champ ; les deux premiers, peut-être Peirithoos, roi des Lapithes et ami du héros, et Phorbas, son pédagogue, se défendent derrière des boucliers ronds ornés d’un oiseau et d’un serpent, tandis que Thésée porte Hélène qui fait un geste de la main vers ses compagnes invisibles pour nous. Ils se dirigent vers les chevaux qui les emmèneront vers l’Attique.téléchargeabl

Evaluation of Self-Esteem, Emotional Intelligence, and their Association with Demographic Factors among Healthcare Professionals in Karachi

Background: Healthcare professionals are exposed to difficult situations that lead to increased stress. Higher emotional intelligence can lead to better psychological adaptation and greater self-esteem while lower emotional intelligence may result in hopelessness and stressful behavior. Objective: To examine self-esteem, emotional intelligence, and their relationship with demographic factors among healthcare professionals in Karachi. Methods: A cross-sectional study was conducted among healthcare professionals using a self-reported questionnaire. The data was collected through Google forms from April 2021 to April 2022. Spearman correlation and Mann-Whitney U test were applied for inferential statistics and the p-value was fixed at ≤0.05. Results: A total of 261 participants responded to the survey with complete responses. The mean age of the participants was 28 (IQR=26-30) years and most of them were females (69%). The median emotional intelligence score of participants was 5.56 (IQR=6.00-4.93) and the median self-esteem score of participants was 29 (IQR=30-27). A weak positive correlation was found between emotional intelligence and self-esteem scores (ρ=0.285, p<0.001). Linear regression analysis showed a significant positive association of education (p=0.024) and a significant negative association of profession (p=0.017) with self-esteem. Moreover, it also showed a significant positive association of age (p=0.045) with emotional intelligence. Conclusion: The study results showed a weak positive correlation between emotional intelligence and self-esteem. Furthermore, education and profession were found to be significantly associated with self-esteem whereas only age was found to be significantly associated with the emotional intelligence of the participants