Adherence to Gluten Free Diet in Pakistan-Role of Dietitian

Celiac disease (CD) is a common multi-system autoimmune disease, affecting approximately 1% of people worldwide 1. Predisposed individuals develop an immune response to gluten, a protein found in the cereal grains: wheat, barley and rye. Autoimmune intestinal damage is the cardinal feature of celiac disease, and typically involves villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes 2. Symptoms may be subclinical, varying from gastrointestinal upset to severe malabsorption 3,4. Skin, nervous system, and multisystem involvement is also recognized. Strict avoidance of gluten-containing foods can reverse both enteric and extra-intestinal manifestations of the disease

Phytochemical Quantification and Characterization of Anti-Diabetic Potential of Polyherbal Formulation by FT-IR and GC-MS Analysis

The main objective of the present study was to develop and evaluate anti-diabetic potential of polyherbal formulation (PHF) using Nigella sativa, Cinnamomumverum, Allium sativum, Zingiberofficinale, Curcuma longa and Trigonellafoenumgraecum for management of diabetes. The PHF was investigated by advanced analytical techniques. The proximate analysis of PHF revealed all parameters were within the limits indicating no adulteration and contamination. In addition, gas chromatography-mass spectrometry (GC-MS) and Fourier transform-infrared (FT-IR) spectroscopy analysis showed the presence of bio-active phytochemicals including phenolic compounds, antioxidants, anti-inflammatory and anti-diabetic constituents that are good therapeutic potential for prevention and management of diabetes. The efficacy of PHF was evaluated by dividing into four groups (PHF 1.5 g, PHF 3.0 g, metformin 500 mg and placebo) of newly diagnosed type 2 diabetic patients for 90 consecutive days and monitored on a monthly basis. PHF 3.0 g dose showed a significantly higher anti-diabetic effect as compared to PHF 1.5 g while comparable results in relation to metformin 500 mg. The phytochemical characterization of PHF will ensure its quality and safety. Moreover, the anti-diabetic efficacy of PHF is comparable with anti-diabetic efficacy of metformin. PHF has the potential to achieve glycemic control in type 2 diabetic patients with a diabetic diet prescribed

Reliability and Validity of the COPE Index among Caregivers of Hemodialysis Patients in Pakistan

Objective: To assess the reliability and validity of the COPE (Carers of Older People in Europe) index tool among the caregivers of dialysis-dependent patients in Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: The study was conducted at the Dialysis Unit of Pakistan Kidney Patients Association Rawalpindi, Bahria International Hospital Rawalpindi and Fauji Foundation Hospital Rawalpindi, Pakistan, from December 2018 to January 2019. Methods: A 15-item COPE index questionnaire was administered, and data were collected from 124 caregivers of patients undergoing regular hemodialysis. A Principal Component Analysis (PCA) was performed on all items of the COPE index to retain the underlying components. Further, Cronbach's alpha was used to assess the internal consistency of the retained component structure and loadings obtained from the PCA and the entire instrument separately. Results: The PCA analysis revealed that, with the context of this study, the COPE index had good internal consistency for the negative aspects of caregiving and social support (Cronbach's alpha scores were 0.864 and 0.781, respectively). For the positive impact items, a Cronbach's alpha score of 0.655 indicated modest internal consistency. Cronbach's alpha of 0.714 for the entire 15 items indicated that the COPE index had good overall internal consistency in our study population. Conclusion: The COPE index was found to be a valid tool for use in Pakistan to assess the caregiver experience, including both positive and negative aspects of caregiving

The Importance of Cultural and Socioeconomic Context in Health Research Design--- Lessons Learnt from a Pilot Study in Pakistan

BACKGROUND AND OBJECTIVE: For many health outcomes, there are an array of published methods, however not all have been validated in the target population. So, it is better to first pilot the selected tools and research strategies thus can reduce cost, effort and time in a larger project. The objective of this study was to present the significance of the pilot study by using an example of an observational study in a tertiary care hospital in Pakistan. METHODOLOGY: This pilot study was carried out in a tertiary hospital located in Peshawar, Pakistan. The data (Socio-demographics, anthropometric measurements, biochemical tests, blood pressure measurement and diet intake) was collected from the un-paid female caregivers looking after hemodialysis-dependent family members The caregiver experience was assessed using the Zarit burden interview (ZBI) scale. Pregnant and lactating caregivers were excluded. RESULTS: Data were collected from 20 participants. The decision to participate in the study was based on male family members. Females were reluctant for providing anthropometric measurements and were not aware of monthly income. The majorities were interested in blood pressure measurement and blood tests as offered free of cost. Almost all participants reported positive aspects of caregiving, thus ZBI was not found suitable in the selected sample. CONCLUSION: The results of the pilot study highlighted the strengths and limitations of the selected data collection tools. The results of the survey can be useful for the healthcare professionals involved in researching on South Asian family caregivers

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

The outcomes of nutritional therapy in patients with non-alcoholic fatty liver disease (NAFLD): pitfalls in getting fit from fat

Objectives: To evaluate the outcomes of nutritional intervention on non-alcoholic fatty liver disease parameters, and to determine the reasons for non-compliance with nutritional therapy. Method: The interventional study was conducted from May 2020 to October 2022 at the National Institute of Liver and Gastrointestinal diseases, Dow University Hospital, Ojha Campus, Karachi, and comprised patients of either gender aged 18-65 years who had been diagnosed with non-alcoholic fatty liver disease based on abdominal ultrasound. Anthropometrics, physical activity level, and biochemical markers were evaluated at baseline and 6 months after the intervention that involved nutritional assessment, counselling and guidance related to dietary modification and optimisation of physical activity level. The effect of the intervention was evaluated by improvement in liver enzymes, biochemical parameters, anthropometric indices and any change in the level of physical activity.  The reasons for noncompliance were also recorded. Data was analysed using SPSS 22. Results: Out of 118 subjects enrolled, 61(51.69%) completed the study. Most patients were females 81(68.6%), married 25(21.2%) and housewives 64(54.2%). There were 16(26.2%) subjects who had 3-10kg weight reduction. The reduction in serum cholesterol and triglyceride levels was not significant (p>0.05). Also, no significant change was observed in the level of physical activity compared to the baseline (p>0.05). Overall, 27(44.3%) patients showed compliance with treatment. The main reasons for noncompliance were lack of time 21(34.4) and knee joint pain 5(8.2%). Conclusion: Lifestyle modification can be beneficial for weight-loss in the management of non-alcoholic fatty liver disease. However, awareness of its importance and willingness in initiating real-life practical steps with subsequent adherence to dietary therapy was found lacking in the sample studied. Key Words: Fatty liver, Non-alcoholic steatohepatitis, Diet therapy, Nutrition, Physical activity