Beyond transmission: Dire need for integration of nutrition interventions in COVID-19 pandemic-response strategies in Developing Countries like Pakistan.

Synergistic associations between infection and nutrition are well known. Impact of nutrition interventions on the outcomes have been scientifically assessed and reported. The role of nutrition in limiting the infection related morbidity and mortality does not appear to be a debatable question but nutrition interventions do not appear to be an essential part of current COVID-19 management strategies. Given the nature of pandemic and lack of organism-specific evidence, variability in nutrition interventions and lack of nutrition interventions is not unexpected. However, delay in realization of the crucial need of nutrition interventions to limit the immediate and long term outcomes at personal and community level may aggravate health related issues that can have long term impact on quality of life and economy. Due to existing undernutrition and lack of nutrition related awareness and competence, need for timely and appropriate interventions is much more critical for developing countries. This manuscript highlights the need and feasibility of various nutrition interventions to assure optimum quality of life during and after COVID-19 pandemic. Available evidence provides enough guidance for nutrition interventions that are safe and promise to accrue various degrees of benefits with almost no likelihood of harm. Nutrition interventions suggested by author are: 1) population level efforts for promoting better use of existing resources; 2) quicker augmentation of nutrition status of high risk people and non-hospitalized cases by use of supplement and individualized guidance and 3) nutritional support of sever case by timely and adequate enteral and parenteral feeding.

Maternal and Infant Health Outcomes Associated with Medical Nutrition Therapy by Registered Dietitian Nutritionists in Pregnant Women with Malnutrition: An Evidence Analysis Center Systematic Review.

Malnutrition during the critical period of pregnancy has significant health outcomes for both the mother and her offspring. Medical nutrition therapy (MNT) by a registered dietitian nutritionist (RDN) may help mitigate negative health effects, although studies that support the role of the RDN have not been comprehensively evaluated. The objective was to explore the health effects of MNT by an RDN on maternal and infant outcomes in pregnant women with malnutrition. A systematic review of studies published between 2000 and 2014 that incorporated MNT by an RDN during pregnancy were retrieved from a PubMed search, using criteria established by the Academy of Nutrition and Dietetics Evidence Analysis Process. Among 94 identified studies, five controlled trials met the inclusion criteria. The initial search was extended to include one study published between 2014 and 2019. Outcomes included maternal gestational weight gain, maternal markers of glycemic control, maternal complications such as hypertension, incidence of caesarean section, infant birth weight both in grams and in clinical categories, infant gestational age, and infant complications. There was good/strong evidence that MNT by an RDN decreased gestational weight gain, although there was no effect on maternal complications, caesarean section deliveries, and gestational age among women with mixed body mass index status or those who were overweight/obese. The evidence was deemed fair in support of an effect on glycemic control, infant birth weight, and infant complications. The heterogeneity in the results are due to the variation among populations studied, types of interventions, and inconsistency among outcomes. In addition, the training and educational requirements of the RDN or the international equivalent may vary widely across the four countries in which studies were conducted. There was good evidence for MNT by an RDN during pregnancy on improving gestational weight gain among overweight/obese women. To better support the role of MNT by an RDN in the health care of pregnant women, research that clearly identifies the role of the RDN in the intervention, includes a control group, and studies more heterogeneous populations is needed.

Vitamin D Supplementation during Pregnancy: An Evidence Analysis Center Systematic Review and Meta-Analysis.

BACKGROUND: Given the high rates of vitamin D deficiency among pregnant women and possible effects on offspring health, a systematic review on this topic was conducted to help inform future practice guidelines. OBJECTIVE: To evaluate associations between maternal vitamin D supplementation, maternal 25-hydroxyvitamin D (25(OH)D) concentrations, and health outcomes. METHODS: A PubMed literature search was conducted to identify studies that examined the health effects of vitamin D supplementation during pregnancy on maternal and infant health outcomes published from 2000 to 2016. Among 976 identified publications, 20 randomized clinical trials met the inclusion criteria. The initial search was extended to include five studies published between July 2016 and September 2018. MAIN OUTCOME MEASURES: Maternal and infant 25(OH)D concentrations, gestational diabetes, preeclampsia or gestational hypertension, cesarean section, maternal parathyroid hormone and calcium concentrations, and infant gestational age, birth weight, and birth length. STATISTICAL ANALYSES: Mean differences, odds ratios, and 95% CIs were calculated, only for the initial search, using separate random-effects meta-analyses for each outcome. RESULTS: Evidence was good or strong that maternal vitamin D supplementation significantly increased maternal (13 studies, n=18, mean difference, 14.1 ng/mL [35.2 nmol/L]; 95% CI=9.6-18.6 ng/mL [24.0-46.4 nmol/L]) and infant (nine studies, n=12; 9.7, 5.2, 14.2 ng/mL [24.2, 12.9, 35.5 nmol/L]) 25(OH)D concentrations, although heterogeneity was significant (I2=95.9% and I2=97.4, respectively, P<0.001). Evidence was fair that vitamin D supplementation significantly decreases maternal homeostatic model assessment-insulin resistance (five studies, n=7; -1.1, -1.5, -0.7) and increases infant birth weight (nine studies, n=11, 114.2, 63.4, 165.1 g), both had insignificant heterogeneity. A null effect of maternal supplementation on other maternal (preeclampsia, cesarean section) and infant (gestational age, birth length) outcomes was found. CONCLUSIONS: Results show vitamin D supplementation during pregnancy improves maternal and infant 25(OH)D concentrations and may play a role in maternal insulin resistance and fetal growth. To further inform practice and policies on the amount of vitamin D, which supports a healthy pregnancy, high quality dose-response randomized clinical trials, which assess pregnancy-specific 25(OH)D thresholds, and appropriately powered clinical outcomes are needed.

Effects of Bariatric Surgery on Maternal and Infant Outcomes of Pregnancy-An Evidence Analysis Center Systematic Review.

BACKGROUND: While obesity presents specific acute and long-term risks to the pregnant woman and her offspring, the effects of bariatric surgery on pregnancy outcomes are undetermined. OBJECTIVE: A systematic review was performed according to the Academy of Nutrition and Dietetics Evidence Analysis Library process to determine the effects of bariatric surgery on both maternal and infant health outcomes of pregnancy. DESIGN: A comprehensive literature search of PubMed was conducted to identify studies published from years 2000 to 2015 that examined the health effects of pregnancy after bariatric surgery. Experimental studies and observational studies with a control group were included. MAIN OUTCOME MEASURES: Outcomes of interest were gestational weight gain, maternal complications (ie, gestational diabetes, pre-eclampsia, eclampsia, hypertension, and postpartum hemorrhage), miscarriage and/or stillbirth, cesarean section, birth weight in grams, birth weight in categories (ie, macrosomia, low birth weight, small for gestational age, and large for gestational age), gestational age and preterm birth, infant illness and complications (ie, perinatal death, admission to neonatal intensive care unit, neonatal illness, and congenital malformation rates), and Apgar scores. RESULTS: Thirteen of 246 studies were included. Compared to body mass index-matched controls without surgery, bariatric surgery before pregnancy reduced infant birth weight in grams, with no effect on total maternal gestational weight gain or Apgar scores. Surgery did not increase risk of adverse outcomes, such as miscarriage and/or stillbirth, preterm birth, or infant complications. Effects of surgery on maternal complications, infant birth weight categories, and surgical delivery rates were inconsistent. CONCLUSIONS: Bariatric surgery is a successful treatment of maternal obesity, but certain surgery-specific risks may exist. More data are needed to determine clinical guidelines. The long-term effects of surgery on pregnancy outcomes are unknown.

Maternal Nutrition during Early Pregnancy and Cardiometabolic Status of Neonates at Birth.

OBJECTIVE: To explore the impact of maternal body weight on maternal nutrition and micronutrient status in early pregnancy and potential impact on metabolic status in newborns. METHODOLOGY: The EU FP7 project GIFTS was conducted from Jan 2012 to May 2014. Demographic details and anthropometric measurements of women in the first trimester of pregnancy were obtained. Blood samples were collected for OGTT, insulin, lipid profile, serum folate, ferritin, vitamin D, vitamin B12, and red cell folate. Newborn anthropometric characteristics were observed. Cord blood samples were collected after delivery for glucose, insulin, and lipid profile of newborns. RESULTS: A total of 301 pregnant mothers, 108 overweight, 63 underweight, and 130 normal weight were included. Prevalence of vitamin D deficiency (<30 ng/mL) and low vitamin B12 (<190 ng/l) were high, 44% and 42%, respectively, in the first trimester. Anemic women (due to B12 or iron deficiency) were 79%, while 72% had low ferritin levels. Gestational diabetes was 16%. Differences were observed between underweight and overweight mothers (P < 0.05) for fasting blood glucose, insulin levels, and serum ferritin were observed. No significant difference was observed between vitamin D, serum B12, and red cell folate levels. CONCLUSION: Prevalence of multiple micronutrient deficiencies was common among Pakistani women during early pregnancy despite the nonvegetarian diet that has important implications for pregnancy care in Pakistan and potentially in expatriate communities living abroad. This trial is registered with ISRCTN number 83599025.

Role of HbA1c in predicting risk for congenital malformations.

AIMS: Association between conventionally identified hyperglycemias and rates of congenital abnormalities is known; however there is less information about role of HbA1c in determining gestational hyperglycemias and associated risks. This study tried to explore the association between HbA1c in women without known diabetes at first antenatal visit and risk of congenital malformations (CM) among Saudi women living at Al-Madinah Al-Monawarah. METHODS: Eleven hundred and eighty (1180), healthy, first-trimester pregnant Saudi females without known diabetes, were selected from various antenatal care clinics of Al-Madinah Al-Monawarah city. General clinical and biochemical data was collected for this study by researchers at first visit and the time of delivery. RESULTS: Nearly one fifth (19.6%) of mothers had above normal HbA1c (>5.7) at first visit. Rates of CM had significant positive association with level of HbA1c. Rate of CM among those who had HbA1c in diabetes range, pre-diabetes range or normal range was 27.8%, 9.8% and 3.0%, respectively. The difference was significant between normal and pre-diabetes at the level P=0.000 and between pre-diabetes and diabetes at level P=0.038. CONCLUSION: In this study HbA1c is found to be a valuable predictor of risk of congenital malformations. This observation calls for further studies and establishment of policies for care of pregnant mothers having higher than normal HbA1c at first visit.

Diabetes education and care in a developing country: observations from Karachi, Pakistan.

OBJECTIVE: To explore the kind of care being received by a sample of middle income group subjects with diabetes in Karachi. DESIGN: Cross-sectional. PLACE AND DURATION OF STUDY: Raana Liaquat Ali Khan College of Home Economics, Karachi from January 2009 to September 2009. PATIENTS AND METHODS: Information was collected from 105 type 2 diabetics through a structured, pre-tested, self administered questionnaire distributed in two colleges only to those students who had any adult onset diabetic in their family. SPSS version 16 was used for data entry and analysis (e.g., chi-square tests). RESULTS: The mean duration of diabetes was 8.9 years. Random blood sugar, blood pressure check and urine test for sugar were the most frequently performed tests. Many important diabetes related tests had not been performed even on subjects with duration of diabetes of 10 years or more such as HbA1c had never been performed for 74% of subjects in this class. Test for circulation had never been performed for 93% of subjects with 1 year's diabetes duration and for 62% of subjects with duration of 10 years or more. More than 90% subjects received information about diet and causes of diabetes; >70% had been informed about diabetes complications, foot care, dental care, self monitoring of blood glucose and testing sugar in urine and only 48% had been educated about insulin injections. Physician was the source of this information for more than 70% of subjects. CONCLUSIONS: This study has explored insufficient clinical monitoring of diabetes complications and provision of casual diabetes education. These observations highlight the need for provision of appropriate diabetes education, both to health care team and professionals.

Changing pattern in the risk factors for diabetes in young adults from the rural area of Baluchistan.

OBJECTIVE: To observe changing pattern in the risk factors for diabetes as overweight, obesity, smoking, hypertension and family history of diabetes in young adults in the rural area of Baluchistan. METHODS: A community based observational study was carried out in the rural area of Baluchistan by conducting two surveys, in the years 2002 and 2009 respectively. The survey was further subdivided into two groups i.e. young adults (15-25 years) and adults (> or = 25 years). In this study, data of young adults was analyzed. Data obtained in 2002 was also analyzed according to the current guidelines and compared with 2009 survey. RESULTS: A total of 230 and 197 young adults participated in 2002 and 2009 surveys respectively. Obesity increased significantly (p < 0.001) from 20 (10.15%) young adults in the year 2002 to 64 (27.82%) in 2009. Similarly 15 (7.61%) young adults were overweight in 2002 which increased to 24 (10.43%) in 2009 (p < 0.317). Smoking increased from 8 (4.06%) to 49 (21.3%) in 2009 (p < 0.001). Family history of diabetes mellitus also showed a significant increase (p < 0.005). Hypertension increased from 13 (6.6%) young adults in 2002 survey to 17 (7.39%) in 2009, the increase was not statistically significant (p < 0.749). CONCLUSION: The present study showed that risk factors for diabetes such as overweight, obesity, smoking, hypertension and family history of diabetes increased over time in the young adults of rural Baluchistan.

Risk assessment of Pakistani individuals for diabetes (RAPID).

OBJECTIVE: To develop and evaluate a risk score to predict people at high risk of developing type 2 diabetes in Pakistan. METHODOLOGY: Cross sectional data regarding primary prevention of diabetes in Pakistan. Diabetes risk score was developed by using simple parameters namely age, waist circumference, and family history of diabetes. Odds ratios of the model were used to assign a score value for each variable and the diabetes risk score was calculated as the sum of those scores. RESULTS: We externally validated the score using two data from 1264 subjects and 856 subjects aged 25 years and above from two separate studies respectively. Validating this score using the first data from the second screening study gave an area under the receive operator characteristics curve [AROC] of 0.758. A cut point of 4 had a sensitivity of 47.0% and specificity of 88% and in the second data AROC is 0.7 with 44% sensitivity and 89% specificity. CONCLUSIONS: A simple diabetes risk score, based on a set of variables can be used for the identification of high risk individuals for early intervention to delay or prevent type 2 diabetes in Pakistani population.

Temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan.

AIMS: To observe temporal changes in the prevalence of diabetes, impaired fasting glucose and its associated risk factors in the rural area of Baluchistan province of Pakistan according to American Diabetes Association criteria by comparing the two surveys done in 2002 and 2009. METHODOLOGY: This community based survey of 1264 subjects aged 25 years and above was conducted from February 2009 to February 2010 in sixteen villages of southern Baluchistan. The temporal changes were assessed in comparison with a similar survey conducted seven years previously. Data from 2002 survey was also re-analyzed according to the latest ADA criteria. RESULTS: A two-fold increase in the prevalence of diabetes (from 7.2% to 14.2%) was seen in 2009 survey and the prevalence of impaired fasting glucose also increased significantly (6.5-11.0%). An important finding was the number of hypertensives and subjects with positive family history of diabetes also increased significantly (p<0.000) from the previous survey. CONCLUSION: Coordinated National Programs for primary prevention to counteract the increasing prevalence of diabetes are the need of time. Further large scale studies with proper risk factor assessment are needed to ascertain the reasons of rising prevalence of glucose intolerance.

Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan.

AIMS: The prevalence of diabetes mellitus and impaired glucose tolerance (IGT) and their relationship to age and obesity were estimated in Punjab, Pakistan by a population-based survey done in 1998. METHODS: Oral glucose tolerance tests were performed in a stratified random sample of 1852 adults aged >or=25 years. The diagnosis of diabetes and IGT were made on the basis of WHO criteria. RESULTS: The prevalence of diabetes was 12.14% in males and 9.83% in females. Overall total glucose intolerance (diabetes and IGT) was present in 16.68% males and 19.37% females. Central obesity, hypertension and positive family history were strongly associated with diabetes. CONCLUSIONS: These results indicate that the prevalence of glucose intolerance is high in the studied population and comparable with the published data from the other three provinces of Pakistan i.e. Sindh, Baluchistan and North West Frontier Province, studied by the same group.

Efficacy of dietetics in low resource communities: dietary intake and BMI of type 2 diabetics living in Karachi before and after receiving dietician's guidance.

This study was planned to assess the dietary intake of diabetic subjects and kind of dietary modification they have made after individualised dietary guidance. Information on clinical and dietary profile of 200 subjects was recorded at first visit of BIDE. Dietary guidance was given by dietician. Second visit was done after 3 months. Subjects having adequate intake of fruit and vegetable, milk and meat was 68, 38 and 63% for males and 52, 40 and 35% for females, respectively. Only 20.4% males and 5.9% females had usual adequate consumption of the four food groups. Overall adequacy of diet improved for 11.1% of males and 27% of females. Weight reduction was observed in 54.8% of females and 32.2% of males. Rate of BMI reduction was significantly higher in the group who had reduced their caloric intake. This first of its kind study from Pakistan, has documented the efficacy of dietary guidance and highlighted the need for further attention to assure balanced intake of foods form various food groups.

Determination of reference values for elevated fasting and random insulin levels and their associations with metabolic risk factors among rural Pakistanis from Sindh Province.

AIM: To assess insulin levels and their association with metabolic risk factors (family history of diabetes, abnormal glucose tolerance, hypertension, overweight and android obesity) among a representative group of Pakistan. METHODS: The study data was taken from the database of a population-based survey conducted in Sindh Province, Pakistan, in 1994 to assess the prevalence of diabetes mellitus and impaired glucose tolerance (IGT). Through stratified random sampling; oral glucose tolerance tests were performed in 967 adults; every fifth sample was estimated for fasting and random (2-hour post-75 gm glucose load) insulin levels. The total number of metabolic risk factors was counted for each subject, and their association with insulin levels studied. RESULTS: Of the 130 subjects, 56.1% were females and 95.4% were Sindhi. The mean age of males and females was 43.84 and 40.61 years, respectively. Family history for diabetes and frequency of overweight had significant positive associations with both fasting and random insulin levels (P < 0.05). Association between hypertension and insulin levels was significant only for random insulin levels, and between android obesity, abnormal glucose tolerance, or male gender and insulin levels only for fasting insulin levels (P < 0.05). Metabolic risk factors had significant positive associations with both fasting (r = 0.351 P = 0.000) as well as random insulin levels (r = 0.364 P = 0.000). CONCLUSION: This paper provides baseline pioneering information applicable to the Pakistani population. Furthermore, the observations made in this study about differences in association of fasting or random insulin levels with various metabolic risk factors highlight the possibility of using either of them for risk assessment. This finding needs to be assessed in a larger and nationally representative sample.

Glycemic control, hypertension and chronic complications in type 2 diabetic subjects attending a tertiary care centre.

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. Sociodemographic 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)] had significant association with high diastolic blood pressure. CONCLUSION: In conclusion this study shows the association of chronic complications with glycemic control and hypertension amongst type 2 diabetics in Karachi. This information needs to be verified by multicentred large scale studies in order to be helpful in planning healthcare and treatment strategies.

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) 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.

Frequency of chronic complications of type II diabetes.

OBJECTIVE: To assess the frequency of chronic complications of type II diabetes in subjects attending a tertiary care unit in Karachi, Pakistan. DESIGN: A cross-sectional analytical study. PLACE AND DURATION OF STUDY: First visit of all type II diabetic subjects attending the outpatient department of Baqai Institute of Diabetology and Endocrinology from September 1996 to December 2001. SUBJECTS AND METHODS: Computerized clinical records of 2199 type II diabetic subjects were analyzed for this study. The clinical and laboratory variables were statistically evaluated with significance at p. RESULTS: Means of glycosylated hemoglobin HbA1c, fasting and random plasma glucose levels, systolic blood pressure, triglycerides and high density lipoproteins (HDL) were higher than the risk indicator value for both genders (p <0.005). Mean body mass index and total blood cholesterol was higher for females only. Hyperglycemia was present in 88%, high HbA1c in 81%, low HDL in 81%, obesity in 66% and hypertriglyceridemia in 54%, neuropathy in 36%, proteinuria in 28% and hypertension in 50% of the subjects. Frequency of obesity, low HDL and hypertension was higher among females (p < 0.001 in each case). Retinopathy (p<0.05), nephropathy (p<0.005), neuropathy (p<0.005) and foot ulcers (p<0.001) were higher among males. Frequency of obesity was significantly higher among those with shorter duration and in younger group while frequency of other complications was higher among those with longer duration and in the older groups. CONCLUSION: Higher rates of complications were observed compared to previous studies. Certain variables showed significant association with gender and age as described above.