1
|
Sharif H, Sheikh SS, Seemi T, Naeem H, Khan U, Jan SS. Metabolic syndrome and obesity among marginalised school-going adolescents in Karachi, Pakistan: a cross-sectional study. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 21:100354. [PMID: 38322154 PMCID: PMC10844970 DOI: 10.1016/j.lansea.2024.100354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/19/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024]
Abstract
Background Metabolic syndrome (MetS) is a cluster of cardiometabolic risk factors which increase the likelihood of developing type 2 diabetes and cardiovascular disease. This study aimed to determine the prevalence of MetS among adolescents living in slums aged 11-18 years in Karachi, Pakistan. Methods Data were collected from 689 adolescents attending five schools in two slum areas of Karachi, Korangi and Baldia, from February 2023 to March 2023. Measurements of weight, height, waist circumference, and blood pressure were obtained from the study participants. Blood samples were collected to assess fasting plasma glucose, High density lipoprotein HDL-cholesterol, and triglyceride levels as per National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III). The prevalence of MetS was estimated using five diagnostic criteria, i.e., International Diabetes Federation (IDF-2007), World Health Organization, NCEP-ATP III, de Ferranti et al., and Cruz and Goran. Findings The study revealed an overall prevalence of MetS among the adolescents in the two slum areas as 16.7%. A higher prevalence of MetS was observed among females (9.1%) and those with lower body mass index BMI (13.6%). The diagnostic criteria proposed by Cruz and Goran were found to be the most sensitive, with a MetS diagnosis rate of 22.93%. The study also identified several significant risk factors associated with MetS, including sedentary lifestyle (7.7%), lack of physical activity (7.5%), increased screen time (1.5%), lower fruit consumption (6.1%), and underweight (7.7%). Among slum-dwelling adolescents, low levels of HDL-cholesterol (33.96 ± 5.21), high triglyceride levels (161.45 ± 63.09), and elevated fasting plasma glucose levels (112.59 ± 28.92) were prevalent components of MetS. Interpretation This study provides compelling evidence of a high prevalence of MetS among marginalised school-going adolescents in Karachi, Pakistan. The findings underscore the importance of early identification of adolescents at risk of developing MetS (especially those living in slum areas) and the implementation of effective preventive strategies to mitigate the risk of type 2 diabetes and cardiovascular disease in later life. Funding None.
Collapse
Affiliation(s)
- Hina Sharif
- SINA Health Education & Welfare Trust, Karachi, Pakistan
| | | | - Tooba Seemi
- SINA Health Education & Welfare Trust, Karachi, Pakistan
| | - Hira Naeem
- SINA Health Education & Welfare Trust, Karachi, Pakistan
| | - Unab Khan
- Department of Family Medicine, Aga Khan University, Karachi, Pakistan
| | - Shah Sumaya Jan
- Department of Anatomy, Government Medical College, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
2
|
Hong Y, Ullah R, Wang JB, Fu JF. Trends of obesity and overweight among children and adolescents in China. World J Pediatr 2023; 19:1115-1126. [PMID: 36920656 PMCID: PMC10015139 DOI: 10.1007/s12519-023-00709-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/20/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Recent decades have shown a rapid increase in the prevalence of overweight and obesity among Chinese children based on several national surveys. Restrictions due to the coronavirus disease 2019 outbreak have worsened its epidemiology. This review updates the trends in the prevalence of overweight and obesity among Chinese children and adolescents and analyzes the underlying reasons to provide evidence for better policy making. METHODS Studies published in English and Chinese were retrieved from PubMed, Google Scholar, China National Knowledge Infrastructure and Wanfang. RESULTS The prevalence of overweight and obesity has been increasing for decades and varies with age, sex and geography but is more pronounced in primary school students. The increase in obesity in boys appeared to be slower, whereas that in girls showed a declining trend. The northern areas of China have persistently maintained the highest levels of obesity with a stable trend in recent years. Meanwhile, the prevalence in eastern regions has dramatically increased. Notably, the overall prevalence of obesity in children has shown a stabilizing trend in recent years. However, the occurrence of obesity-related metabolic diseases increased. The effect of migrants floating into east-coast cities should not be neglected. CONCLUSIONS The high prevalence of overweight and obesity among Chinese children and adolescents persists but with varying patterns. Obesity-related metabolic diseases occur more frequently despite a stable trend of obesity. Multiple factors are responsible for the changing prevalence. Thus, comprehensive and flexible policies are needed to effectively manage and prevent the burden of obesity and its related complications.
Collapse
Affiliation(s)
- Ye Hong
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China
| | - Rahim Ullah
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China
| | - Jian-Bing Wang
- Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Jun-Fen Fu
- Department of Endocrinology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, 310052, China.
| |
Collapse
|
3
|
Chen ZY, Liu L, Zhuang XX, Zhang YC, Ma YN, Liu Y, Wen DL. Lipid accumulation product is a better predictor of metabolic syndrome in Chinese adolescents: a cross-sectional study. Front Endocrinol (Lausanne) 2023; 14:1179990. [PMID: 37424867 PMCID: PMC10326626 DOI: 10.3389/fendo.2023.1179990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023] Open
Abstract
Aim Confirm and compare the degree of associations of non-traditional lipid profiles and metabolic syndrome (MetS) in Chinese adolescents, determine the lipid parameter with better predictive potential, and investigate their discriminatory power on MetS. Methods Medical measurements, including anthropometric measurements and biochemical blood tests, were undergone among a total sample of 1112 adolescents (564 boys and 548 girls) aged from 13 to 18 years. Univariate and multivariate logistic regression analyses were applied for assessing the relationships between the levels of traditional/non-traditional lipid profiles and MetS. We performed Receiver Operating Characteristic (ROC) analyses to mensurate the effectiveness of lipid accumulation product (LAP) on the diagnosis of MetS. Meanwhile, areas under the ROC curve and the cut-off values were calculated for MetS and its components. Results Univariate analysis showed that all our lipid profiles were closely associated with MetS (P< 0.05). LAP index showed the closest association with MetS than the other lipid profiles. Additionally, ROC analyses indicated that the LAP index showed sufficient capabilities to identify adolescents with MetS and its components. Conclusion The LAP index is a simple and efficient tool to identify individuals with MetS in Chinese adolescents.
Collapse
Affiliation(s)
- Zi-yi Chen
- Institute of Health Sciences, China Medical University, Shenyang, Liaoning, China
| | - Lei Liu
- School of Health and Life Sciences, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Xu-xiu Zhuang
- Institute of Health Sciences, China Medical University, Shenyang, Liaoning, China
| | - Yi-cong Zhang
- Institute of Health Sciences, China Medical University, Shenyang, Liaoning, China
| | - Ya-nan Ma
- School of Public Health, China Medical University, Shenyang, Liaoning, China
| | - Yang Liu
- Institute of Health Sciences, China Medical University, Shenyang, Liaoning, China
| | - De-liang Wen
- Institute of Health Sciences, China Medical University, Shenyang, Liaoning, China
| |
Collapse
|
4
|
Song Y, Wade H, Zhang B, Xu W, Wu R, Li S, Su Q. Polymorphisms of Fat Mass and Obesity-Associated Gene in the Pathogenesis of Child and Adolescent Metabolic Syndrome. Nutrients 2023; 15:2643. [PMID: 37375547 DOI: 10.3390/nu15122643] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Childhood metabolic syndrome (MetS) is prevalent around the world and is associated with a high likelihood of suffering from severe diseases such as cardiovascular disease later in adulthood. MetS is associated with genetic susceptibility that involves gene polymorphisms. The fat mass and obesity-associated gene (FTO) encodes an RNA N6-methyladenosine demethylase that regulates RNA stability and molecular functions. Human FTO contains genetic variants that significantly contribute to the early onset of MetS in children and adolescents. Emerging evidence has also uncovered that FTO polymorphisms in intron 1, such as rs9939609 and rs9930506 polymorphisms, are significantly associated with the development of MetS in children and adolescents. Mechanistic studies reported that FTO polymorphisms lead to aberrant expressions of FTO and the adjacent genes that promote adipogenesis and appetite and reduce steatolysis, satiety, and energy expenditure in the carriers. The present review highlights the recent observations on the key FTO polymorphisms that are associated with child and adolescent MetS with an exploration of the molecular mechanisms underlying the development of increased waist circumference, hypertension, and hyperlipidemia in child and adolescent MetS.
Collapse
Affiliation(s)
- Yongyan Song
- Central Laboratory, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu 610106, China
| | - Henry Wade
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast BT9 5DL, UK
| | - Bingrui Zhang
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast BT9 5DL, UK
| | - Wenhao Xu
- Clinical Medical College, Chengdu University, Chengdu 610106, China
| | - Rongxue Wu
- Section of Cardiology, Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, IL 60637, USA
| | - Shujin Li
- Central Laboratory, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu 610106, China
| | - Qiaozhu Su
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, Belfast BT9 5DL, UK
| |
Collapse
|
5
|
Sun J, Ma X, Yang L, Jin X, Zhao M, Xi B, Song S. The number of metabolic syndrome risk factors predicts alterations in gut microbiota in Chinese children from the Huantai study. BMC Pediatr 2023; 23:191. [PMID: 37085796 PMCID: PMC10120097 DOI: 10.1186/s12887-023-04017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/14/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Evidence on the effect of gut microbiota on the number of metabolic syndrome (MetS) risk factors among children is scarce. We aimed to examine the alterations of gut microbiota with different numbers of MetS risk factors among children. METHODS Data were collected from a nested case-control study at the baseline of the Huantai Childhood Cardiovascular Health Cohort Study in Zibo, China. We compared the differences in gut microbiota based on 16S rRNA gene sequencing among 72 children with different numbers of MetS risk factors matched by age and sex (i.e., none, one, and two-or-more MetS risk factors; 24 children for each group). RESULTS The community richness (i.e., the total number of species in the community) and diversity (i.e., the richness and evenness of species in the community) of gut microbiota decreased with an increased number of MetS risk factors in children (P for trend < 0.05). Among genera with a relative abundance greater than 0.01%, the relative abundance of Lachnoclostridium (PFDR = 0.009) increased in the MetS risk groups, whereas Alistipes (PFDR < 0.001) and Lachnospiraceae_NK4A136_group (PFDR = 0.043) decreased in the MetS risk groups compared to the non-risk group. The genus Christensenellaceae_R-7_group excelled at distinguishing one and two-or-more risk groups from the non-risk group (area under the ROC curve [AUC]: 0.84 - 0.92), while the genera Family_XIII_AD3011_group (AUC: 0.73 - 0.91) and Lachnoclostridium (AUC: 0.77 - 0.80) performed moderate abilities in identifying none, one, and two-or-more MetS risk factors in children. CONCLUSIONS Based on the nested case-control study and the 16S rRNA gene sequencing technology, we found that dysbiosis of gut microbiota, particularly for the genera Christensenellaceae_R-7_group, Family_XIII_AD3011_group, and Lachnoclostridium may contribute to the early detection and the accumulation of MetS risk factors in childhood.
Collapse
Affiliation(s)
- Jiahong Sun
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wen Hua Xi Road, Jinan, 250012, China
| | - Xiaoyun Ma
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wen Hua Xi Road, Jinan, 250012, China
| | - Liu Yang
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wen Hua Xi Road, Jinan, 250012, China
| | - Xuli Jin
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wen Hua Xi Road, Jinan, 250012, China
| | - Min Zhao
- Department of Nutrition and Food Hygiene, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Bo Xi
- Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wen Hua Xi Road, Jinan, 250012, China.
| | - Suhang Song
- Taub Institute for Research in Alzheimer 's disease and the Aging Brain, Columbia University, New York, NY, USA
| |
Collapse
|
6
|
Li J, Song Y, Shi L, Jiang J, Wan X, Wang Y, Ma Y, Dong Y, Zou Z, Ma J. Long-term effects of ambient PM 2.5 constituents on metabolic syndrome in Chinese children and adolescents. ENVIRONMENTAL RESEARCH 2023; 220:115238. [PMID: 36621550 DOI: 10.1016/j.envres.2023.115238] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 06/17/2023]
Abstract
Metabolic syndrome (MetS) is considered a main public health issue as it remarkably adds the risk of cardiovascular disease, leading to a heavy burden of disease. There is growing evidence linking fine particulate matter (PM2.5) exposure to MetS. However, the influences of PM2.5 constituents, especially in children and adolescents, remain unclear. Our study was according to a national analysis among Chinese children and adolescents to examine the associations between long-term exposure to PM2.5 main constituents and MetS. A total of 10,066 children and adolescents aged 10-18 years were recruited in 7 provinces in China, with blood tests, health exams, and questionnaire surveys. We estimated long-term exposures to PM2.5 mass and its five constituents, containing black carbon (BC), organic matter (OM), inorganic nitrate (NO3-), sulfate (SO42-), and soil particles (SOIL) from multi-source data fusion models. Mixed-effects logistic regression models were used with the adjustment of a variety of covariates. In the surveyed populations, 2.9% were classified as MetS. From the single-pollutant models, we discovered that long-term exposures to PM2.5 mass, BC, OM, NO3-, as well as SO42-, were significantly associated with the prevalence of MetS, with odds ratios (ORs) per 1 μg/m3 that were 1.02 (95% confidence interval (CI): 1.01, 1.03) for PM2.5 mass, 1.24 (95% CI: 1.14, 1.35) for BC, 1.07 (95% CI: 1.04, 1.11) for OM, 1.09 (95% CI: 1.04, 1.13) for NO3-, and 1.14 (95% CI:1.04, 1.24) for SO42-. The influence of BC on the prevalence of MetS was robust in both the multi-pollutant model and the PM2.5-constituent joint model. The paper indicates long-term exposure to PM2.5 mass and specific PM2.5 constituents, particularly for BC, was significantly associated with a higher MetS prevalence among children and adolescents in China. Our results highlight the significance of establishing further regulations on PM2.5 constituents.
Collapse
Affiliation(s)
- Jing Li
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| | - Yi Song
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| | - Liuhua Shi
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, 30322, USA
| | - Jun Jiang
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| | - Xiaoyu Wan
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| | - Yaqi Wang
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| | - Yinghua Ma
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| | - Yanhui Dong
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China.
| | - Zhiyong Zou
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China.
| | - Jun Ma
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, 100191, China
| |
Collapse
|
7
|
Dundar C, Terzi O, Arslan HN. Comparison of the ability of HOMA-IR, VAI, and TyG indexes to predict metabolic syndrome in children with obesity: a cross-sectional study. BMC Pediatr 2023; 23:74. [PMID: 36765298 PMCID: PMC9921359 DOI: 10.1186/s12887-023-03892-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND The increasing trend in childhood obesity needs to be closely monitored and intervened due to long-term health issues such as metabolic syndrome, cardiovascular diseases, hypertension, and type 2 diabetes. We aimed to determine and compare the cut-off values for the visceral adiposity index (VAI), triglyceride-glucose index (TyG), and HOMA-IR for predicting metabolic syndrome (MetS). METHODS This population-based cross-sectional study was conducted in May 2019 in Samsun, Turkey. The study included 169 children with obesity aged 9 and 10 years. After anthropometric and clinical evaluation, fasting blood samples were collected from the children. The areas under the curve of the visceral adiposity index, triglyceride-glucose index, and HOMA-IR were compared by receiver-operating-characteristic (ROC) analysis in predicting the MetS. RESULTS The total prevalence of MetS was 21.3% in children with obesity, and it was two times higher in girls than in boys. The mean values of TyG and VAI were significantly different in those who have and have not MetS in both genders. However, the HOMA-IR index was higher only in girls with MetS and did not differ in boys by having MetS. The VAI and the TyG index both had statistically significant cut-off values in both sexes and a larger ROC area than the HOMA-IR index in predicting MetS. CONCLUSIONS The VAI and TyG index are effective indicators in assessing the MetS risk in children with obesity. Both indexes can be considered useful tools in pediatric research and the evaluation of interventions. However, the HOMA-IR index formula needs to be developed taking into account age, gender, and ethnicity.
Collapse
Affiliation(s)
- Cihad Dundar
- Dept. of Public Health, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey.
| | - Ozlem Terzi
- grid.411049.90000 0004 0574 2310Dept. of Public Health, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Hatice Nilden Arslan
- grid.411049.90000 0004 0574 2310Dept. of Public Health, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| |
Collapse
|
8
|
Prevalence Trends of Metabolic Syndrome among Korean Children and Adolescents from a Population-Based Cross-Sectional Survey. Life (Basel) 2022; 12:life12091404. [PMID: 36143440 PMCID: PMC9503497 DOI: 10.3390/life12091404] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/29/2022] [Accepted: 09/06/2022] [Indexed: 12/23/2022] Open
Abstract
The prevalence of metabolic syndrome (MetS) is increasing worldwide. This study aimed to investigate the prevalence trend of metabolic syndrome among Korean adolescents and to examine the effect of changes in dietary components on metabolic syndrome components. It has used the data of children and adolescents (8718 subjects aged 10−18) from the National Health and Nutrition Survey IV-VII (KNHANES 2007−2018) to estimate the recent prevalence of MetS and identify related nutritional factors. The definition of MetS used modified NCEP-ATP III and IDF criteria. The prevalence of MetS among Korean adolescents in 2007−2018 was 4.6% using the modified NCEP-ATP III criteria, and the trend of MetS increased significantly (p trend = 0.02). In the overweight and obese groups, the risk of MetS increased 7.08 (95% CI, 5.19−9.79) and 27.13 (95% CI, 20.90−35.24) compared to the normal-weight group. During KNHANES IV-VII, overall caloric intake increased, carbohydrate and sodium intake decreased, but fat intake increased (KNHANE-IV; 21.3% to VII; 24.0%, p < 0.001). These fat intakes were significantly correlated with an increase in systolic blood pressure, fasting blood glucose, and waist circumference. The prevalence of MetS is also increasing in Korean adolescents, and changes in dietary habits are related. In the future, it is also necessary to study the relationship of MetS to lifestyle.
Collapse
|
9
|
Central body fat deposits are associated with poor vitamin D status in Chinese children and adolescents. Nutrition 2022; 99-100:111651. [DOI: 10.1016/j.nut.2022.111651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/27/2021] [Accepted: 02/28/2022] [Indexed: 11/16/2022]
|
10
|
Peng SS, Yu Y, Yu X, Guo D, Su L, Li H, Luo P, Chen PY, Wu SL, Huang Y, Zhao Y, Fang AP. Adherence to the Chinese Dietary Guidelines and Metabolic Syndrome among Children aged 6-14 years. Food Funct 2022; 13:9772-9781. [DOI: 10.1039/d2fo00637e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The role of diet in the development of childhood metabolic syndrome (MetS) has not been clearly elucidated. This study aims to investigate the association between the adherence to the Chinese...
Collapse
|
11
|
Association between serum zinc concentrations and metabolic risk factors among Chinese children and adolescents. Br J Nutr 2021; 126:1529-1536. [PMID: 33472712 DOI: 10.1017/s0007114521000258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The aim of the present study was to examine whether serum Zn concentrations were associated with metabolic risk factors in Chinese children and adolescents. This was a cross-sectional study including 3241 participants, aged 6 to 17 years, from Jiangsu, China. Metabolic risk factors included fasting glucose (FG), total cholesterol (TC), TAG, HDL-cholesterol, LDL-cholesterol, systolic blood pressure and diastolic blood pressure. Data were analysed using multi-variable linear regression and generalised additive models, which were adjusted for age, sex, high-sensitive C-reactive protein, estimated glomerular filtration rate, BMI and region of residence, to assess the associations of serum Zn concentrations with metabolic risk factors. We observed a negative association between serum Zn concentrations and FG (coefficient = -0·532; 95 % CI -0·569, -0·495; P < 0·001). Moreover, TC (coefficient = 0·175; 95 % CI 0·127, 0·222; P < 0·001), HDL-cholesterol (coefficient = 0·137; 95 % CI 0·082, 0·193; P < 0·001) and LDL-cholesterol (coefficient = 0·195; 95 % CI 0·128, 0·263; P < 0·001) were found to be positively associated with Zn levels. A generalised additive model showed that the negative association between serum Zn and FG was weak at lower serum Zn concentrations and was stronger with the increase in serum Zn concentrations. Additionally, a U-shaped association between serum Zn and TAG was observed. Serum Zn concentrations were associated with FG, TC, TAG, HDL-cholesterol and LDL-cholesterol levels in Chinese children and adolescents. Lower levels of serum Zn were more likely related to a poor metabolic status.
Collapse
|
12
|
Chae J, Seo MY, Kim SH, Park MJ. Trends and Risk Factors of Metabolic Syndrome among Korean Adolescents, 2007 to 2018. Diabetes Metab J 2021; 45:880-889. [PMID: 34225415 PMCID: PMC8640158 DOI: 10.4093/dmj.2020.0185] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/04/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND There is a lack of recent research on the changes in risk factors for metabolic syndrome (MetS) in the Asian pediatric population. We aimed to determine the 12-year trends in the prevalence of MetS and relevant lifestyle factors such as smoking, exercise, and calorie intake among Korean adolescents. METHODS We investigated trends in MetS and lifestyle factors among 6,308 adolescents aged 12 to 18 years from the Korea National Health and Nutrition Examination Survey, 2007 to 2018. RESULTS The prevalence of MetS was stable from 2007 to 2018 (1.7% to 2.2%). There were significant increases in the prevalence of central obesity (from 8.1% to 11.2%, P=0.012) and hyperglycemia (from 5.3% to 10.4%, P<0.001) and decreases in hypo-high-density lipoprotein (HDL)-cholesterolemia (from 22.4% to 14.8%, P<0.001). Total calorie intake and calorie intake from fat significantly increased (P<0.001), whereas calorie intake from carbohydrates significantly decreased (P<0.001) during the study period. The proportions of tobacco smokers and regular walkers significantly decreased from 2007 to 2018. After controlling for all covariates, total calorie intake was positively correlated with waist circumference (P<0.05). HDL-cholesterol was negatively associated with carbohydrate consumption (P<0.01) and positively associated with fat consumption (P<0.001). Regular walking and regular strength training were associated with lower waist circumference (P<0.05). Smoking was associated with lower fasting glucose levels (P<0.01). CONCLUSION Although the prevalence rate of MetS is stable among Korean adolescents, the prevalence of central obesity and hyperglycemia has increased greatly in the recent decade. Public education on proper dietary intake and lifestyle modification is required.
Collapse
Affiliation(s)
- Jiun Chae
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Moon Young Seo
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Shin-Hye Kim
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
- Shin-Hye Kim https://orcid.org/0000-0003-0413-122X Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea E-mail:
| | - Mi Jung Park
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
- Corresponding authors: Mi Jung Park https://orcid.org/0000-0002-7202-500X Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea E-mail:
| |
Collapse
|
13
|
Siwarom S, Aekplakorn W, Pirojsakul K, Paksi W, Kessomboon P, Neelapaichit N, Chariyalertsak S, Assanangkornchai S, Taneepanichskul S. Metabolic syndrome in Thai adolescents and associated factors: the Thai National Health Examination Survey V (NHES V). BMC Public Health 2021; 21:678. [PMID: 33827482 PMCID: PMC8028250 DOI: 10.1186/s12889-021-10728-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/29/2021] [Indexed: 01/19/2023] Open
Abstract
Background Presence of metabolic syndrome (MetS) in early life may influence cardiovascular outcome later in adulthood. There is limited data regarding MetS among Thai adolescents. This study aimed to estimate the prevalence of MetS and related factors in Thai adolescents. Methods Data on MetS components of 1934 Thai adolescents aged 10–16 years were obtained from the 5th National Health Examination Survey. Age at first screen time exposure, duration of screen time, frequency of food intake and physical activities were collected from interviews. MetS was defined according to 3 definitions: International Diabetes Federation (IDF), Cook’s, and de Ferranti’s. Results The prevalence of MetS was 4.1% by IDF, 8.0% by Cook’s, and 16.8% by de Ferranti’s definition. The overall prevalence was higher in male (19.0%) than female adolescents (15.3%). The most common MetS components composition among Thai adolescents was high waist circumference with high serum triglyceride and low HDL-cholesterol (40.0% for IDF, 22.6% for Cook’s and 43.5% for de Ferranti’s definition). Exposure to screen media during the first 2 years of life had a 1.3- fold increased odds of MetS by 1 out of 3 definitions (OR 1.30, 95% CI. 1.01–1.68). Duration of physical activity associated with decreased odds of MetS by Cook’s definition (OR 0.96, 95% CI. 0.92–0.99). Conclusions The prevalence of MetS among Thai adolescents was higher than previously reported by other studies. Screen media exposure during the first 2 years of life should be discouraged and measures to promote physical activity among children and adolescents should be strengthen. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10728-6.
Collapse
Affiliation(s)
- Sirinapa Siwarom
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wichai Aekplakorn
- Department of Community Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phayathai, Ratchathewi, Bangkok, 10400, Thailand.
| | - Kwanchai Pirojsakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Witchuri Paksi
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pattapong Kessomboon
- Department of Community Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nareemarn Neelapaichit
- Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | |
Collapse
|
14
|
Morioka T, Mori K, Emoto M. Is Stiffness Parameter β Useful for the Evaluation of Atherosclerosis?~ Its Clinical Implications, Limitations, and Future Perspectives ~. J Atheroscler Thromb 2021; 28:435-453. [PMID: 33583910 PMCID: PMC8193788 DOI: 10.5551/jat.rv17047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Atherosclerosis comprises two components, atherosis and sclerosis, characterized by morphological wall thickening and functional stiffening, respectively, of the arterial wall. In recent years, much interest has been directed to the role of functional changes in large arteries, i.e., increased stiffness or decreased elasticity, on the development of cardiovascular diseases. In fact, the clinical evaluation of arterial stiffness is increasingly performed in patients with cardiovascular risk factors. Local arterial stiffness is measured using an ultrasound technique implemented with an echo-tracking system at the common carotid and femoral arteries. Several indices of local arterial stiffness are obtained by ultrasound, among which stiffness parameter β is unique because it is the least affected by blood pressure at the time of measurement. Evidence from cross-sectional studies indicates that increased stiffness parameter β is associated with a number of cardiovascular risk factors, such as older age, smoking, insufficient physical activity, hypertension, obesity, metabolic syndrome, insulin resistance, type 2 diabetes, chronic kidney disease, and comorbid cardiovascular disease. Results from several prospective observational studies also suggest that carotid stiffness parameter β is a useful surrogate marker of cardiovascular events and/or mortality, although the results differ depending on the characteristics of the study subjects. Furthermore, several interventional studies have shown that carotid stiffness parameter β improved after lifestyle modification or drug treatment. In this review, we summarize the current evidence of stiffness parameter β of the carotid artery and discuss its clinical implications as a marker of vascular health or as a predictor of cardiovascular outcomes.
Collapse
Affiliation(s)
- Tomoaki Morioka
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine
| | - Katsuhito Mori
- Department of Nephrology, Osaka City University Graduate School of Medicine
| | - Masanori Emoto
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine
| |
Collapse
|
15
|
Xu P, Liu A, Li F, Tinkov AA, Liu L, Zhou JC. Associations between metabolic syndrome and four heavy metals: A systematic review and meta-analysis. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2021; 273:116480. [PMID: 33486246 DOI: 10.1016/j.envpol.2021.116480] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/19/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
Four most concerned heavy metal pollutants, arsenic, cadmium, lead, and mercury may share common mechanisms to induce metabolic syndrome (MetS). However, recent studies exploring the relationships between MetS and metal exposure presented inconsistent findings. We aimed to clarify the relationship between heavy metal exposure biomarkers and MetS using a meta-analysis and systematic review approach. Literature search was conducted in international and the Chinese national databases up to June 2020. Of selected studies, we extracted the relevant data and evaluated the quality of each study's methodology. We then calculated the pooled effect sizes (ESs), standardized mean differences (SMDs), and their 95% confidence intervals (CIs) using a random-effect meta-analysis approach followed by stratification analyses for control of potential confounders. Involving 55,536 participants, the included 22 articles covered 52 observational studies reporting ESs and/or metal concentrations on specific metal and gender. Our results show that participants with MetS had significantly higher levels of heavy metal exposure [pooled ES = 1.16, 95% CI: 1.09, 1.23; n = 42, heterogeneity I2 = 75.6%; and SMD = 0.22, 95% CI: 0.15, 0.29; n = 32, I2 = 94.2%] than those without MetS. Pooled ESs in the subgroups stratified by arsenic, cadmium, lead, and mercury were 1.04 (95% CI: 0.97, 1.10; n = 8, I2 = 61.0%), 1.10 (0.95, 1.27; 11, 45.0%), 1.21 (1.00, 1.48; 12, 82.9%), and 1.26 (1.06, 1.48; 11, 67.7%), respectively. Pooled ESs in the subgroups stratified by blood, urine, and the other specimen were 1.22 (95% CI: 1.08, 1.38; n = 26, I2 = 75.8%), 1.06 (1.00, 1.13; 14, 58.1%), and 2.41 (1.30, 4.43; 2, 0.0%), respectively. In conclusion, heavy metal exposure was positively associated with MetS. Further studies are warranted to examine the effects of individual metals and their interaction on the relationship between MetS and heavy metals.
Collapse
Affiliation(s)
- Ping Xu
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, 518100, China
| | - Aiping Liu
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, 518100, China
| | - Fengna Li
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, 518100, China
| | - Alexey A Tinkov
- Yaroslavl State University, 150003, Yaroslavl, Russia; IM Sechenov First Moscow State Medical University (Sechenov University), 119146, Moscow, Russia
| | - Longjian Liu
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, 19104, USA
| | - Ji-Chang Zhou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, 518100, China; Guangdong Province Engineering Laboratory for Nutrition Translation, Guangzhou, 510080, China.
| |
Collapse
|
16
|
Su Y, Lu Y, Li W, Xue M, Chen C, Haireti M, Li Y, Liu Z, Liu Y, Wang S, Yao H. Prevalence and Correlation of Metabolic Syndrome: A Cross-Sectional Study of Nearly 10 Million Multi-Ethnic Chinese Adults. Diabetes Metab Syndr Obes 2020; 13:4869-4883. [PMID: 33335411 PMCID: PMC7737555 DOI: 10.2147/dmso.s278346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 12/26/2022] Open
Abstract
PURPOSE This study aimed to examine the prevalence and correlates of metabolic syndrome (MetS) in multi-ethnic populations of Northwest China based on Large-scale provincial health checking data. PATIENTS AND METHODS A total of 9,745,640 Chinese aged ≥18 years in Xinjiang, the largest autonomous region of multi-ethnic in China, were enrolled from Feb. to Sep. 2019. MetS was defined by modified Adult Treatment Panel (ATP III) criteria. RESULTS The overall prevalence of MetS was 20.85% [Sex: 20.06% female, 21.56% male; Age: 39.22% 60-years and above, 26.32% 40- to 59-years and 9.56% 18- to 39-years; Ethnicity: 28.19% Hui followed by Han (26.39%), Uyghur (18.56%), Other (18.61%), Kazak (17.98%), Mongolian (17.87%), Kyrgyz (14.44%)]. People living in cities and towns (23.03%) or North (24.78%) had higher prevalence of MetS than rural (19.94%) and South (17.66%). Although the prevalence of hypertension, smoking, drinking and lack of physical activity were higher in Kyrgyz, Mongolian and Kazak than those of other ethnic groups, the risk of MetS was lower. CONCLUSION The results indicated that a high prevalence of MetS in Hui and Han groups and people living in cities and towns. Living in North Xinjiang and elder population tend to have higher prevalence of MetS. The prevention and management of MetS in these populations should be prioritized.
Collapse
Affiliation(s)
- Yinxia Su
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
- Health Management Institute, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Yaoqin Lu
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
- Center of Disease Control and Prevention, Urumqi, Xinjiang, People’s Republic of China
| | - Wenli Li
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Mingyue Xue
- Health Management Institute, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
- The Fourth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Chen Chen
- School of Biomedical Sciences, University of Queensland, Brisbane4072, Australia
| | - Muyaseer Haireti
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Yuanyuan Li
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Zhenhui Liu
- Department of Microrepair and Reconstruction, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Yanshi Liu
- Department of Microrepair and Reconstruction, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Shuxia Wang
- Health Management Institute, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
| | - Hua Yao
- Health Management Institute, Xinjiang Medical University, Urumqi, Xinjiang, People’s Republic of China
- Correspondence: Hua Yao; Shuxia Wang Email ;
| |
Collapse
|
17
|
Gong M, Wen S, Nguyen T, Wang C, Jin J, Zhou L. Converging Relationships of Obesity and Hyperuricemia with Special Reference to Metabolic Disorders and Plausible Therapeutic Implications. Diabetes Metab Syndr Obes 2020; 13:943-962. [PMID: 32280253 PMCID: PMC7125338 DOI: 10.2147/dmso.s232377] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Obesity and hyperuricemia mutually influence metabolic syndrome. This study discusses the metabolic relationships between obesity and hyperuricemia in terms of pathophysiology, complications, and treatments. METHODS We searched for preclinical or clinical studies on the pathophysiology, complications, and therapy of obesity and hyperuricemia on the PubMed database. RESULTS In this systemic review, we summarized our searching results on topics of pathophysiology, complications and therapeutic strategy. In pathophysiology, we firstly introduce genetic variations for obesity, hyperuricemia and their relationships by genetic studies. Secondly, we talk about the epigenetic influences on obesity and hyperuricemia. Thirdly, we describe the central metabolic regulation and the role of hyperuricemia. Then, we refer to the character of adipose tissue inflammation and oxidative stress in the obesity and hyperuricemia. In the last part of this topic, we reviewed the critical links of gut microbiota in the obesity and hyperuricemia. In the following part, we review the pathophysiology of major complications in obesity and hyperuricemia including insulin resistance and type 2 diabetes mellitus, chronic kidney disease, cardiovascular diseases, and cancers. Finally, we recapitulate the therapeutic strategies especially the novel pharmaceutic interventions for obesity and hyperuricemia, which concurrently show the mutual metabolic influences between two diseases. CONCLUSION The data reviewed here delineate the metabolic relationships between obesity and hyperuricemia, and provide a comprehensive overview of the therapeutic targets for the management of metabolic syndromes.
Collapse
Affiliation(s)
- Min Gong
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Thiquynhnga Nguyen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Chaoxun Wang
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Jianlan Jin
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, People’s Republic of China
- Correspondence: Ligang Zhou Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai201399, ChinaTel +8613611927616 Email
| |
Collapse
|
18
|
Bitew ZW, Alemu A, Ayele EG, Tenaw Z, Alebel A, Worku T. Metabolic syndrome among children and adolescents in low and middle income countries: a systematic review and meta-analysis. Diabetol Metab Syndr 2020; 12:93. [PMID: 33117455 PMCID: PMC7590497 DOI: 10.1186/s13098-020-00601-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) is a clustering of cardiovascular risk factors, which is rising in the low and middle income countries (LMICs). There are various studies with inconsistent findings that are inconclusive for policy makers and program planners. Thus, this systematic review and meta-analysis aimed at estimating the pooled prevalence of MetS and its components in LMICs. METHODS Electronic searches were conducted in international databases including PubMed, Web of Science, EMBASE (Elsevier), Scopus, CINAHL (EBSCOhost), Science direct (Elsevier), Food Science and Technology Abstracts (FSTA), Global Health and Medline, and other sources (World Cat, Google Scholar, and Google). The pooled estimates were computed in the random effect model. The pooled prevalence was computed using the three diagnostic methods (IDF, ATP III and de Ferranti). Publication bias was verified using funnel plot and Egger's regression test. Subgroup and sensitivity analysis were performed to identify the possible sources of heterogeneity among the included studies. RESULT In this study, 142,142 children and adolescents from 76 eligible articles were included to compute the pooled prevalence of MetS and its components in LMCIs. MeTs among overweight and obese population was computed from 20 articles with the pooled prevalence of 24.09%, 36.5%, and 56.32% in IDF, ATP III and de Ferranti criteria, respectively. Similarly, a total of 56 articles were eligible to compute the pooled prevalence of MetS in the general population of children and adolescents. Hence, Mets was found in 3.98% (IDF), 6.71% (ATP III) and 8.91% (de Ferranti) of study subjects. Regarding the components of MetS, abdominal obesity was the major component in overweight and obese population and low HDL-C was the most common component in the general population. This study also revealed that males were highly affected by MetS than females. CONCLUSION This study illustrates that MetS among children and adolescents is an emerging public health challenge in LMICs, where the prevalence of obesity is on the move. Preventive strategies such as community and school based intervention need to be designed. Promoting physical activities and healthy eating behaviors could avert this problem.
Collapse
Affiliation(s)
| | | | | | - Zelalem Tenaw
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Anmut Alebel
- College of Health Science, Debremarkose University, Debre Markos, Ethiopia
- Australian Centre for Public and Population Health Research, School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW Australia
| | - Teshager Worku
- College of Health and Medical Sciences, School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
| |
Collapse
|