Obesity-associated metabolites in relation to type 2 diabetes risk: A prospective nested case-control study of the CARRS cohort

AIMS

To determine whether obesity-associated metabolites are associated with type 2 diabetes (T2DM) risk among South Asians.

MATERIALS AND METHODS

Serum-based nuclear magnetic resonance imaging metabolomics data were generated from two South Asian population-based prospective cohorts from Karachi, Pakistan: CARRS1 (N = 4017) and CARRS2 (N = 4802). Participants in both cohorts were followed up for 5 years and incident T2DM was ascertained. A nested case-control study approach was developed to select participants from CARRS1 (N_cases  = 197 and N_controls  = 195) and CARRS2 (N_cases  = 194 and N_controls  = 200), respectively. First, we investigated the association of 224 metabolites with general obesity based on body mass index and with central obesity based on waist-hip ratio, and then the top obesity-associated metabolites were studied in relation to incident T2DM.

RESULTS

In a combined sample of the CARRS1 and CARRS2 cohorts, out of 224 metabolites, 12 were associated with general obesity and, of these, one was associated with incident T2DM. Fifteen out of 224 metabolites were associated with central obesity and, of these, 10 were associated with incident T2DM. The higher level of total cholesterol in high-density lipoprotein (HDL) was associated with reduced T2DM risk (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.53, 0.86; P = 1.2 × 10^-3 ), while higher cholesterol esters in large very-low-density lipoprotein (VLDL) particles were associated with increased T2DM risk (OR 1.90, 95% CI 1.40, 2.58; P = 3.5 × 10^-5 ).

CONCLUSION

Total cholesterol in HDL and cholesterol esters in large VLDL particles may be an important biomarker in the identification of early development of obesity-associated T2DM risk among South Asian adults.

Determinant of repeat revascularization within 5 years of Percutaneous Coronary Intervention at a tertiary care hospital, Karachi: A matched case-control study

Objective

To determine factors associated with repeat revascularization among adults aged 25 years and above within 5 years of first Percutaneous Coronary Intervention (PCI) at a tertiary care hospital.

Methods

A matched case-control study was conducted through a hospital records review. A total of 90 cases with repeat revascularization and 180 controls without repeat revascularization were included. Data was analyzed using Multiple Conditional Logistic Regression.

Results

The mean age was similar in cases and controls (60.05 ± 10.01 vs 62.20 ± 10.43 years) and sex (male: 77.8% vs. 76.1%). History of being an ever-smoker (40% vs. 25%), overweight (36.3% vs. 30.6%), and poor glycemic control (23.3% vs. 12.2%) were more among the cases than controls. However, obesity (53.7% vs. 44.3%) and pre-diabetes (16.1% vs. 7.8%) were more in controls compared to cases.

Upon matching on the time of index PCI, the adjusted odds of ever smokers among patients with repeat revascularization was 2.47 times the odds of ever smokers among patients who did not undergo revascularization. Increasing stent diameter by 1 mm was found to reduce the risk of repeat revascularization by 51%.

Conclusions

Smoking cessation and appropriate selection of stent diameter in patients undergoing revascularization can reduce the risk of repeat revascularization in the future.

•

Study assessed determinants of repeat revascularization after initial PCI from a large tertiary care hospital in Karachi.

•

Ever smokers undergoing index PCI have 2.47 times increased risk of repeat revascularization.

•

1 mm increase in stent diameter reduces 51% risk of repeat revascularization.

•

Association between smoking and repeat revascularization may be a severe problem than estimated due to the reporting bias.

•

More effective and well-tolerated strategies are needed for smoking cessation and sustain abstinence.

Lifetime risk of diabetes in metropolitan cities in India

AIMS/HYPOTHESIS

We aimed to estimate the lifetime risk of diabetes and diabetes-free life expectancy in metropolitan cities in India among the population aged 20 years or more, and their variation by sex, age and BMI.

METHODS

A Markov simulation model was adopted to estimate age-, sex- and BMI-specific lifetime risk of developing diabetes and diabetes-free life expectancy. The main data inputs used were as follows: age-, sex- and BMI-specific incidence rates of diabetes in urban India taken from the Centre for Cardiometabolic Risk Reduction in South Asia (2010-2018); age-, sex- and urban-specific rates of mortality from period lifetables reported by the Government of India (2014); and prevalence of diabetes from the Indian Council for Medical Research INdia DIABetes study (2008-2015).

RESULTS

Lifetime risk (95% CI) of diabetes in 20-year-old men and women was 55.5 (51.6, 59.7)% and 64.6 (60.0, 69.5)%, respectively. Women generally had a higher lifetime risk across the lifespan. Remaining lifetime risk (95% CI) declined with age to 37.7 (30.1, 46.7)% at age 60 years among women and 27.5 (23.1, 32.4)% in men. Lifetime risk (95% CI) was highest among obese Indians: 86.0 (76.6, 91.5)% among 20-year-old women and 86.9 (75.4, 93.8)% among men. We identified considerably higher diabetes-free life expectancy at lower levels of BMI.

CONCLUSIONS/INTERPRETATION

Lifetime risk of diabetes in metropolitan cities in India is alarming across the spectrum of weight and rises dramatically with higher BMI. Prevention of diabetes among metropolitan Indians of all ages is an urgent national priority, particularly given the rapid increase in urban obesogenic environments across the country. Graphical abstract.

Associations of sickness absence for pain in the low back, neck and shoulders with wider propensity to pain

Objectives

To explore the association of sickness absence ascribed to pain at specific anatomical sites with wider propensity to musculoskeletal pain.

Methods

As part of the CUPID (Cultural and Psychosocial Influences on Disability) study, potential risk factors for sickness absence from musculoskeletal pain were determined for 11 922 participants from 45 occupational groups in 18 countries. After approximately 14 months, 9119 (78%) provided follow-up information about sickness in the past month because of musculoskeletal pain, including 8610 who were still in the same job. Associations with absence for pain at specific anatomical sites were assessed by logistic regression and summarised by ORs with 95% CIs.

Results

861 participants (10%) reported absence from work because of musculoskeletal pain during the month before follow-up. After allowance for potential confounders, risk of absence ascribed entirely to low back pain (n=235) increased with the number of anatomical sites other than low back that had been reported as painful in the year before baseline (ORs 1.6 to 1.7 for ≥4 vs 0 painful sites). Similarly, associations with wider propensity to pain were observed for absence attributed entirely to pain in the neck (ORs up to 2.0) and shoulders (ORs up to 3.4).

Conclusions

Sickness absence for pain at specific anatomical sites is importantly associated with wider propensity to pain, the determinants of which extend beyond established risk factors such as somatising tendency and low mood. Better understanding of why some individuals are generally more prone to musculoskeletal pain might point to useful opportunities for prevention.

Determinants of international variation in the prevalence of disabling wrist and hand pain

Background

Previous research has indicated that wide international variation in the prevalence of disabling low back pain among working populations is largely driven by factors predisposing to musculoskeletal pain more generally. This paper explores whether the same applies to disabling wrist/hand pain (WHP).

Methods

Using data from the Cultural and Psychosocial Influences on Disability (CUPID) study, we focused on workers from 45 occupational groups (office workers, nurses and other workers) in 18 countries. Among 11,740 participants who completed a baseline questionnaire about musculoskeletal pain and potential risk factors, 9082 (77%) answered a further questionnaire after a mean interval of 14 months, including 1373 (15%) who reported disabling WHP in the month before follow-up. Poisson regression was used to assess associations of this outcome with baseline risk factors, including the number of anatomical sites other than wrist/hand that had been painful in the 12 months before baseline (taken as an index of general propensity to pain).

Results

After allowance for other risk factors, the strongest associations were with general pain propensity (prevalence rate ratio for an index ≥6 vs. 0: 3.6, 95% confidence interval 2.9–4.4), and risk rose progressively as the index increased. The population attributable fraction for a pain propensity index > 0 was 49.4%. The prevalence of disabling WHP by occupational group ranged from 0.3 to 36.2%, and correlated strongly with mean pain propensity index (correlation coefficient 0.86).

Conclusion

Strategies to prevent disability from WHP among working populations should explore ways of reducing general propensity to pain, as well as improving the ergonomics of occupational tasks.

Multimorbidity in South Asian adults: prevalence, risk factors and mortality

BACKGROUND

We report the prevalence, risk factors and mortality associated with multimorbidity in urban South Asian adults.

METHODS

Hypertension, diabetes, heart disease, stroke and chronic kidney disease were measured at baseline in a sample of 16 287 adults ages ≥20 years in Delhi, Chennai and Karachi in 2010-11 followed for an average of 38 months. Multimorbidity was defined as having ≥2 chronic conditions at baseline. We identified correlates of multimorbidity at baseline using multinomial logistic models, and we assessed the prospective association between multimorbidity and mortality using Cox proportional hazards models.

RESULTS

The adjusted prevalence of multimorbidity was 9.4%; multimorbidity was highest in adults who were aged ≥60 years (37%), consumed alcohol (12.3%), body mass index ≥25 m/kg2 (14.1%), high waist circumference (17.1%) and had family history of a chronic condition (12.4%). Compared with adults with no chronic conditions, the fully adjusted relative hazard of death was twice as high in adults with two morbidities (hazard ratio [HR] = 2.3; 95% confidence interval [CI]: 1.6, 3.3) and thrice as high in adults with ≥3 morbidities (HR = 3.1; 95% CI: 1.9, 5.1).

CONCLUSION

Multimorbidity affects nearly 1 in 10 urban South Asians, and each additional morbidity carries a progressively higher risk of death. Identifying locally appropriate strategies for prevention and coordinated management of multimorbidity will benefit population health in the region.

Drivers of international variation in prevalence of disabling low back pain: Findings from the Cultural and Psychosocial Influences on Disability study

Background

Wide international variation in the prevalence of disabling low back pain (LBP) among working populations is not explained by known risk factors. It would be useful to know whether the drivers of this variation are specific to the spine or factors that predispose to musculoskeletal pain more generally.

Methods

Baseline information about musculoskeletal pain and risk factors was elicited from 11 710 participants aged 20–59 years, who were sampled from 45 occupational groups in 18 countries. Wider propensity to pain was characterized by the number of anatomical sites outside the low back that had been painful in the 12 months before baseline (‘pain propensity index’). After a mean interval of 14 months, 9055 participants (77.3%) provided follow‐up data on disabling LBP in the past month. Baseline risk factors for disabling LBP at follow‐up were assessed by random intercept Poisson regression.

Results

After allowance for other known and suspected risk factors, pain propensity showed the strongest association with disabling LBP (prevalence rate ratios up to 2.6, 95% CI: 2.2–3.1; population attributable fraction 39.8%). Across the 45 occupational groups, the prevalence of disabling LBP varied sevenfold (much more than within‐country differences between nurses and office workers), and correlated with mean pain propensity index (r = 0.58).

Conclusions

Within our study, major international variation in the prevalence of disabling LBP appeared to be driven largely by factors predisposing to musculoskeletal pain at multiple anatomical sites rather than by risk factors specific to the spine.

Significance

Our findings indicate that differences in general propensity to musculoskeletal pain are a major driver of large international variation in the prevalence of disabling low back pain among people of working age.

Comparison of multiple obesity indices for cardiovascular disease risk classification in South Asian adults: The CARRS Study

BACKGROUND

We comparatively assessed the performance of six simple obesity indices to identify adults with cardiovascular disease (CVD) risk factors in a diverse and contemporary South Asian population.

METHODS

8,892 participants aged 20-60 years in 2010-2011 were analyzed. Six obesity indices were examined: body mass index (BMI), waist circumference (WC), waist-height ratio (WHtR), waist-hip ratio (WHR), log of the sum of triceps and subscapular skin fold thickness (LTS), and percent body fat derived from bioelectric impedance analysis (BIA). We estimated models with obesity indices specified as deciles and as continuous linear variables to predict prevalent hypertension, diabetes, and high cholesterol and report associations (prevalence ratios, PRs), discrimination (area-under-the-curve, AUCs), and calibration (index χ2). We also examined a composite unhealthy cardiovascular profile score summarizing glucose, lipids, and blood pressure.

RESULTS

No single obesity index consistently performed statistically significantly better than the others across the outcome models. Based on point estimates, WHtR trended towards best performance in classifying diabetes (PR = 1.58 [1.45-1.72], AUC = 0.77, men; PR = 1.59 [1.47-1.71], AUC = 0.80, women) and hypertension (PR = 1.34 [1.26,1.42], AUC = 0.70, men; PR = 1.41 [1.33,1.50], AUC = 0.78, women). WC (mean difference = 0.24 SD [0.21-0.27]) and WHtR (mean difference = 0.24 SD [0.21,0.28]) had the strongest associations with the composite unhealthy cardiovascular profile score in women but not in men.

CONCLUSIONS

WC and WHtR were the most useful indices for identifying South Asian adults with prevalent diabetes and hypertension. Collection of waist circumference data in South Asian health surveys will be informative for population-based CVD surveillance efforts.

Is the "South Asian Phenotype" Unique to South Asians?: Comparing Cardiometabolic Risk Factors in the CARRS and NHANES Studies

BACKGROUND

In the context of rising obesity in South Asia, it is unclear whether the "South Asian phenotype"(described as high glucose, low high-density lipoprotein cholesterol, and high triglycerides at normal ranges of body weight) continues to be disproportionately exhibited by contemporary South Asians relative to other race/ethnic groups.

OBJECTIVES

We assessed the distinctiveness of the South Asian cardiometabolic profile by comparing the prevalence of combined high glucose, high triglycerides, and low high-density lipoprotein cholesterol (combined dysglycemia and dyslipidemia) in resident South Asians with 4 race/ethnic groups in the United States (Asians, black persons, Hispanics, and white persons) overall and by body mass index (BMI) category.

METHODS

South Asian data were from the 2010 to 2011 Center for Cardiometabolic Risk Reduction in South Asia Study, representative of Chennai and New Delhi, India and Karachi, Pakistan. U.S. data were from the 2011 to 2012 National Health and Nutrition Examination Survey, representative of the U.S.

POPULATION

Combined dysglycemia and dyslipidemia was defined as fasting blood glucose ≥126 mg/dl and triglyceride/high-density lipoprotein cholesterol ratio >4. Logistic regression was used to estimate the relative odds and 95% confidence intervals of combined dysglycemia and dyslipidemia associated with each race/ethnic group (referent, U.S. white persons). Models were estimated among adults aged 20 to 79 years by sex and BMI category and accounted for age, education, and tobacco use. Data from 8,448 resident South Asians, 274 U.S. Asians, 404 U.S. black persons, 308 U.S. Hispanics, and 703 U.S. white persons without previously known diabetes were analyzed.

RESULTS

In the normal body weight range of BMI 18.5 to 24.9 kg/m(2), the prevalence of combined dysglycemia and dyslipidemia among men and women, respectively, was 33% and 11% in resident South Asians, 15% and 1% in U.S. Asians, 5% and 2% in U.S. black persons, 11% and 2% in U.S. Hispanics, and 8% and 2% in U.S. white persons. Compared with U.S. whites persons, South Asians were more likely to present with combined dysglycemia and dyslipidemia at all categories of BMI for men and at BMI 18.5 to 29.9 for women in adjusted models. The most pronounced difference between South Asians and U.S. white persons was observed at normal weight (adjusted odds ratio: 4.98; 95% confidence interval: 2.46 to 10.07 for men) (adjusted odds ratio: 9.09; 95% confidence interval: 2.48 to 33.29 for women).

CONCLUSIONS

Between 8% and 15% of U.S. men and 1% and 2% of U.S. women of diverse race/ethnic backgrounds exhibited dysglycemia and dyslipidemia at levels of body weight considered "healthy," consistent with the cardiometabolic profile described as the "South Asian Phenotype." Urban South Asians, however, were 5 to 9 times more likely to exhibit dysglycemia and dyslipidemia in the "healthy" BMI range compared with any other U.S. race/ethnic group.

Descriptive Epidemiology of Somatising Tendency: Findings from the CUPID Study

Somatising tendency, defined as a predisposition to worry about common somatic symptoms, is importantly associated with various aspects of health and health-related behaviour, including musculoskeletal pain and associated disability. To explore its epidemiological characteristics, and how it can be specified most efficiently, we analysed data from an international longitudinal study. A baseline questionnaire, which included questions from the Brief Symptom Inventory about seven common symptoms, was completed by 12,072 participants aged 20-59 from 46 occupational groups in 18 countries (response rate 70%). The seven symptoms were all mutually associated (odds ratios for pairwise associations 3.4 to 9.3), and each contributed to a measure of somatising tendency that exhibited an exposure-response relationship both with multi-site pain (prevalence rate ratios up to six), and also with sickness absence for non-musculoskeletal reasons. In most participants, the level of somatising tendency was little changed when reassessed after a mean interval of 14 months (75% having a change of 0 or 1 in their symptom count), although the specific symptoms reported at follow-up often differed from those at baseline. Somatising tendency was more common in women than men, especially at older ages, and varied markedly across the 46 occupational groups studied, with higher rates in South and Central America. It was weakly associated with smoking, but not with level of education. Our study supports the use of questions from the Brief Symptom Inventory as a method for measuring somatising tendency, and suggests that in adults of working age, it is a fairly stable trait.

Vegetarianism and cardiometabolic disease risk factors: Differences between South Asian and US adults

OBJECTIVES

Cardiometabolic diseases are increasing disproportionately in South Asia compared with other regions of the world despite high levels of vegetarianism. This unexpected discordance may be explained by differences in the healthfulness of vegetarian and non-vegetarian diets in South Asia compared with the United States. The aim of this study was to compare the food group intake of vegetarians with non-vegetarians in South Asia and the United States and to evaluate associations between vegetarianism and cardiometabolic disease risk factors (overweight/obesity, central obesity, diabetes, hypertension, high triacylglycerols, high low-density lipoprotein, low high-density lipoprotein, and high Framingham Heart Score).

METHODS

Using cross-sectional data from adults (age 20-69 y) in South Asia (Centre for Cardiometabolic Risk Reduction in South-Asia [CARRS] 2010-2011; N = 15 665) and the United States (National Health and Nutrition Examination Survey 2003-2006; N = 2159), adherence to a vegetarian diet was assessed using food propensity questionnaires. Multivariable logistic regression was used to estimate odds ratios and predicted margins (e.g., adjusted prevalence of the outcomes).

RESULTS

One-third (33%; n = 4968) of adults in the South Asian sample were vegetarian compared with only 2.4% (n = 59) in the US sample. Among South Asians, vegetarians more frequently ate dairy, legumes, vegetables, fruit, desserts, and fried foods than non-vegitarians (all P < 0.05). Among Americans, vegetarians more frequently ate legumes, fruit, and whole grains, and less frequently ate refined cereals, desserts, fried foods, fruit juice, and soft drinks than non-vegetarians (all P < 0.05). After adjustment for confounders (age, sex, education, tobacco, alcohol, and also city in CARRS), South Asian vegetarians were slightly less frequently overweight/obese compared with non-vegetarians: 49% (95% confidence interval [CI], 45%-53%) versus 53% (95% CI, 51%-56%), respectively; whereas US vegetarians were considerably less frequently overweight/obese compared with non-vegetarians: 48% (95% CI, 32%-63%) versus 68% (95% CI, 65%-70%), respectively. Furthermore, US vegetarians were less likely to exhibit central obesity than non-vegetarians: 62% (95% CI, 43%-78%) versus 78% (95% CI, 76%-80%), respectively.

CONCLUSIONS

There is greater divergence between vegetarian and non-vegetarian diets in the United States than in South Asia, and US vegetarians have more consistently healthier food group intakes than South Asian vegetarians. Vegetarians in both populations have a lower probability of overweight/obesity compared with non-vegetarians. The strength of this association may be stronger for US vegetarian diets, which were also protective against central obesity.

Obesity and its Relation With Diabetes and Hypertension: A Cross-Sectional Study Across 4 Geographical Regions

BACKGROUND

The implications of rising obesity for cardiovascular health in middle-income countries has generated interest, in part because associations between obesity and cardiovascular health seem to vary across ethnic groups.

OBJECTIVE

We assessed general and central obesity in Africa, East Asia, South America, and South Asia. We further investigated whether body mass index (BMI) and waist circumference differentially relate to cardiovascular health; and associations between obesity metrics and adverse cardiovascular health vary by region.

METHODS

Using baseline anthropometric data collected between 2008 and 2012 from 7 cohorts in 9 countries, we estimated the proportion of participants with general and central obesity using BMI and waist circumference classifications, respectively, by study site. We used Poisson regression to examine the associations (prevalence ratios) of continuously measured BMI and waist circumference with prevalent diabetes and hypertension by sex. Pooled estimates across studies were computed by sex and age.

RESULTS

This study analyzed data from 31,118 participants aged 20 to 79 years. General obesity was highest in South Asian cities and central obesity was highest in South America. The proportion classified with general obesity (range 11% to 50%) tended to be lower than the proportion classified as centrally obese (range 19% to 79%). Every standard deviation higher of BMI was associated with 1.65 and 1.60 times higher probability of diabetes and 1.42 and 1.28 times higher probability of hypertension, for men and women, respectively, aged 40 to 69 years. Every standard deviation higher of waist circumference was associated with 1.48 and 1.74 times higher probability of diabetes and 1.34 and 1.31 times higher probability of hypertension, for men and women, respectively, aged 40 to 69 years. Associations of obesity measures with diabetes were strongest in South Africa among men and in South America among women. Associations with hypertension were weakest in South Africa among both sexes.

CONCLUSIONS

BMI and waist circumference were both reasonable predictors of prevalent diabetes and hypertension. Across diverse ethnicities and settings, BMI and waist circumference remain salient metrics of obesity that can identify those with increased cardiovascular risk.

The Role of Neighborhood Environment in Promoting Risk Factors of Cardiovascular Disease among Young Adults: Data from Middle to High Income Population in an Asian Megacity

Background

Modifiable risk factors of cardiovascular diseases (CVD) have their triggers in the neighborhood environments of communities. Studying the environmental triggers for CVD risk factors is important to understand the situation in a broader perspective. Young adults are influenced the most by the environment profile around them hence it is important to study this subset of the population.

Methods

This was a descriptive study conducted using the EPOCH research tool designed by the authors of the PURE study. The study population consisted of young adults aged 18-25 in two areas of Karachi. The study setting was busy shopping malls frequented by young adults in the particular community being studied.

Results

Our total sample size was 120 individuals, who consented to be interviewed by our interviewers. Less than 50% of the population recognized some form of restriction regarding smoking in their communities. The largest contributor to tobacco advertising was actors smoking in movies and TV shows with 89% responses from both communities. Only 11.9% of the individuals disapproved of smoking cigarettes among men with wide acceptance of ‘sheesha’ across all age groups. Advertising for smoking and junk food was more frequent as compared to smoking cessation, healthy diet and exercise in both the areas. Unhealthy food items were more easily available in contrast to healthier options. The cost of healthy snack food options including vegetables and fruits was higher than sugary drinks and foods.

Conclusion

This assessment showed that both communities were exposed to environments that promote risk factors for cardiovascular diseases.

Socioeconomic status and cardiovascular risk in urban South Asia: The CARRS Study

BACKGROUND

Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear.

METHODS

We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high household assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category.

RESULTS

Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0-29.9 and ≥30 kg/m(2); waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups.

CONCLUSIONS

SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia.

Self-medication with antibiotics among non-medical university students of Karachi: a cross-sectional study

Background

The prevalence of self -medication with antibiotics is quite high in developing countries as opposed to developed countries. Antibiotics are often taken erroneously for certain ailments, without having the appropriate knowledge of their use. This carries potential risks for the individual as well as the community, in form of several side effects such as antibiotic resistance. Therefore the prevalence of self-medicated antibiotics in developing countries needs to be studied.

Methods

A descriptive cross-sectional study was carried out at six different non-medical universities of Karachi. 431 students were included in the study. Data was collected using self-administered questionnaires and analyzed using SPSS version 19.

Results

50.1% students reported having self-medicated themselves in the past 6 months and 205 (47.6%) reported self-medication with antibiotics. Amoxicillin was the most self-prescribed antibiotic (41.4%). Awareness of the adverse effects of antibiotics was demonstrated by 77.3% of the students and sleep disturbance was the most commonly known (46.5%) side effect. 63.1% denied having any knowledge about antibiotic resistance and only 19.9% correctly knew that indiscriminate use of antibiotics can lead to increased antibiotic resistance.

Conclusion

The prevalence of self-medication with antibiotics among the non-medical university students was high despite the awareness of adverse effects. Antibiotic resistance was a relatively unknown terminology.

Electronic supplementary material

The online version of this article (doi:10.1186/2050-6511-15-74) contains supplementary material, which is available to authorized users.

Disabling musculoskeletal pain in working populations: is it the job, the person, or the culture?

To compare the prevalence of disabling low back pain (DLBP) and disabling wrist/hand pain (DWHP) among groups of workers carrying out similar physical activities in different cultural environments, and to explore explanations for observed differences, we conducted a cross-sectional survey in 18 countries. Standardised questionnaires were used to ascertain pain that interfered with everyday activities and exposure to possible risk factors in 12,426 participants from 47 occupational groups (mostly nurses and office workers). Associations with risk factors were assessed by Poisson regression. The 1-month prevalence of DLBP in nurses varied from 9.6% to 42.6%, and that of DWHP in office workers from 2.2% to 31.6%. Rates of disabling pain at the 2 anatomical sites covaried (r = 0.76), but DLBP tended to be relatively more common in nurses and DWHP in office workers. Established risk factors such as occupational physical activities, psychosocial aspects of work, and tendency to somatise were confirmed, and associations were found also with adverse health beliefs and group awareness of people outside work with musculoskeletal pain. However, after allowance for these risk factors, an up-to 8-fold difference in prevalence remained. Systems of compensation for work-related illness and financial support for health-related incapacity for work appeared to have little influence on the occurrence of symptoms. Our findings indicate large international variation in the prevalence of disabling forearm and back pain among occupational groups carrying out similar tasks, which is only partially explained by the personal and socioeconomic risk factors that were analysed.

Solid fuel use is a major risk factor for acute coronary syndromes among rural women: a matched case control study

OBJECTIVES

Almost half of the world's population uses solid fuel for cooking, exposing women to high levels of particulate pollution in indoor air. The risk of acute coronary syndrome (ACS) was assessed among rural women, according to their use of solid fuel.

STUDY DESIGN

Matched case control study.

METHODS

Data were collected at a public tertiary care hospital in a rural district of Pakistan. Seventy-three women with ACS were compared with controls, individually matched for sex and age (± 5 years), who were admitted to hospital for other reasons. Fuels used for cooking and exposures to potentially confounding variables were ascertained through a questionnaire administered at interview and measurement of height and weight. Conditional logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

After adjustment for potential confounding factors, current use of solid fuel was strongly associated with ACS (OR 4.8, 95% CI: 1.5-14.8), and risk was lowest in women who had last used solid fuel more than 15 years earlier. The population attributable fraction for ACS in relation to current use of solid fuel was 49.0% (95% CI: 41.3%-57.4%).

CONCLUSIONS

These findings support the hypothesis that indoor air pollution from use of solid fuel is an important cause of ACS. Our study demonstrates the feasibility of case-control studies in rural populations of women to address this question, and is an encouragement to larger and statistically more powerful investigations.

Knowledge and practices regarding cigarette smoking among adult women in a rural district of Sindh, Pakistan

OBJECTIVE

To determine the prevalence of cigarette smoking and to obtain information on socio-demographic factors and attitude regarding cigarette smoking among adult women in a rural district of Sindh Province, Pakistan.

METHODS

A cross sectional community based survey was done in a rural district of Sindh province of Pakistan using a two stage cluster sampling design. A pre tested questionnaire was used to interview 502 adult women (aged 18- 60 years) from the study site. The study was approved by the ethical research committee and informed consent was taken from participants.

RESULTS

A total of 502 women were interviewed for this study. Approximately 71% of women were illiterate and 44% of women were in the age group of 18-24 years. A high number (10%) of adult women were smokers. Age at initiation among women (18-24 years) was 42%. A significant difference for questions regarding smoking effects on health (p = 0.02) and knowledge regarding smoking causes respiratory disease (p = 0.02) was observed in this survey.

CONCLUSION

It was concluded that the prevalence of smoking among women is on the rise in this rural district of Pakistan. Young age at initiation is an important finding that needs to be addressed.

Incidence of typical and atypical hanging among 66 hanging cases

Present Study conducted prospectively to find out the position of knot in the neck in all hanging cases coming for post mortem examination at Mymensingh Medical College Mortuary in the year 2005. Hanging is a process in which the body is suspended with a ligature around the neck, which causes constriction of air passage preventing exchange of air between atmosphere & alveoli of lungs, leading to asphyxia & death. The constriction force is either the weight of the whole body or the weight of the head alone. A weight of 2Kg is sufficient for death in hanging. According to position of knot hanging is of two types-Typical hanging and Atypical hanging. In typical hanging the knot of the ligature should be at the nape of the neck and the knot of the ligature at any site other than the nape of the neck is Atypical hanging. A total of 557 postmortems were conducted in the year 2005 out of which 66 cases were of hanging. Among these, 66 cases (100%) position of knot on neck were on center of occiput (Typical hanging) in 14 cases (21.21%), on right side in 17 cases (25.75%), on left side in 21 cases (31.81%) and on front of neck in 14 cases (21.21%). Total of 52 cases are of Atypical hanging. This study suggests that Atypical hanging is more common (78.78%) than Typical hanging (21.21%) and more on left side of the neck (31.81%). Study at S.P. Medical College and A.G Hospitals, Bikaner in 2004 shows that out of 390 cases 35 (8.97%) were of hanging. Amongst those 35 cases in 33 cases position of knot on nape of the neck in 5 cases (15.15%), right side of neck 15 cases (45.45%), left side of neck in 11 cases (33.33%) and front of the neck 2 cases (6%). In their study, Typical hanging was found in 15.15% and Atypical hanging was in 84.85%; and Maximum on right side of the neck i.e. 45.45%. In both the studies Atypical hanging was more common but Maximum was on right side in their study and We found maximum on left side.

Survey and surveillance development in settings with low human immunodeficiency virus prevalence

In most countries, during the early phases of a human immunodeficiency virus epidemic, independently initiated surveys of perceived high-risk groups tend to precede the development of formal surveillance systems. Unfortunately, in low-prevalence settings, small sample sizes produce unreliable estimates of prevalence and trends, with an inevitable tendency towards positive results. In our study, we present sample size calculations and typical samples used in actual surveys, with Pakistan as our example. More useful data on risk behaviour and potential for spread can be derived from the study of commoner sexually transmitted diseases and associated risk behaviours, including assessments of knowledge, attitudes, beliefs and practices.

Community knowledge, attitude and practices regarding sexually transmitted infections in a rural district of Pakistan

OBJECTIVE

To determine knowledge, attitude and practices regarding sexually transmitted infections in district Khairpur, Sindh, Pakistan.

DESIGN AND METHODOLOGY

A needs assessment study employing a community based survey, key informant interviews and focus group discussions was conducted in all seven sub-districts of the district. This paper is based on the results of the key informant interviews and the focus group discussions. Thirty interviews and six group discussions were held with members of the community and with the health care providers.

RESULTS

There was little awareness regarding causes and prevention of sexually transmitted infections in the community. The situation was slightly better among health care providers. While health care providers believed that the prevalence of sexually transmitted infections is high, the community did not consider themselves at risk. The community believed that these diseases are a problem among a sub-population of male adolescents, especially those who have homosexual relations. However, due to social norms, they rarely discussed such health problems with other family members or elders. Adolescents with any sexual health problems visit hakims and quacks. The community was aware about aetiology and some of the risk factors associated with AIDS and hepatitis, most probably due to the recent public health campaigns against both diseases.

CONCLUSION

Considering the suspected high prevalence of sexually transmitted infections and the relative lack of knowledge, it is imperative that a public health intervention be initiated. This must include educating not only the community but also the health workers. The governments' initiative to train community workers in reproductive health is a step in the right direction (JPMA 52:21, 2002).

Health and social impacts of improved stoves on rural women: a pilot intervention in Sindh, Pakistan

To assess the acceptability, social and health impacts of improved stoves among women. A cross-sectional study was conducted from April to May 2002 among households using improved stoves in the two villages of District Thatta and Hyderabad, Sindh, Pakistan. A questionnaire was administered to 45 women using improved stoves named Smoke Free Stoves (SFS). The same questionnaire was administered to a sample of 114 women, using Traditional Stoves (TS). Carbon monoxide (CO) levels were measured in a sample of both groups. Multivariate analysis was carried out to adjust for confounders. In addition, focus group discussions (FGDs) were conducted to evaluate the perception of women regarding acceptability and impact of SFS on women. A majority of women reported that SFS produce less smoke and have a beneficial impact on their health. In the multivariate analysis, symptoms of dry cough (AOR=0.61; 95% CI 0.26-1.41), sneezing (AOR=0.54; 95% CI 0.22-1.30) and tears while cooking (TWC) (AOR=0.51; 95% CI 0.21-1.21) are less likely to occur in women using SFS compared to TS. However, the results were not statistically significant possibly due to the small sample. The mean (+/-s.e.) CO levels were 15.4+/-3.4 ppm in SFS and 28.5+/-5.7 ppm in TS kitchens with a mean difference of -13.1 (95% CI -29.5 and 3.2). The results indicate a trend favorable for SFS and suggest that a larger scale project should be undertaken to reach to a definitive conclusion, ideally using a longitudinal design.

PRACTICAL IMPLICATIONS

In order to enhance IAQ in kitchens in developing regions of the world stoves for burning of biomass should be constructed in a way that the emission of fuel gases are low. In this way the risk of negative health effects will be reduced.

Utility of participatory rural appraisal for health needs assessment and planning

BACKGROUND

While poverty and lack of life opportunities are root causes of a high burden of disease and infant and maternal mortality, inadequate health care contributes heavily. Often those who are left without care are those who need it most. Existing health services are managed without taking into account acceptance and need perspectives. This further reduces the effectiveness of and equity in health care. In order to guide the planning of reproductive health services by a national NGO, health needs were assessed in a district in Sindh using a combination of participatory rural appraisal (PRA) and qualitative and quantitative research methods. PRA is considered as a better framework to assess, analyse and develop programs with communities.

OBJECTIVE

The objective of PRA was to initiate community involvement and to understand the needs of health care from a community perspective.

METHODOLOGY

PRA was conducted with groups of men and women from three rural areas in a district of Sindh, Pakistan using a life cycle framework. The community members identified various stages of their life with the associated health issues.

RESULTS

This research was empowering to community members as it facilitated community involvement. The respondents took charge of the process of identification of health needs at PRA sessions. PRA helped identify health problems considered prevalent and important by the community. More importantly, it helped potential service providers and the community to initiate community involvement in planning.

CONCLUSION

PRA is not only an effective tool for assessment and analysis of health issues but also a vehicle to promote community involvement. Additionally, participatory methods contribute to understand the context of quantitative data generated for planning purposes.

Health needs of clients as reported by medical practitioners from two districts of Sindh

OBJECTIVE

To identify the major health and reproductive health problems for which people consult local medical practitioners.

METHODOLOGY

Forty-one practitioners completed a self-administered questionnaire. A startified purposive sample of practitioners was selected by asking the community members from various towns and rural areas to identify practitioners who have most busy practices and are perceived as providing quality care.

RESULTS

Nine of the forty-one practitioners were females. Twenty-two were consulted mainly by women and another seventeen by an equal number of women and men. Practitioners pointed to malnutrition, malaria, gastrointestinal and respiratory tract problems as being the most common ailments. They identified menstrual problems, malnutrition among pregnant women, burning micturition and vaginal discharge as the most common reproductive health problems of their clients. Only 16 medical practitioners said that they diagnosed someone in the last one-month as suffering from sexually transmitted infections.

CONCLUSION

The survey helped in developing an understanding of health issues from provider perspective. Findings indicate a concordance between what has been revealed by previous population based studies in similar situations and to what health problems practitioners pointed as common. While a comprehensive needs-assessment requires surveys and qualitative interviews with communities, consultations with relatively fewer medical practitioners could also provide a quick and fair approximation of priority health problems in the area.

Community knowledge, attitude and practices regarding sexually transmitted infections in a rural district of Pakistan

OBJECTIVE

To determine knowledge, attitude and practices regarding sexually transmitted infections in district Khairpur, Sindh, Pakistan.

DESIGN AND METHODOLOGY

A needs assessment study employing a community based survey, key informant interviews and focus group discussions was conducted in all seven sub-districts of the district. This paper is based on the results of the key informant interviews and the focus group discussions. Thirty interviews and six group discussions were held with members of the community and with the health care providers.

RESULTS

There was little awareness regarding causes and prevention of sexually transmitted infections in the community. The situation was slightly better among health care providers. While health care providers believed that the prevalence of sexually transmitted infections is high, the community did not consider themselves at risk. The community believed that these diseases are a problem among a sub-population of male adolescents, especially those who have homosexual relations. However, due to social norms, they rarely discussed such health problems with other family members or elders. Adolescents with any sexual health problems visit hakims and quacks. The community was aware about aetiology and some of the risk factors associated with AIDS and hepatitis, most probably due to the recent public health campaigns against both diseases.

CONCLUSION

Considering the suspected high prevalence of sexually transmitted infections and the relative lack of knowledge, it is imperative that a public health intervention be initiated. This must include educating not only the community but also the health workers. The governments' initiative to train community workers in reproductive health is a step in the right direction.

Out-of-pocket expenses borne by the users of obstetric services at government hospitals in Karachi, Pakistan

OBJECTIVE

Financing health services is a challenge for health policy makers world over, especially in developing countries. Alternate mechanisms such as user fees are being proposed. However, there is a feeling that in developing countries, users of government hospitals spend appreciable personal income to obtain "free services" at these facilities.

METHODS

This study aimed to measure the extent and the factors associated with of out-of-pocket expenses borne by the users of obstetric care at government hospitals. It also aimed to determine willingness of consumers to bear out of pocket expenses. It was conducted in three government hospitals in Karachi.

RESULTS

Seven hundred cases were registered in the study. Sixty-five percent of them had a monthly household income of less than Rupees (Rs.) 3000. Overall, users spent mean of Rs. 590 as out-of-pocket expenses for obstetric services. Of this Rs. 330 was spent on drugs and Rs. 24 on user fees. Thirty-nine percent of the patients were willing to spend out of pocket for services provided at government hospital and 39% declined to do so. Of the patients indicating willingness to spend, 98% agreed to do so for drugs.

CONCLUSION

The results suggest that considerable expenses are borne out of pocket by the users of government hospitals for supposedly "free services". If user fees are to be increased the government needs to provide services for which the people will pay, such as drugs, otherwise increase in this fees will simply add to financial burden on the users.

Adult mortality in slums of Karachi, Pakistan

OBJECTIVE

Cause-specific death rates are rarely available to guide health interventions for adults in South Asia. We report mortality patterns among Karachi's urban poor.

METHODS

We conducted verbal autopsies for adult deaths under active surveillance during 1990-1993 in five urban slums of Karachi. Two physicians assigned underlying cause of death by consensus. Analysis included cause- and category-specific rates, 45Q15s and comparison with 1991 Japanese national statistics.

RESULTS

All 345 adult deaths (15-59 years) in the 5 slums (total population 45,389) were included. Male mortality exceeded female (4.4 vs 3.3/1000, p = .02). Noncommunicable diseases claimed 59% of deaths, communicable and reproductive 27% and injuries, 15%. The leading identified death rates (/100,000) among women were: circulatory disorders (66), maternal causes (33), tuberculosis (30), and burns (23); and among men they were: circulatory disorders (124) tuberculosis (30) and road traffic accidents (30). Overall Karachi adult mortality was 3.7 times Japanese rate. Compared to Japan, adults in Karachi had one to two orders of magnitude excess mortality due to maternal causes, tuberculosis and burns. Circulatory disorders and tuberculosis accounted for 47% of excess male mortality; these plus maternal causes and burns accounted for 55% of excess female mortality.

CONCLUSION

These mortality levels and patterns compel interventions and research for poor urban adults beyond maternal health. Women's health would equally benefit from tuberculosis control or burn prevention. Men need safer travel. Both need improved cardiovascular health.

Survey and surveillance development in settings with low human immunodeficiency virus prevalence

In most countries, during the early phases of a human immunodeficiency virus epidemic, independently initiated surveys of perceived high-risk groups tend to precede the development of formal surveillance systems. Unfortunately, in low-prevalence settings, small sample sizes produce unreliable estimates of prevalence and trends, with an inevitable tendency towards positive results. In our study, we present sample size calculations and typical samples used in actual surveys, with Pakistan as our example. More useful data on risk behaviour and potential for spread can be derived from the study of commoner sexually transmitted diseases and associated risk behaviours, including assessments of knowledge, attitudes, beliefs and practices.

Risk factors for lower urinary tract cancer: the role of total fluid consumption, nitrites and nitrosamines, and selected foods

Many cases of lower urinary tract cancer cannot be attributed to the known risk factors of cigarette smoking and certain occupational chemical exposures. Data from a case-control study conducted on Oahu, Hawaii, from 1979 to 1986 were used to determine the role of several additional exposures in the etiology of lower urinary tract cancer, such as total fluid intake and dietary nitrites and nitrosamines, as well as intake of selected foods. A total of 195 male and 66 female lower urinary tract cancer cases of Caucasian and Japanese ancestry were matched to two population-based controls on age, sex, and race. Total fluid intake, and tap water in particular, showed a strong inverse dose-response relationship to cancer risk among women (odds ratio (OR) for highest to lowest quartile of total fluid intake = 0.3; trend P < 0.01).. This association was stronger in smokers than nonsmokers. Although fluid intake showed no overall association among men, the findings among smokers were suggestive of an effect similar to that found in women. Intake of dietary nitrites and nitrosamines was positively associated with risk in Japanese men (for nitrites, OR for highest to lowest tertile = 2.0; trend P = 0.05; for nitrosamines, OR for highest to lowest tertile = 3.0; trend P = 0.01). Consumption of processed meats, in particular bacon, sausage, and ham, was also significantly associated with increased risk in Japanese men. No other ethnic sex group exhibited this association with processed meats, although an effect was suggested for sausage in Japanese females and for bacon in Caucasian females. Unfortunately, it was not possible to determine whether these elevated risks were due to the fat, nitrite, or sodium content of the processed meats, or to the fact that they may have been fried.