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ii
The Canadian Journal of Clinical Nutrition (CJCN) is the official
journal of Association of Editors, and is published by Global Science
Heritage, Toronto, Canada. Global Science heritage is a registered
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Editorial Board
Editors
Allal Ouhtit, MSc, PhD, Department of Genetics, College of Medicine and Health
Sciences, Sultan Qaboos University, Oman
Mostafa Waly, MSc, MPH, PhD, Department of Food Science and Nutrition,
College of Agricultural and Marine Sciences, Sultan Qaboos University, Oman
Yahya Al-Farsi, MD, MPH, Dr.PH, Department of Family Medicine and Public
Health, College of Medicine and Health Sciences, Sultan Qaboos University,
Oman
Managing Editors
Neeru Bhatt, MSc, PhD, Associate
Research Fellow, Department of Food
Science and Nutrition, College of
Agricultural and Marine Sciences, Sultan
Qaboos University, Oman
Azza Abd El-Moneim Attia Mohamed,
MSc, PhD, Lecturer of Histology, Ain
Shams University, Cairo, Egypt
Eman Ahmed Mahmoud Mahmoud El-
Shabasy, MSc, PhD, Lecturer of
Biology, Zoology Department, Faculty of
Science, Mansoura University, Egypt
Hamza M. Abu-Tarboush, MSc, PhD, Professor, Food Science and Nutrition
Department, College of Agriculture, King
Saud University, Riyadh, Saudi Arabia
Hassan I.H. El-Sayyad, MSc, PhD, Professor of Experimental Embryology,
Zoology Department, Faculty of Science,
Mansoura University, Egypt
Rajiv Lochan Gaur, PhD, Department
of Pathology, Stanford Blood Center,
Stanford University, Palo Alto, USA
Syed Tasleem Raza, MSc, PhD, Assistant Professor and Head Molecular
Diagnosis in Biochemistry Department,
ERA‘S Lucknow Medical College,
Lucknow, India
Zafar Iqbal, MPhil, PhD, Assistant
Professor of Genetics, King Saud Bin
Abdulaziz University of Health Sciences,
National Guards Health Affairs, Riyadh,
Saudi Arabia
Administration
Ishita Gupta, MSc, Department of Genetics, College of Medicine and Health Sciences,
Sultan Qaboos University, Oman
iv
Advisory Board
Ali, Amanat, MSc, PhD, Associate
Professor, Department of Food Science
and Nutrition, College of Agricultural
and Marine Sciences, Sultan Qaboos
University, Oman
Ali, Badreldin H, BVSc, PhD, Professor,
Department of Pharmacology and
Clinical Pharmacy, College of Medicine
and Health Sciences, Sultan Qaboos
University, Oman
Al-Farsi, Khalil, MD, PhD, Consultant,
Department of Hematology, College of
Medicine and Health Sciences, Sultan
Qaboos University, Oman
Al-Khaduri, Maha, MD, PhD,
Consultant, Department of Obstetrics and
Gynecology, College of Medicine and
Health Sciences, Sultan Qaboos
University, Oman
Al-Sabah, Haleama H, MSc, PhD,
Assistant Professor, Department of
Public Health, Faculty of Medicine, Al-
Najah National University, Palestine
Al-Shafaee, Mohamed, MD, Dr.PH,
Associate Professor, Department of
Family Medicine and Public Health,
College of Medicine and Health
Sciences, Sultan Qaboos University,
Oman
Al-Sharabati, Marwan, MD, Dr.PH,
Associate Professor, Department of
Behavioral Medicine, College of
Medicine and Health Sciences, Sultan
Qaboos University, Oman
Al-Sinani, Siham, MD, Consultant,
Department of Gastroenterology, Sultan
Qaboos University Hospital, Oman
Al-Zadjali, Majed, MD, MSc, Director,
Department of Malaria Eradication,
Ministry of Health, Oman
Arafa, Mostafa, MD, MPH, Dr.PH,
Professor, Cancer Research Unit, King
Saud University, Riyadh, Saudi Arabia
Ausman, Lynne, PhD, Professor, Jean
Mayer USDA HNRCA, Tufts University,
Boston, USA
El-Badawy, Amal, MSc, PhD, Assistant
Professor, Department of Fundamentals
and Administration Nursing, College of
Nursing, Sultan Qaboos University,
Oman
Farhat, Mohamed F, MPH, DrPH,
Professor, Department of Nutrition, High
Institute of Public Health, Alexandria
University, Egypt
Gad, Ashry, MD, DrPH, Professor,
Department of Epidemiology, High
Institute of Public Health, Alexandria
University, Egypt
Hussein, Izzeldi, PhD, Micronutrients
Specialist, Institute of Brain Chemistry
and Human Nutrition, London, United
Kingdom
Kilani, Hashim, PhD, Professor,
Department of Physical Education,
College of Education, Sultan Qaboos
University, Oman
Mo‘ez Al-Islam E.M. Faris, MSc, PhD,
Assistant Professor, Department of
Nutrition, Faculty of Pharmacy and
Medical Sciences, Petra University,
Amman, Jordan
v
Musaiger, Abdulrahman O, MPH, DrPH,
Professor of Human Nutrition, Head of
Arab Center for Nutrition Research,
Bahrain
Obeid, Omer, MD, PhD, Professor,
Department of Nutrition and Food
Science, American University, Beirut,
Lebanon
Sabra, Amr A, MD, MPH, Dr.PH,
Professor, Department of Primary Health
Care, High Institute of Public Health,
Alexandria University, Egypt / Assistant
Professor & Consultant Family and
Community Medicine Department,
College of Medicine, University of
Dammam, Saudi Arabia
Saleh, Jumana, PhD, Associate Professor,
Department of Clinical Biochemistry,
College of Medicine and Health
Sciences, Sultan Qaboos University,
Oman
Wessig,Volkmar, PhD, Associate
Professor, Department of Pharmaceutical
Sciences College of Pharmacy Glendale,
Midwestern University, USA
Yousef, Randa, MD, DrPH, Associate
Professor, Department of Family
Medicine and Public Health, College of
Medicine and Health Sciences, Sultan
Qaboos University, Oman
vi
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ix
Table of Contents
Editorial
Ouhtit A, Gupta I, Sheikh Z, Shanmuganathan S, Al-Farsi Y, Waly MI, Raj HG M. Nutrigenomics
and Complementary Alternative Medicine. Canad J Clin Nutr 2013; 1 (1): 1-4.
Research Articles
Janbi OS, Sabra AA, Sebiany AM, Hafez AS. Predictors of Maternal Weight Gain during Normal
and High Risk Pregnancies: A Retrospective Study in Primary Care, Eastern Saudi Arabia. Canad J
Clin Nutr 2013; 1 (1): 5-15.
Rady M, Al-Muslemani M, Salama R. Determinants of Overweight and Obesity among Qatari
Children (2-5 years) in Doha, Qatar-2010. Canad J Clin Nutr 2013; 1(1): 16-26.
Gad A, AL-Quaiz J, Khoja T, As-Sharif A, Al-Manea H, Al-Edriss A, Shafi S. Anemia among
Primary School Children (5 -12 years) in Riyadh Region, Saudi Arabia: A Community-Based Study.
Canad J Clin Nutr 2013; 1(1): 27-34.
Mohamed BA, Alhamdan AA, Samarkandy MM. Dietary Practice and Physical Activity in Children
with Down Syndrome and Their Siblings in Saudi Arabia. Canad J Clin Nutr 2013; 1(1): 35-46.
Mohamed AA, Saad MM, Abdeen SH, Marei MK. Generation of Insulin Producing Cells using
Mesenchymal Stem Cells Derived from Bone Marrow of New-Zealand White Rabbits. Canad J Clin
Nutr 2013; 1(1): 47-66.
Waly MI, Al-Farsi YM, Ouhtit A. The Role of Folate on Colorectal Cancer in the Arabian Gulf
Cooperation Council Countries: An Overview. Canad J Clin Nutr 2013; 1(1): 67-73.
Letter to the Reader
Waly MI. Should Children with Autism Continue Taking Folic Acid Supplement? Canad J Clin Nutr
2013; 1(1): 74.
The Canadian Journal of Clinical Nutrition, Volume 1/Number 1, January 2013 ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)
Canad J Clin Nutr is published by Global Science Heritage (http://www.globalscienceheritage.org), a registered publisher by the Library and Archives/Government of Canada, Business License Number: 220080600 (www.collectionscanada.gc.ca).
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Nutrigenomics and Complementary Alternative Medicine
Allal Ouhtit1, Ishita Gupta
1, Zoya Sheikh
1, Somya Shanmuganathan
1, Yahya Al-Farsi
2,
Mostafa I. Waly3,4
, Madhwa HG Raj5*
1Department of Genetics,
2Department of Family Medicine and Public Health,
3Department
of Food Science and Nutrition, Sultan Qaboos University, Muscat, Oman 4Department of Nutrition, High Institute of Public Health, Alexandria University, Egypt
5Department of Obstetrics and Gynecology, Louisiana State University Health Sciences
Center, New Orleans, Louisiana, USA
*Corresponding Author: Dr. Madhwa HG Raj. Email: [email protected]
ABSTRACT
Nutrigenomics applied high-throughput ‗omics‘ techniques in nutrition research to enable
investigation into interactions between nutrients with the genome at a molecular level. One of
the emerging areas of research in nutri-genomics includes Complementary Alternative
Medicine (CAM), which can be used to treat various diseases including type2 diabetes,
cancer and obesity. Research in CAM includes identification of the active compounds present
in various herbal and dietary products, and evaluating these compounds for their effects on
human health. Only few studies have explored the effects of these compounds when used in
synergistic, additive or antagonistic combinations. One of the striking features of CAM is the
low toxicity of natural compounds used as supplements. However most of the active
ingredients are not ―hydrophyllic‖ but are ―lypophyllic‖, resulting in limited absorption from
GI tract, when ingested orally. This has led to limited bioavailability and it needs application
of innovative techniques to overcome this problem. We have evaluated combination therapy
and its effects as a solution to this problem. This report will discuss general concepts in
nutrigenomics related to CAM, effects of combination therapies and possible mechanisms of
action that come in to play with combination therapies, with particular focus on
phytocompounds used as anti-cancer agents.
Key words: Nutrigenomics, Phytochemicals, CAM, Cancer.
Ouhtit A, Gupta I, Sheikh Z, Shanmuganathan S, Al-Farsi Y, Waly MI, Raj HG M.
Nutrigenomics and Complementary Alternative Medicine. Canad J Clin Nutr 2013; 1 (1): 1-4.
Nutrigenomics studies the effects of food
and its constituents at molecular level so as
to gain insight into the mechanisms of
interaction between nutrients and other
dietary bioactives with the genome.
Nutrigenomics aims to understand the
body‘s response to different types of diets
and food through various ‗omics‘
techniques including transcriptomics,
proteomics and metabolomics, although
the most common technique used is
transcriptomic analysis (1). Tools used to
measure the transcriptome are well
developed including gene expression
microarray profiling, single nucleotide
polymorphisms (SNPs) and genotyping. In
contrast, tools to measure the proteome
and metabolome are less developed
including techniques such as gel
electrophoresis, mass spectophotometry,
nuclear magnetic resonance imaging, and
chromatography (2); This technique has
provided a considerable amount of data on
several factors such as novel function of
food factors, the unknown mechanism of
the effect of nutrients, and even safety
Page 1-4
The Canadian Journal of Clinical Nutrition, Volume 1/Number 1, January 2013 ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)
Canad J Clin Nutr is published by Global Science Heritage (http://www.globalscienceheritage.org), a registered publisher by the Library and Archives/Government of Canada, Business License Number: 220080600 (www.collectionscanada.gc.ca).
Pag
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issues of foods (3). Nutrigenomics is
emerging as a new competent field in
research that integrates genetics and
dietary recommendations to study protein
expression and metabolite production.
Nutrigenomics can help improve our
understanding of how nutrition influences
metabolic pathways and homeostatic
control, which can be used to discover
naturally occurring chemical agents in
food to help prevent the onset of diseases
such as obesity, type-2 diabetes and
cancer. Nutrigernomics, also involves
determining certain genes and markers
during the early phase of diet-related
diseases. Once such a marker or a gene is
identified and measured in an individual,
the degree to which they can be
susceptible to the onset of that particular
disease can be quantified and a
personalized dietary recommendation can
be established for the individual.
Nutrigenomics aims to elucidate the effect
of bioactive food compounds on health
that can lead to the development of
functional foods that keep people healthy
according to their individual needs. One
area of particular research interest in
nutrigenomics can include Complementary
Alternative Medicine (CAM). Recently,
research in CAM includes identification of
the active compounds present in various
herbal and dietary products, and evaluating
their anti-cancer properties. Polyphenols
from green tea, grape seed/skin,
anthocyanin and pigments from many
flowers, algae, fruits and vegetables are
some of the compounds that have been
tested. A common property of many of
these compounds is their anti-oxidant/free
radical scavenging ability. However, some
compounds preferentially induce high free
radical formation selectively in cance
cells, to cause growth inhibition and death
of cancer cells without affecting normal
cells.
Extensive studies on CAM have focused
on effects of individual compounds
derived from herbs/plants, using
concentrations that are typically higher
than their ‗bioavailable‘ concentration (the
serum levels achieved by oral intake of
extracts, as practiced in CAM). However,
only few studies explored the effects of
these compounds when used in synergistic,
additive or antagonistic combinations; and
each of the individual chemicals used in a
combination could target multiple
signaling pathways in the cancer cell. One
of the striking features of oral
administration of CAM was the low
toxicity and showed effects on various
types of cancers. The synergistic and / or
additive mechanisms that come into play
during combination therapies result in
reducing the ―effective dose‖ to
‗bioavailable‘ levels. Thus while
individual compounds are not effective by
themselves, combination becomes
effective.
In collaboration with Prof. Madhwa Raj‘s
group (the Louisiana State University,
New Orleans, Louisiana), and based on
the idea of Synergism theory we
performed extensive studies where we
tested the effects of the combination of 2
compounds, Indole-3-carbinol (I3C) and
Resveratrol, each used at ‗bioavailable’
levels, on SK-OV-3 ovarian cancer cells
(3). SK-OV-3 cells were treated with
various doses of I3C, RE or I3C+RE and
proliferation assay was used to examine
cell growth. The study revealed that
I3C+RE synergized to induce a higher
number of cell death than each of these
compounds used individually (3).
Analysis of apoptosis-associated genes
revealed inhibition of Retinoblastoma
protein (Rb) and Survivin (SVV) gene
expression levels; this was accompanied
by elevation of p21, a p53-downstream
transcriptional target gene (3). Cell cycle
was inhibited at both G1 and G2/M by
individual treatments, and accentuated by
a combination. ELISA revealed that
while, CA125 was inhibited by either I3C
or RE treatments, basal nitric oxide
production was inhibited by I3C and I3C
The Canadian Journal of Clinical Nutrition, Volume 1/Number 1, January 2013 ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)
Canad J Clin Nutr is published by Global Science Heritage (http://www.globalscienceheritage.org), a registered publisher by the Library and Archives/Government of Canada, Business License Number: 220080600 (www.collectionscanada.gc.ca).
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+ RE but not RE alone (3), in addition
microarray analysis was performed and
we have identified several unique genes
that are overexpressed as a result of
combination therapy (manuscript in
preparation).
Ongoing studies in our laboratories are
testing the combination of dozens of
other compounds in several cancers In
addition; selected phytochemical
combinations will be tested to validate
their anti-cancer effects in vivo using
xenograft model of breast cancer (4).
Future work will include the
establishment of a powerful combination
of compounds (each individual
compound is used at its bioavailable
concentration in a synergistic/additive
manner) that can potentially induce a
maximal cell growth inhibition/cell death
in vitro and in vivo. Furthermore, in
addition to understanding the underlying
molecular mechanisms of the
combination, these studies will lead to the
identification of potential biomarkers or
candidate gene targets to guide the design
of anti-cancer therapeutic strategies,
follow progress of therapies as well as in
early diagnosis.
REFERENCES
1. Kato H. Nutrigenomics: The
cutting edge and Asian
perspectives. Asia Pac J Clin Nutr
2008; 17 (1):12-15.
2. Hesketh J. Personalised nutrition:
How far as nutrigenomics
progressed?. Europ J Clin Nutr
2012 [Epub ahead of print].
3. Raj M, Abd-Elmageed ZY, Zhou J,
Gaur RL, Nguyen L, Azam GA,
Braley P, Rao PN, Fathi IM, Ouhtit
A. Synergestic action of dietary
phyto-antioxidants on survival and
proliferation of ovarian cancer
cells. Gynecological Oncology
2008; 110(3): 432-438.
4. Ouhtit A, Abd Elmageed YZ,
Abdraboh M, Lioe
TF, Raj MG. In
vivo evidence of a direct role of the
standard form of CD44 in breast
metastasis. Am J Pathol (In press)
The Canadian Journal of Clinical Nutrition, Volume 1/Number 1, January 2013 ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)
Canad J Clin Nutr is published by Global Science Heritage (http://www.globalscienceheritage.org), a registered publisher by the Library and Archives/Government of Canada, Business License Number: 220080600 (www.collectionscanada.gc.ca).
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Table 1: Bioactive compounds and their mechanisms of action
Source Active
Ingredient
Literature
Broccoli
-Indole-3-
Carbinol
(I3C)
I3C induces apoptosis, inhibits cell growth and has antiangiogenic
activities
I3C induces G1 cell cycle arrest and inactivates Akt
I3C inhibits activation of transcription factors including nuclear factor-
kappa B, SP1, estrogen receptor, androgen receptor and nuclear factor-E2-
related factor 2 (Nrf2)
Grape skin
and seeds
Resveratrol
(RE)
RE interferes with AKT, enhances p53, and induces apoptosis
RE exhibits Cox-1 inhibitory activity, and causes G1 arrest
RE induces apoptosis by TRAIL sensitization and down regulates
survivin expression
RE possesses vasorelaxing, anti-inflammatory, anti-lipidemic, anti-
estrogenic, antioxidant, anti-fungal and antibacterial properities
Tea
Epigallo-
Catechin
Gallate (ECG)
ECG inhibits Hsp90 function, hypoxia and serum induced HIF-1 alpha
protein accumulation, and VEGF expression
ECG enhanced responses induced by curcumin on breast cancer cells
Spirulina
Phycocyanin
(PC)
P inhibits cell proliferation and apoptosis in different cancer cell lines
P inhibits MDR1 through reactive oxygen species and cyclooxygenase-2
mediated pathways
Turmeric
roots
Curcumin
(CUR)
CUR binds to a number of proteins and inhibits the activity of various
kinases, induces apoptosis, and has anti-proliferative effect
CUR regulates expression of inflammatory enzymes, cytokines, adhesion
molecules and cell survival proteins
CUR down regulates cyclin D1, cyclin E, MDM2 and up regulates tumor
suppressors p21, p27 and p53
CUR exhibits antioxidant, anti-inflammatory, antiviral, antibacterial,
antifungal and anticancer activities
Stamens of
Saffron
Crocin (Cr) Saffron causes apoptosis inhibits DMBA-induced skin carcinogenesis
Saffron and its main constituents, such as crocusatin H, crocin-1 and
crocin-3 have anticancer and anti-tumour activities
Plant food
Quercetin
(Querc)
Quercetin downregulates mutant p53 in BC cells leading to G1 phase
arrest of cell cycle, inhibits tyrosine kinase, both in- vitro and in- vivo
A number of these actions have also been demonstrated in ovarian cancer
cells via inhibition of heat shock protein 70
It sensitized cisplatin in inhibiting proliferation of ovarian cancer cells
It increased TGF-β and inhibited OVCAR-433 ovarian cancer cell
proliferation, as administration of a monoclonal antibody to TGF-β
reversed these effects
The Canadian Journal of Clinical Nutrition, Volume 1/Number 1, January 2013 ISSN 1927-8942 (Print Edition), ISSN 1927-8950 (Online Edition)
Canad J Clin Nutr is published by Global Science Heritage (http://www.globalscienceheritage.org), a registered publisher by the Library and Archives/Government of Canada, Business License Number: 220080600 (www.collectionscanada.gc.ca).
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Predictors of Maternal Weight Gain during Normal and High Risk
Pregnancies: a Retrospective Study in Primary Care, Eastern Saudi Arabia
Olfat S. Janbi 1, Amr A. Sabra
1,2*, AbdulAziz M. Sebiany
1, Ahmed S.Hafez
1,3
1Department of Family and Community Medicine, College of Medicine, University of
Dammam, Saudi Arabia. 2
Primary Health Care Divisions, High Institute of Public Health,
Alexandria University, Egypt. 3Department of Community, Environmental and Occupational
Medicine, Faculty of Medicine, Ain-Shams University, Egypt
*Corresponding Author: Professor Amr Ahmed Sabra. Email: [email protected]
ABSTRACT
Background: Pregnancy is the only time in a woman's life where weight gain is expected and
encouraged. Therefore, women are concerned whether pregnancy will have an impact on their
body weight. Objective: To determine gestational weight gain during normal and high risk
pregnancy and to find-out the maternal factors that are associated with maternal weight gain
during normal and high risk pregnancies. Subjects and Methods: A retrospective study was
conducted in Al-Khobar city, Eastern Saudi Arabia. All pregnant women registered, during the
year 2010-2011 (n=323), at three randomly selected primary health care centers were included in
the study. The number of records with completed registered studied variables and weight gain
during pregnancy was 229 records (70.9% of total records) was divided according to the criteria
of high risk pregnancy, into two groups, namely normal pregnancy (n=123) and high risk
pregnancy (n=106). The maternal body weight gain was divided into three categories as low
weight gain (≤ 8.0 kg), normal weight gain (8.1—16.0 kg) and high weight gain (≥ 16.1 kg).
Statistical analysis was done using descriptive and analytic statistics as well as logistic regression
analysis. Results: The rate of women having normal maternal weight gain during normal
pregnancy was 35% as compared to those 18.9% during high risk pregnancy. While, 63.4% of
women had low weight gain during normal pregnancy, 80.2% of them had low weight during
high risk pregnancy. About 31.2% of women during normal pregnancy were aged 35-45years old
when compared to 68.8% of women during high risk pregnancy and the difference was
statistically significant (p<0.01). Increased parity and number of living children are significantly
associated with low maternal weight gain during normal pregnancy. Decreased antenatal visits
during high risk pregnancy were significantly associated with low weight gain during high risk
pregnancy. Conclusion: Low weight gain was more during high risk pregnancy; increase in
parity and number of living children during normal pregnancy, decreased antenatal visits during
high risk pregnancy are significantly associated with low maternal weight gain. Suitable measures
should be taken to control maternal body weight gain during pregnancy.
Key words: Maternal Weight Gain, Primary Health Care, Predictors, Saudi Arabia.
Janbi OS, Sabra AA, Sebiany AM, Hafez AS. Predictors of maternal weight gain during
normal and high risk pregnancies: a retrospective study in primary care, Eastern Saudi Arabia.
Canad J Clin Nutr 2013; 1 (1): 5-15.
INTRODUCTION
Pregnancy is the only time in a woman's
life where weight gain is expected and
encouraged. Therefore, women are
concerned whether pregnancy will have an
impact on their body weight. There are
many body changes during pregnancy: an
inevitable one is that pregnancy and
weight gain go hand in hand, not making it
any easier for the body image during
pregnancy. Maternal weight gain in
pregnancy can serve as a good mean of
assessing the wellbeing of the pregnant
mother (1). The weight of the growing
fetus itself should expect to have a gain
between 10-12 kg and a 12-15kg of ‗baby‘
respectively with a single pregnancy.
During the first trimester pregnancy
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weight gain should be between 1-2 kg, and
then about 500g per week for the rest of
the pregnancy term (2).
Inadequate prenatal weight gain and low
weight gain during pregnancy are
significant risk factors for intra-uterine
growth retardation, pre-term delivery and
low birth weight in infants (3-7).
Excessive weight gain on the other hand
can lead to adverse maternal and fetal
outcomes (8,9). Accordingly, suggestions
for optimal weight gain is needed to ensure
the best outcomes (10- 12). Gestational
weight gain was defined as the difference
between the maternal weight measured
within one week prior to delivery and the
maternal weight recorded at the first visit
to the hospital. Gestational weight gains
were grouped into three categories as low
weight gain (≤ 8.0 kg), normal weight gain
(8.1—16.0 kg) and over weight gain (≥
16.1 kg) (13).
Excessive gestational weight gain, in
Saudi Arabia, is emerging as an important
predictor of maternal and offspring
obesity, as well as obstetrical
complications. Independent of their weight
entering pregnancy, mothers who gain
excessively during pregnancy are more
likely to deliver by cesarean section, have
an unsuccessful trial of labor after
cesarean section, develop pre-eclampsia,
retain excessive weight after delivery, and
become overweight or obese in later life
(14). Various studies reported that the
socio-demographic predictors of excessive
weight gain during pregnancy were null
parity, pre-pregnancy overweight, body
mass index, low socioeconomic status, and
young maternal age (2,4,6,8,14). The
nature of weight gain during normal and
high risk pregnancy in Saudi Arabia
remains undetermined. The aim of the
present study was to determine gestational
weight gain during normal and high risk
pregnancy and find-out the maternal
factors associated with weight gain during
normal and high risk pregnancies.
SUBJECTS AND METHODS
A retrospective epidemiological
investigation based on population
background was conducted during the year
2012 in Al-Khobar city, part of the eastern
province in the Kingdom of Saudi Arabia
(KSA). Married fertile women having
children in catchments of randomly
selected primary health care centers
(PHCCs) were the units of observation and
the target population of the present study.
All available medical records of pregnant
women in three out of the eight PHCCs, in
Al-Khobar city, were randomly selected
namely; Al-Akrabia, Ibn Hayyan and Al-
Bayonia PHCCs. The specific inclusion
criteria of the present study were the
presence obstetric records of Saudi and
Non Saudi women that attended their first
antenatal visit during the study period in
the selected PHCCs. The records of all
pregnant women, who were developed
according to the World Health
Organization (WHO) known as "Mother
and child health passport", who started
their antenatal care from 1st October 2010
to 30th September 2011 were collected
from the three randomly selected PHCCs.
The total number of these antenatal
records was 323, and the number of
records with complete registered studied
variables and gained weight during
pregnancy was 229 records which
represented 70.9% of the total records;
they were divided according to the criteria
of high risk pregnancy,(15) into two
groups, namely normal pregnancy (n=123)
and high risk pregnancy (n=106). The
available maternal variables in the present
study were socio-demographic and
reproductive characteristics as well as
family, past-medical and surgical histories,
current obstetric history and maternal body
weight gain. Obstetric outcome included
preeclampsia, eclampsia, gestational
diabetes, ante partum hemorrhage, full
term and postdate deliveries. Values of
maternal body weight gain were divided
into three categories as low weight gain (≤
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8.0 kg), normal weight gain (8.1—16.0 kg)
and high weight gain (≥ 16.1 kg) (13).
Demographic, antenatal data were
explored; and women with normal weight
were used as the reference or the
comparison group for data analysis. The
socio-economic status of the mothers was
determined by scoring system (16) using
parental education (0-4 scores for either
paternal or maternal education); Paternal
occupation (2-7 scores) and maternal
occupation (0-1 score). Accordingly, the
total score of socio-economic status ranged
from 2-16 scores.
Data entry and verification was done and
variables were described using frequency
distribution for categorical variables. The
chi-square (χ2) and Fishers Exact test were
used as a test of significant values for
comparison of categorical variables and t
test was used as a test of significance for
quantitative variables. P value < 0.05 was
chosen as the level of statistical
significance using Statistical Package of
Social Sciences (SPSS) version16 (17).
Logistic regression analysis was done to
determine the main factors associated with
weight gain and the results were expressed
as Odds Ratio (OR) and corresponding
95% as confidence interval (CI). Pilot
study was applied on fifteen files in Al-
Akrabia PHCC in order to test the validity
and reliability. Permission was taken from
the concerned authority to conduct the
study and confidentiality of the
information was strictly adhered, with data
to be used only for research purpose.
RESULTS
The total registered records of women who
attended antennal care during the study
period were 323 records and 29.1% were
excluded due to lack of registration of
some variables under the study. A total of
229 maternal antenatal records were
enrolled in the study. They were classified
into normal (n=123) and high risk
pregnancy (n=106) groups according to
the criteria of high risk pregnancy15. The
criteria of high risk pregnancy were
previous stillbirth or neonatal deaths (4%),
isoimmunisation RH (5.9%), previous
surgery on reproductive tract (14.2%),
history of low birth weight (< 2500g) in
last pregnancy (7.7%), and any medical
disease or condition (23.2%) (Table 1).
Maternal weight gain was normal in 35%
women during normal pregnancy as
compared to 18.9% of the women during
high risk pregnancy. However, low weight
gain during normal pregnancy was
observed among 63.4% women during
normal pregnancy when compared to
80.2% during high risk pregnancy. The
overweight gain was approximately the
same during normal and high risk
pregnancies (Figure 1). During normal
pregnancy 31.2% of women were in the
age group of 35-45years old compared to
68.8% during high risk pregnancy and the
difference was statistically significant
(p<0.01) (Table 2). Moreover, there was
no statistical significant difference
between the studied women during normal
and high risk pregnancies regarding
nationality and maternal occupation. The
reproductive characteristics of studied
women revealed that 47.5% of them
during normal pregnancy had abortions
compared to 52.5% who had undergone
abortion during high risk pregnancy; and
28.1% of women during normal had 5 or
more living children as compared to 71.9%
of women during high risk pregnancies.
(Table 2). Family history of women
showed that diabetes mellitus,
hypertension, multiple pregnancy, and
consanguinity are nearly the same during
normal and high risk pregnancy (Table 3).
Increase parity and increased number of
living children are significantly associated
with low maternal weight gain during
normal pregnancy (Table 3). However,
decreased antenatal visits during high risk
pregnancy were significantly associated
with low maternal weight gain during high
risk pregnancy (Table 4). Moreover, an
association between maternal weight gain,
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obstetric outcomes and prenatal
morbidities was determined; however, the
number of women during normal
pregnancy was too small. Logistic
regression analysis revealed that mother‘s
education (OR= 1.7, CI =1.12- 2.45,
Model X2 (15) = 19.95, P<0.5) was the
only significant (P<0.05) predicting factor
associated with maternal weight gain
during normal pregnancy (Table 4).
However, during high risk pregnancy
neither socio-demographic factors nor
reproductive characteristics were
predictors of maternal weight gain.
DISCUSSION
Maternal weight was recorded at almost
all antenatal primary care attendees and
weight gain was considered as a clinical
test during antenatal care. The amount of
maternal weight gain was found to be
compatible with normal pregnancy
outcome (18-20).These have led to studies
resulting in recommended weight gain
during pregnancy (21). In the present study
most of the women studied in Saudi were
aged 25-35 years (56%); 94.1% were
Saudi nationals and 95% were housewives.
The findings are similar to the study done
among Qatari married women (15), but a
higher value for maternal age was reported
by a study in Saudi Arabia (23). The
reproductive characteristics of Saudi
women showed that 26.6% had abortion
and 34.1% had up to two children; this
finding is inconsistent with other studies.
(6,8,13,22). Past-medical history of
anemia was observed among 20.4%,
14.2% had past surgical history of
cesarean section, 27.5% had normal body
weight gain (8.1 to <16) during pregnancy
and the mean antenatal visits was 2.5±1.2.
Data of other previous studies (3, 13, 15,
23, 24) were inconsistent with these
findings in the present study. The criteria
of high risk pregnancy were previous
stillbirth or neonatal deaths (4%),
isoimmunisation RH (5.9%), previous
surgery on reproductive tract (14.2%),
history of low birth weight in last
pregnancy (7.7%), and any medical
disease or condition (23.2%). This study
showed that there was statistically
significant (P<0.01) difference in age
distribution of studied women during
normal and high risk pregnancies.
However, there was no statistical
significant difference between the studied
women during normal and high risk
pregnancies regarding nationality and
maternal occupation.
Also the reproductive characteristics of
studied women revealed that there was
statistical significant (P<0.01) difference
between the studied women during normal
and high risk pregnancies number of living
children. Family history of women showed
that diabetes mellitus, hypertension,
multiple pregnancy, and consanguinity are
similar during normal and high risk
pregnancy. Moreover, 18.8% of women
studied during normal pregnancy had past-
medical history of anemia, 12.5% had
past-surgical history of caesarean section,
56.9% had 3-4 antenatal visits, 60%
delivered pre-term babies and 68.8% had
normal maternal weight gain during
normal pregnancy.
Excessive gestational weight gain in Saudi
Arabia is emerging as an important
predictor of maternal obstetric
complications. Mothers who gain weight
excessively during pregnancy are more
likely to deliver by caesarean section,
develop pre-eclampsia, and become
overweight or obese in later life (14).
Increase parity and increased number of
live births are significantly associated with
low maternal weight gain during normal
pregnancy. However, decreased antenatal
visits during high risk pregnancy were
significantly associated with low maternal
weight gain during high risk pregnancy.
These finding are inconsistent with
findings of other studies performed in
Ghana (2), Africa (25), Saudi Arabia
(23,24) Also, there is an association
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between maternal weight gain and either
obstetric outcomes or prenatal morbidities,
although the present study involved small
number of women in each variable under
investigation during normal pregnancy.
Logistic regression analysis revealed that
mother‘s education (OR= 1.7, CI =1.12- 2.
45) (P<0.05) was the only significant
predicting factor associated with maternal
weight gain during normal pregnancy.
However, none of the socio-demographic
factors and reproductive characteristics
was found to be predictors of maternal
weight gain during high risk pregnancy.
This is not in-accordance with various
studies, which reported that an antenatal
visit during pregnancy was the significant
preventive factor against adverse
pregnancy outcome and complications
(11-15).
CONCLUSION
The results of the present study
demonstrated that 29.1% of the records
were incomplete and was missing
important data which may have not been
performed or not recorded. Low maternal
body weight gain during normal pregnancy
was significantly associated with increase
parity and increased number of children.
However, decreased antenatal visits during
high risk pregnancy were associated only
significantly with low maternal weight
gain. Also there is an association between
maternal weight gain and obstetric
outcomes and prenatal morbidities.
Logistic regression analysis demonstrated
that mother‘s education was the only
significant predicting factor associated
with maternal body weight gain during
normal pregnancy. From the results of the
present study, it is recommended that all
primary health care team members
providing antenatal care services should
receive continuous medical education and
in-service training about the new WHO
model and be aware about the principles
and importance of proper registration and
recording. Health education sessions
should be conducted for all females with
particular attention to pregnant women
about the hazards associated with
excessive body weight gain during
pregnancy and the different methods of its
control, with special emphasis on lifestyle
modification.
Conflicts of Interest
The authors indicated no potential or
actual conflict of interest pertaining to this
study.
Authors' Contributions
All authors made full contribution to data
acquisition, interpretation of results,
drafting and revising the final manuscript.
All authors read and approved the final
manuscript.
Study Limitations
There were no limitations.
Acknowledgements
The authors deeply extended their
appreciation to the study subjects for their
dedicated effort to complete this study.
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Canad J Clin Nutr is published by Global Science Heritage (http://www.globalscienceheritage.org), a registered publisher by the Library and Archives/Government of Canada, Business License Number: 220080600 (www.collectionscanada.gc.ca).
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Table 1: Number and percent distribution of studied pregnant women with criteria of
high risk pregnancy
*a pregnant woman may have more than one risk pregnancy factors
Criteria of high risk pregnancy pregnant Women with high
risk of pregnancy factors*
No. %
Obstetric history:
1-Previus stillbirths or neonatal loss 13 4.0
2-History of 3 or more consecutive spontaneous abortions 3 0.9
3-Birth weight of last baby < 2500g 25 7.7
4-Birth weight of last baby > 4500g 2 0.6
5-Last pregnancy hospital admission for H.T. or eclampsia / preeclampsia 3 0.9
6-Previous surgery on reproductive tract 46 14.2
Current pregnancy:
1-Diagnosed or suspected multiple pregnancy 1 0.3
2-Age >40 years 9 2.8
3-Isoimmuization RH(-) in current or previous pregnancy 19 5.9
4-Vaginal bleeding 6 1.9
5-Pelvic mass 2 0.6
6-Blood pressure140/90mmHg or more at booking 2 0.6
7-Cardiac diseases, Diabetes mellitus, or renal diseases 5 1.5
8-Any other severe medical diseases or conditions 75 23.2
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Table 2: Demographic, reproductive characteristics and family history of studied pregnant
women during normal and high risk pregnancies
Characteristics N
Normal
pregnancy
(n=123)
High risk
pregnancy
(n=106)
Test of
Significance
P value 229 No. % No. %
A-Demographic characteristics
1-Age group (years)
15-<25 60 43 71.7 17 28.3
25- <35 137 70 51.1 67 48.9 χ2 =14.651, P<0.01
35- 45 32 10 31.2 22 68.8
2-Nationality
Saudi 217 118 54.4 99 45.6 FET=0.74, P>0.05
Non-Saudi 12 5 4.7 7 57.3
3-Women occupation
House wife 221 121 58.8 100 45.2 χ2 =2.75, P>0.05
Working for cash 8 2 25.0 6 75.0
B- Reproductive characteristics
1-Abortions 59 28 47.5 31 52.5 FET=1.25, P>0.05
2-Stillbirths 2 0 0.0 2 100.0 --------
3-Number of living children
1-2 74 38 51.4 36 48.6 χ2 =17.56, P<0.01
3-4 56 28 50.0 28 50.0
≥5 32 9 28.1 23 71.9
No living children 67 48 71.6 19 28.4
C-Family History
Diabetes Mellitus 121 63 52.1 58 47.9
Multiple pregnancy 29 12 41.4 17 58.6 χ2 =2.899, P>0.05
hypertension 109 61 56.0 48 44.0
Blood disorders 6 4 66.7 2 33.3
Consanguinity 20 9 45.0 11 55.0
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Table 3: Maternal body gain and socio-demographic characteristics of studied pregnant
women during normal and high risk pregnancies
*P<0.05
Table 4: Logistic regression analysis of significant factors predicting maternal body weight gain
among studied pregnant women during normal pregnancy
Maternal Body Gain
Normal pregnancy (n=123) High risk pregnancy (n=106)
Variables Normal
weight gain
Low
weight gain
Over
weight
gain
Normal
weight
gain
Low
weight gain
Over
weight
gain
(8.1-<16) (<8) (≥16) (8.1-<16) (<8) (≥16)
(n=43 ) (n=78 ) (n=2 ) (n=20) (n=85 ) (n=1 )
Age (x ±SD) 25.3±3.9 27.1±5.6 25.0±11.3 29.0 ±5.5 29.8±5.9 -----
Parity (x ±SD) 2.2 ±1.4 3.5 ±2.3* 2.5 ±2.1 3.5 ±2. 9 2.8 ±0.85* -----
Number of Antenatal
care visits (x ±SD) 3.4 ±0.7 3.1 ±0.9 3.0 ±0.001 3.5 ±0. 7 4.5±2.8 -------
Number of living
children (x ±SD) 0.97 ±1.2 1.9±1.8* 2.5±2.1* 2.1 ±1.9 1.9±1.8 --------
Variables B coefficient B P-value O.R.
95 % Confidence
interval of O.R.
Lower Upper
Mother education 0.503 0.2 0.012 1.7 1.12 2.45
Constant 91.19 7.84 ------ ---- ------ -----
Model X2 = 19.95, P >0.05
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Figure 1: Percentage of pregnant women achieved body weight gain during normal and
high risk pregnancy
0
10
20
30
40
50
60
70
80
90
Low weight gain Normal weightgain
high weight gain
63.4
35
1.6
80.2
18.9
0.9
Per
cen
tag
e
Normal pregnancy
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Determinants of Overweight and Obesity among Qatari Children (2-5
years) in Doha, Qatar-2010
Mervat Rady
1, 2*, Mariam Al-Muslemani
1, Rasha Salama
1, 3
1Joint Program of Arab Board in Community and Family Physicians, Doha, Qatar.
2Department of
Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain-Shams University,
Egypt. 3Department of Community Medicine, Faculty of Medicine, Suez Canal University, Egypt
*Corresponding Author: Dr. Mervat Rady, Consultant Trainer -Arab Board Program, Primary Health
Care-Doha, Department of Family and Community Medicine, Qatar. Email: [email protected]
ABSTRACT
Background: Childhood obesity is a major global burden with modifiable and preventable
underlying risk factors. Objective: to determine risk factors for overweight and obesity
among children; 2-5 years old in Doha city, Qatar. Subjects and Methods: A cross sectional
approach was conducted from July 2009 to April 2010. Six primary health care centers were
randomly selected using the cluster sample technique. Data was collected by Pre-designed
and pre-tested interview questionnaire with children's mothers to elicit the information about
children socioeconomic characteristics, dietary history and physical activity. Weight and
height were measured and BMI was calculated. Overweight and obesity were assessed by
WHO- BMI for age growth charts. Results: the overall prevalence of overweight and obesity
was 26.9%. The final model of multiple logistic regression analysis showed that important
determinants of overweight and obesity were positive family history of obesity, low levels of
physical activity and consuming high caloric food items more than 4 times per week.
Conclusion: The study documented high prevalence of overweight and obesity among
preschool children in Doha city. Family history of obesity, low levels of playing outdoors and
dietary pattern were determinants of overweight/obesity. Suitable recommendations were
issued to prevent childhood overweight and obesity among preschoolers.
Key words: Preschoolers, Qatar, Overweight, Obesity, determinants.
Rady M, Al-Muslemani M, Salama R. Determinants of Overweight and Obesity among Qatari
Children (2-5 years) in Doha, Qatar-2010. Canad J Clin Nutr 2013; 1(1): 16-26.
INTRODUCTION
Childhood obesity is a condition where
excess body fat negatively affects a child's
health or wellbeing (1). Developing
countries have seen an increase in child
obesity since they started to adapt the
westernized lifestyles and behaviors with
excess positive energy balance, accelerated
by an increasingly sedentary lifestyle in
recent decades (2, 3). The increasing
consumption of fats, sweeteners, energy
dense foods, and fast food meals compared
to traditional diets with higher intake of
cereals characterize the current era. The
result is a series of nutritional inequities in
many nations, communities, and
households. Technology and transportation
throughout the food supply chain have
facilitated the production and distribution
of foods associated with the nutrition
transition, while cultural influences have
introduced new foods into developing
countries and shaped the desire for those
foods (4, 5). State of Qatar is being
classified among the countries passed
through advanced nutritional transition
stage, with high level of overweight and
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obesity, and micronutrient deficiencies in
some population sub-groups (6).
Determining the risk factors of preschool
overweight and obesity can serve as a
basis for planning policies and cost
effective intervention programs as well as
a baseline for further research. So the aim
of this study was to identify determinants
of overweight and obesity among
preschool children aged 2 to 5 years in
Doha city.
SUJECTS AND METHODS
Study Design
This cross-sectional study was conducted
from July 2009 to April 2010 in sample
units of six randomly selected primary
health care centers (PHCCs) from the total
10 centers list of Al-Doha city; the capital
of Qatar.
Sample Size
The sample size was estimated by using
the formula: n= DEFFECT [z2 α/2 (pq)
/d2]; the prevalence of obesity was taken
as 16% (7), the degree of precision of the
estimate was set at 5% and the design
effect of cluster sampling was set as 1.8.
Using the previous formula the sample
size was estimated to be 371. After adding
an inflation rate 30%, an additional 112
children were added. Thus 483 children
were selected for this study.
Study Population
The study subjects were apparently healthy
children including boys and girls aged 2-5
years who attended these centers with their
mothers and agreed to participate by
maternal written consent. The following
children were excluded; children with
chronic diseases or using medications
capable to interfere with weights or
heights, and children with physical
deformities or if the mothers were
unwilling to participate. The study
protocol was approved by the ethical
committee of Hamad Medical Corporation
and Primary Health Care Corporation. A
prior consent for the study was taken from
the mothers.
Study Tools
At each center, a structured interview
questionnaire was used. It consists of 36
closed ended questions in Arabic about:
Children‗s characteristics: age, sex, child
siblings‗ number and birth order; parents
characteristics: educational level, maternal
job, family income and family history of
obesity; children‗s behaviors and habits as
regard eating habits, daily activity and
exercise and the recorded anthropometric
measurements of the child and his/her
mother. Data collection process was done
separately in a private room for each child
to ensure privacy. The pretest of the
questionnaire had been done prior to the
real data collection among 30 mothers.
Weights and heights were taken by trained
nurses in the centers using the standard
techniques with a sensitivity of 0.1 cm and
0.1 kg respectively. Zero error was set
daily. BMI was calculated and the
children were identified as overweight if
the BMI was ≥85th- <97th percentile and
obese if BMI was ≥97th percentile
according to age-sex specific percentiles of
BMI using the WHO BMI-for-age growth
charts (8).
Exclusive breast feeding: was defined as
that the child being fed no food or drinks
even the water other than the breast milk.
Eating behaviors and habits: they were
based on food frequency. It is concerning
type of food usually consumed by Qatari
children in a week. The categories of each
food item were classified by the author as
follow: > 4 days per week: Every day or 5-
6 times per week, ≤ 4 times per week:
equal to and below 4 times per week and
Never/very seldom: never or 2 days or 1
day per month. Daily life activity: This
refers to the average length of time
children spend on each activity in a day.
The reference for watching television, and
playing indoor games (such as computer
games, game boy, and play station) were
considered to be < 2 hours per day. For
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playing outdoors, we considered the
reference to be ≥ 1 hour by day. Exercise:
This refers to whether the child
participates in any type of sports, or
exercise suitable for his/her age; the ideal
frequency per week was considered 3
times per week and duration per time not
less than 30 minutes.
Statistical Analysis
All data entries were double checked for
any errors. Association of each categorical
variable with overweight and obesity was
assessed using X2 test and the strength of
their association was computed by the
unadjusted odds (95% confidence
interval). Variables showing statistically
significant (P<0.05) association with the
outcome variable (overweight and obesity)
were considered as risk factors for the
outcome. These variables were
simultaneously entered into a step wise
logistic regression model to determine the
independent risk factors of overweight and
obesity. Data analysis was performed
using the SPSS statistical package. In this
study P value < 5 % was considered as
statistical significant.
RESULTS
A total 464 children from the selected 6
PHCCs who satisfied the inclusion criteria
and agree to participate, were enrolled in
the study, out of them 50.2% were boys
and 49.8 were girls with mean sample age
41.69 ±10.2 months. 98 of the studied
children were under weights according to
body category and excluded from the
analysis. The overall prevalence of
overweight and obesity was 12.9% and
14%. The prevalence of overweight and
obesity was 10.6% and 15.5% in boys and
15.2 and 12.5% in girls. The overall
difference between boys and girls was
statistically insignificant.
Table 1 represents the bivariate
relationship of some socioeconomic and
nutritional habits variables were
statistically significant (P<0.05) and were
associated with increased risk of
overweight and obesity as the odds ratios
exceeded the unity, while for high protein
and green vegetables intake; both were
significant protective variables and the
since the odds ratio was 0.05 and 0.41
respectively.
Table 2 shows the statistically significant
bivariate relationship of some physical
activity variables which were associated
with increased risk of overweight and
obesity as the odds ratios exceeded (1) and
the 95% CI does not contain the unity,
P<0.05. The data on table 2, also shows
that there is a very low percent 11.2%
(41/366) of children who practice sports or
exercise in our sample and there is no
relation between the history of doing
exercise and occurrence of OW&OB
among the children since P>0.05.
However, the duration and frequency per
week were significantly associated with
occurrence of OW&OB among children in
this age group since higher percent of
OW&OB were among those practice
sports for less than 30 minutes per time
and less than 3 times per week compared
to the other categories and P< 0.001 in the
two situations.
Table 3 illustrates that, when the variables
showing significant association at P<0.05
were simultaneously considered in the
logistic regression model with overweight
and obesity as a binary outcome versus the
normal weights, it was observed that
children with positive family history of
obesity, negative history of daily breakfast
and with exclusive breast feeding ≤ 4
months were having 7.4 times (OR= 7.4;
95% CI =2.9-12.8), 7.9 times (OR=7.9;
95% CI=4.1-19.7) and 8.5 times (OR=8.5;
95% CI=5.7-18.3) more risk of
overweight and obesity respectively.
Similarly, children eating meals full of
carbohydrates, bakery and sugary foods
for more than 4 days per week having 8.5
times (CI=1.6-12.5), 3.7times (CI=1.5-9.3)
and 6.2 (4.1-15.5) times more risk of
overweight and obesity respectively. The
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risk of overweight and obesity is nearly
twice when the child consumed fast food
meals more than 4 times/week (OR=1.9,
CI=1.2-4.1). Playing outdoors in the
weekends for less than 1 hrs/day was
associated with the risk of overweight and
obesity of 18.9 times (OR=18.9; CI=11.3-
26.7).
DISCUSSION
In the present study, the prevalence of
overweight and obesity was 12.9% and
14%; being 10.7% and 15.5% in boys and
15.2% and 12.5% in girls, respectively. In
a study done by Supreme council of Health
in coordination with the WHO-EMRO
(2008), the prevalence of overweight
among less than 5 years Qatari children
was 28.7% (6). Also, Al-Najeeb et al.,
showed that the rate of obesity and
overweight was 23% and 16% respectively
among primary school Qatari children (9).
The results of these studies mean that the
problem of overweight and obesity among
the Qatari children is a real health problem
and reflecting the negligence or
underestimation of the problem. Although
the mechanism of obesity development is
not fully understood, it is confirmed that
obesity occurs when energy intake exceeds
energy expenditure. There are multiple
etiologies for this imbalance, hence, and
rising prevalence of obesity cannot be
addressed by a single etiology. Genetic
factors influence the susceptibility of a
given child to an obesity-conductive
environment. However, environmental
factors, life style preferences, and cultural
environment seem to play major roles in
the rising prevalence of obesity worldwide
(10). Parental obesity is the best predictor
of childhood obesity as reported by Abdul
Wahab et al., in Kuwaiti (11). Also,
Shepherd (2009), reported that the first
cause of excess body fat in children is a
genetic factor especially among near
relatives (12). From the family history of
obesity point of view, the present study
shows strong relation between family
history and children body status suggesting
the genetic effect. This relation may be
due the fact that parents and children
usually share dietary habits and have
similar physical activity levels, thus
contributing towards the greater risk of
obesity in certain families. Also, busy
families today rely on convenient foods
which often come from fast food
establishments, other restaurants, and the
frozen and prepackaged food sections of
the grocery store.
Hurried families no longer have time to sit
down to eat meals together, even though
eating together has been associated with
greater intake of foods from the basic food
groups in both children and adults,
furthermore it was reported that infant
weight gain is associated with an
interaction between the duration of
breastfeeding and the timing of
complementary food introduction (13).
Moreover, they specify the interaction
which was identified for longer durations
of breastfeeding than 20 weeks. In the
meantime, they recognize earlier
complementary food induction (< 16
weeks) was associated with greater infant
weight gain. In a wide-ranging meta-
analysis, Harder et al., included 17 studies,
reported the duration of breast feeding;
and included children fed exclusively with
infant formula for comparison (14). Based
on these data, they reported that the
duration of breast feeding was inversely
associated with risk of overweight,
independent of the definition of
overweight used and the age of the
participants in the studies.
Fast food intake is one of the risk factors
for obesity and overweight in the present
study. It is more energy dense and higher
in fat content. The same result was
observed by David et al and Weyermann et
al., as the prevalence of overweight and
obesity grew from in children with
frequent snaking and consumption of junk
food (15, 16). Excess consumption of
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carbohydrates, bakery, fatty and the sugary
items were significant risk factors for
overweight and obesity. The same result
was obtained in a number of cross-
sectional and longitudinal studies (10, 17,
18). Consumption of these items increases
weight as they add more calories and
satiety is not addressed. However, Food
frequency methods like the one we used in
our study, measure usual diet, but estimate
caloric intake poorly (10). Other methods
such as 24-hour recall or food diaries
evaluate caloric intakes more accurately,
however, estimate short-term not long-
term intake (19). Mahshid et al., reported
that, total energy intake is difficult to
measure accurately at a population level
(10).
A number of studies in western countries
failed to correlate the excess in obesity
rates with the total energy intake and even
they reported lower level of energy intake
among obese children compared with their
lean counterparts (20). Evaluation of food
intake among pre-school children is an
even more difficult task because there is
little data about food habits and
preferences of this age group in the
literature. Older age groups especially
school- children, teens and adolescents
have been investigated much more
thoroughly (21). Also, food evaluation
using parents recall is always liable to bias
due to over or under estimation as reported
also by Schonfeld and Warden, who
reported that this method is not a valid
measurement (22). Our results document
the relation between missing breakfast and
occurrence of overweight and obesity
among children. The odds to become an
overweight or obese child are 8 times more
among children skipping breakfast than the
children do not do that. Unfortunately,
28% of study sample skips to take the
breakfast daily. It was reported that one
out of every three children skips breakfast.
Skipping breakfast expose a hungry child
to eat more portions from the high caloric
lunch meal or to snack frequency (9).
The role of physical inactivity in the
process of obesity is very clear in the
present study as the obesity rate is
significantly higher among the inactive
group of children. It has been hypothesized
that a steady decline in physical activity
among all age groups has heavily
contributed to rising rates of obesity all
around the world. Numerous studies have
shown that sedentary behaviors like
watching TV and playing computer games
are associated with increased prevalence of
obesity (23). Furthermore, parents from
these studies report that they prefer having
their children watch TV at home rather
than play outside unattended because
parents are then able to complete their
chores while keeping an eye on their
children (24).
In addition, increased proportions of
children who are being driven and low
participation rates in sports particularly
among female children (25), are also
associated with increased obesity
prevalence which is very obvious among
our sample since a very small percent of
the children participate in exercise or sport
activity. Since both parental and children‘s
choices fashion these behaviors, it is not
surprising that overweight children tend to
have overweight parents and are
themselves more likely to grow into
overweight adults than normal weight
children (26). Although, the population-
based studies which relate physical activity
to obesity are limited, but they concluded
that increased physical activity might
decrease the accelerated weight gain
epidemic (27-30). In the present study, it
was found that children who did not play
outdoor games had an increased risk of
overweight and obesity. By encouraging
children to play outdoor games not only
increases their physical activity but also
they remain fit.
CONCLUSION
The major conclusion drawn from this
study is that family history of obesity,
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absence of daily breakfast, consuming fast
food, excess carbohydrates, bakery and
sugary food items with low levels of
physical activity are associated with higher
prevalence of overweight and obesity
among Qatari preschool children attending
the primary care centers. Accordingly,
there is a need to apply nutritional
education programs to mothers regarding
feeding of their children during this age
group (2-5 years), and encouraging out-
door activities suitable for their age as a
preventive strategies for childhood
overweight and obesity.
Conflicts of Interest
The authors indicated no potential or
actual conflict of interest pertaining to this
study.
Authors' Contribution
All authors made full contribution to data
acquisition, interpretation of results,
drafting and revising the final manuscript.
All authors read and approved the final
manuscript.
Study Limitations
There were certain limitations of the
present study; the study relied on the
mother's memory-recall which influenced
by limited degree of loss of information as
regard their children physical activity and
dietary patterns. Dietary history was based
only on qualitative data and didn‘t take
into consideration type and amount of
foods in details.
Acknowledgements
We would like to thank all nurses,
technicians and physicians for their kind
support in data collection and laboratory
analysis. We also thank the children and
their parents for contribution in the study.
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Table 1: Bivariate relationship between the socioeconomic and dietary habit variables,
overweight and obesity among Qatari children 2-5 years old attending PHCCs-2010
Variables
Body Category
Overweight
& Obese
(n=125)
No. (%)
Normal
(n=241)
No. (%)
OR (95%CI)
P-Value
Positive family history of obesity 80 (64.0) 28 (11.6) 13.2 (7.5-23.5) <0.001
Exclusive Breast feeding ≤ 4 months 114 (91.2) 189 (78.4) 2.9 (1.4-5.7) <0.001
> 3 meals per day 40 (32.0) 40 (16.6) 2.4 (1.4-4.1) <0.001
Negative history of daily breakfast 80 (64.0) 34 (14.1) 10.8 (6.3-18.7) <0.001
Snacks consumption ≥ onetime/day 92 (73.6) 142 (58.9)
1.94 (0.8-4.5) <0.05
Soft drinks consumption ≥ onetime/day 97 (77.6)
137 (56.8)
2.74 (1.5-5.1)
<0.001
Artificial juice consumption ≥ onetime/day 105 (84)
121(50.2)
17.4 (4.1-23.6)
<0.001
Protein intake > 4 days/week 16 (12.8)
57 (23.7)
0.05 (0.01-0.4) <0.001
Dairy products intake > 4 days/week 69 (55.2) 96 (39.8) 1.86 (1.2-2.9) <0.01
Carbohydrate products intake > 4 days/week 34 (27.2)
8 (3.3)
36.(8.9-150.7) <0.001
Sugary products intake > 4 days/week 76 (60.8)
15 (6.2)
14.8 (6.3-34.9)
<0.001
Bakery products intake > 4 days/week 64 (51.2)
18 (7.5)
5.5 (2.2-13.8) <0.001
Fatty meals intake > 4 days/week 6 (4.8) 2 (0.8) 11.1 (2.1-59.2) <0.001
Fast food meals intake > 4 days/week 24 (19.2)
23 (9.5)
3.6 (1.7-7.9) <0.001
Green vegetable intake ≥ onetime/day 78 (62.4)
173 (71.8)
0.41(0.17-0.98)
<0.05
Fruits & fresh juice intake ≥ onetime/day 18 (14.4)
12 (4.9)
2.9 (1.3-6-7)
<0.01
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Table 2: Bivariate relationship between the physical activity habits variables,
overweight and obesity among Qatari children 2-5 years old attending PHCCs-2010
Variables
Body category
Overweight &
Obese(n=125)
N0. (%)
Normal
(n=241)
No. (%)
OR (95%CI) P-Value
Spend time for sleeping > 8 hrs/day 57 (45.6) 46 (19.1) 3.55 (2.2-5.9) <0.001
Spend time watching TV > 2 hrs/day 103 (82.4) 166 (68.9) 2.12 (1.2-5.9) <0.01
Spend time playing other electronic
games > 2 hrs/day
33 (26.4) 21 (8.7) 4.32 (2.4-7.9) <0.001
Spend time playing outdoors in
weekdays < 1 hr/day
90 (72) 124 (51.4) 2.43 (1.5-3.9) <0.001
Spend time playing outdoors in
weekends < 1 hr/day
114 (91.2) 37 (15,4) 57.1(27.1-67.2) <0.001
Positive history of practicing exercise 18 (14.4) 23 (9.5) 0.63(0.31-.29) >0.05
Time sport <30 min/time 18 (72.2) 23 (13.04) 17.3 (3.5-85.2) <0.001
Frequency/week <3 times/week 18 (88.8) 23 (26.1) 22.7(3.9-29.1) <0.001
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Table 3: Risk factors using stepwise logistic regression analysis
Variables Category AOR (95%CI) P-Value
Family history of obesity No
Yes
1.00
7.4 (2.9-12.7)
<0.01
Exclusive breast feeding > 4 months
≤ 4 months
1.00
8.5 (5.7-18.3)
<0.01
Daily breakfast intake Yes
No
1.00
7.9 (4.1-19.7)
<0.001
Meals full of carbohydrates ≤ 4 days/week
> 4 days/week
1.00
8.5 (1.6-12.5)
<0.05
Bakery foodstuffs intake ≤ 4 days/week
> 4 days/week
1.00
3.7 (1.5-9.3)
<0.001
Sugary foodstuffs intake ≤ 4 days/week
> 4 days/week
1.00
6.2 (4.02-15.5)
<0.001
Fast food meals intake ≤ 4 days/week
> 4 days/week
1.00
1.9 (1.2-4.1)
<0.001
Playing outdoors in weekends ≥ 1 hr/day
< 1 hr/day
1.00
18.9 (11.3-26.7)
<0.001
Constant -57.023
The overall predictive % of the model=94% (R2
= 0.943)
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Anemia among Primary School Children (5 -12 years) in Riyadh Region,
Saudi Arabia: A Community-Based Study
Ashry Gad
1*, Joharah AL-Quaiz
1, Tawfik Khoja
2, Abdullah As-Sharif
3, Hamad Al-Manea
3,
Abdullah Al Edriss3, Sheikh Shafi
1
1Department of Family and Community Medicine, College of Medicine, King Saud
University, 2 Director Executive Board Council for Gulf cooperation States, 3Ministry of
Health, Riyadh, Saudi Arabia.
*Corresponding Author: Prof. Ashry Gad Mohamed. Email: [email protected]
ABSTRACT
Background: Anemia among school aged children is known to be an important global
public health problem in both developing and developed countries. It affects the physical and
intellectual functions of the affected children. School years are ideal opportune time to
intervene to prevent and control anemia. Objectives: The objective of the study is to
investigate the frequency of anemia and the associated dietary and medical risk factors in
school aged children in Riyadh region. Subject and Methods: A cross sectional survey was
carried out in Riyadh region. The study sample was selected using the two stages of cluster
sampling technique. Standardized Arabic questionnaire was completed by parents of school
aged children by two well trained nurses. Dietary frequency was requested for the last week
prior to the interview. A venous blood sample was taken for hemoglobin estimation. Anemia
in school aged children was defined according to the WHO definition. Results: The total
sample was 1117 children, 49.9% males and 50.1% females. Prevalence of anemia was
22.3% (22.4% in males & 22.2% in females). Frequent eating of red meat reduced the risk of
anemia (OR=0.8). Frequent drinking of cola or sour milk (Laban) with lunch meal
significantly increased the risk of anemia (OR=1.52, 1.06-2.16 and OR=1.55, 1.07-2.25
respectively). Family history of hereditary blood disorders or iron deficiency anemia
increased the risk of anemia in school aged children (OR=5.48, 1.02-31.21 and OR= 3.38,
1.74-6.54 respectively). Conclusions: Anemia in school children is a moderate public health
problem in Riyadh region. Drinking sour milk with lunch and positive family history
increases the risk of anemia in school children.
Key words: anemia, school aged children, Diet.
Gad A, AL-Quaiz J, Khoja T, As-Sharif A, Al-Manea H, Al-Edriss A, Shafi S. Anemia among
primary school children (5 -12 years) in Riyadh region, Saudi Arabia: a community-based
study. Canad J Clin Nutr 2013; 1(1): 27-34.
INTRODUCTION
Anemia prevalence rate in pediatric
population can be an important indicator
of nutritional status (1).
Iron deficiency is
the main cause of anemia; therefore
anemia prevalence can be used as a proxy
for prevalence of iron deficiency anemia
(2). Anemia among school-aged children is
known to be a significant global public
health problem affecting 305 million
people around the world. In developing
countries its prevalence ranges from
29.2% to 79.6% (3). Even in USA as many
as 20% of children are assumed to become
anemic at some point by the age of 18
years (4). It can cause many adverse
effects on child health, including delayed
psychomotor development, impaired
cognitive function, IQ loss and increased
Page 27-34
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susceptibility to lead toxicity (5, 6).
Correction of iron deficiency at this age
group enhances children‘s learning
potential in schools, increases their fitness
and work capacity. In addition
improvement of girls‘ iron status may help
to prevent anemia during the reproductive
years (7-10).
The prevalence of anemia as a public
health problem is categorized as follows:
<5% no public health problem; 5-19.9%
mild public health problem; 20-39.9%
moderate public health problem and ≥40%
severe public health problem (8-11). Only
two countries among 192 WHO member
states anemia is not a public health
problem. It is mild in 40, moderate in 81
and severe in 69 states (11). The school
years are an opportune time to intervene,
and indeed the school setting offers an
ideal distribution system, and interventions
must be based on sound epidemiological
understanding of the problem at this age
group (11). Nutritive status of school aged
children is vulnerable (3); we therefore
conducted this cross sectional survey to
investigate the frequency of anemia and
the associated dietary and medical risk
factors in school aged children in Riyadh.
SUJECTS AND METHODS
Study design and setting
A Community based household cross
sectional survey was conducted over a
period of 4 months. Saudi subjects from
Riyadh region, older than one year, were
recruited on voluntary basis as a reference
population for this study. Riyadh region,
with a population amounted to 3.726.523
Saudi persons (Ministry of Planning,
preliminary results of 1425 (2004 G)
census. The study was approved by
Ministry of Health.
Sampling
The sample size was calculated on the
assumption of 30% prevalence of IDA in
Riyadh (5). At 95% confidence level and
acceptance of 2% as degree of precision,
the sample size was 2016 persons if the
simple random method was used. Due to
the large reference population, cluster
sampling technique was applied and a
design effect of 2 was used. The sample
size increased to 4032. A response rate for
blood extraction was assumed to be 60-
70% and accordingly the final sample size
was calculated to include 6204
participants. Out of these 1117 school
aged children were included in this study.
Two stage cluster sampling technique was
used to accomplish the study. In the first
stage 36 clusters were selected
proportionally allocated with the number
of population in each PHCC catchments
area. In the second stage a constant
number was selected per cluster.
Assuming that the average Saudi family in
Riyadh region is 7 persons, 25 households
were included in each cluster.
Data Collection
A Standardized Arabic questionnaire-
interview was designed to satisfy the study
objectives. It investigated about socio-
demographic characteristics, dietary,
medical history of each child 5-12 years
old within the family. Data were collected
by two well trained nurses. For nutritional
status assessment the dietary frequency
was requested for the last week prior to
interview. A venous blood sample was
taken for hemoglobin estimation. Anemia
was defined according to WHO
hemoglobin level in Children 5-11.99
years (< 11.5 g/dl) (12).
Statistical Analysis
The data was entered and analyzed, using
SPSS PC version 17.0 statistical software.
The outcome variable was dichotomized as
anemia (presence or absence). The study
variables related to socio-demographic,
medical history and dietary assessments
were used to observe and quantify the
statistical association. Odds ratio (OR) was
used to measure an association between
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the two categorical variables. To adjust
odds ratios of the variables that proved to
be statistically associated with the
occurrence of anemia in the bivariate,
analysis were entered into multivariate
logistic regression model. The 95%
confidence intervals for adjusted odds
ratios were calculated. A p-value of <0.05
was considered as statistically significant.
RESULTS
Total 1117 school aged children were
included for this study. Out of this 557
(49.9%) were males and 560 (50.1%) were
females. Only 753 (67.4%) parents gave
consent for blood sampling. Prevalence of
anemia was 168 (22.3%), with no
statistically significant difference between
males and females (P>0.05).Table 1 shows
that frequent eating of red meat reduced
the risk of anemia (OR=0.8), however this
risk reduction was not statistically
significant (CI=0.56 -1.14). Frequent
drinking of cola or sour milk (Laban) with
lunch meal significantly increased the risk
of anemia (OR=1.52, 1.06-2.16 and
OR=1.55, 1.07-2.25 respectively).
Blood related disorders in the child and/or
his family are shown in Table 2. Family
history of hereditary blood disorders or
iron deficiency anemia increased the risk
of anemia in school aged children
(OR=5.48, 1.02-31.21 and OR= 3.38,
1.74-6.54 respectively). Personal history
of blood transfusion and IDA were risk
factors for anemia in the studied children
(OR=11.48, 1.06-288.4 and OR=3.11,
1.57-6.17 in order).
Table 3 displays results of multivariate
logistic regression analysis and revealed
that drinking sour milk (Laban) with lunch
and family history of anemia were
independent risk factors for developing
anemia in school aged children in Riyadh
region.
DISCUSSION
The present study revealed that anemia is a
moderate public health problem among
school aged children in Riyadh region
(22.3%). A national study conducted
eleven years ago reported prevalence of
anemia of similar figure of 24.8% among
Saudi children younger than 14 years with
the highest prevalence being in the Eastern
region (41.3%) (13). The former study
used hemoglobin level of 11.2 gm/dl as a
threshold for anemia which is lower than
the current WHO (11.5 gm/dl) used in the
current study. Also another study in
Jeddah that included 2000 school children
found that 20.5% of them were anemic
(14). The low prevalence of anemia in
North America may be attributed to the
fortification of iron in most of the
available foods there (15).
Al-Othaimeen et al., conducted a study
among 1210 school girls aged 7-14 years
old in Riyadh city and found that 30% had
hemoglobin level <11 gm/dl. Prevalence
rate of the latter study is higher than the
present work (22.2%) (16), this may be
attributed to the inclusion of girls aged 12-
14 years where most of them were
menstruating. Higher rate was also
reported by Rasheed et al., who
investigated 285 primary school girls in
urban area of Al-Khober in the Eastern
province of Saudi Arabia. They found that
26.4% of girls had anemia (hemoglobin
level <11 gm/dl) (17).
Haemoglobin level was used in this study
as an indicator for Iron status in the body.
Kihli-Kumar recommended the assessment
of hemoglobin as the most common
method of assessing anemia (3, 18).
School children were chosen for the study
as rapid growth in school aged children
increases the demand for iron (19) and
anemia is estimated to affect one half of
school age children in developing
countries (20). The school years are an
opportune time to intervene, and
interventions must be based on sound
epidemiologic understanding of the
problem in this age group (2). It has been
suggested that when anemia prevalence is
20%, iron deficiency exists in 50% of the
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population and when anemia prevalence is
greater than 40% the entire population
suffers from some degree of iron
deficiency.
Several dietary factors can influence iron
absorption. Enhancing factors are ascorbic
acid which is found in citric fruits, meat,
fish and poultry. Inhibitory factors include
tannic acid which is found in tea, coffee
and chocolate, and calcium which is
present in milk and dairy products (21,
22). Cross sectional surveys revealed that
the frequency of meat and dairy
consumption determines hemoglobin
values in school age children (23).
In the
present work meat was a protective factor
in bivariate analysis (OR=0.8). Sour milk
called Laban by the Saudi public was
approved to be a risk factor for anemia in
school aged children (OR=1.48). Its high
contents of calcium may explain this
finding particularly as it is used during or
just after lunch meal which is the main
meal of the Saudi population, thus
inhibiting the absorption of iron.
Drinking tea or coffee in the current work
did not influence the prevalence of anemia
(p>0.05). On the same line Temme and
Van Hoydonck conducted a PubMed
search and reported that tea consumption
does not influence iron status in Western
countries in which people have adequate
iron stores. Only in populations with
marginal iron status there seems to be a
negative association between tea
consumption and iron status (24). Poulter
J and Nelson M reviewed 35 references
investigating the impact of drinking tea on
iron status and reported that according to
the available evidence restriction of
drinking tea is advised only to groups at
risk of iron deficiency. It is advised to
drink tea between meals or to wait at least
one hour after eating before drinking tea
(25).
Presence of positive family history of
anemia is an independent risk factor for
occurrence of anemia in school aged
children in the current work (OR=2.42,
1.18-4.94). This may be due to common
exposure to iron deficient diets by the
family or presence of hereditary blood
diseases within the family. In addition, this
diagnosis of IDA in Saudi Arabia is more
complicated with the high incidence of
hemoglobin disorders such as sickle cell
and thalassemia traits (26, 27).
CONCLUSION
Anemia is a moderate public health
problem among school aged children in
Riyadh region. Iron fortification is highly
recommended. Health education programs
should be conducted in schools to
highlight the risk factors of anemia
particularly drinking sour milk with meals.
Children with family history of anemia
should be screened for anemia and treated
if indicated.
Conflicts of Interest
The authors indicated no potential or
actual conflict of interest pertaining to this
study.
Authors' Contributions
All authors made full contribution to data
acquisition, interpretation of results,
drafting and revising the final manuscript.
All authors read and approved the final
manuscript.
Limitation of the Study
The limitations of the present study are the
relatively low response rate due to fear of
children and their parents from blood
extraction, and the lack of classification of
nutritional anemia into IDA and non-iron
deficiency anemia as ferritin level
estimation was not done.
Acknowledgements
We would like to thank all nurses,
technicians and physicians for their kind
support in data collection and laboratory
analysis. We also thank the children and
their parents for contribution in the study.
This study was funded by Saudi Ministry
of Health.
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Table 1: Dietary factors and anemia in school children, Riyadh, Saudi Arabia
Food Intake Status Odds
Ratio
95% Conf.
Interval
P
Anemic healthy
Frequent eating of
red meat
Yes
No
93
83
341
243
0.8 0.56 -1.14 0.19
Frequent eating of
vegetable
Yes
No
115
60
358
223
1.19 0.83 – 1.73 0.33
Frequent drinking
of Tea & coffee
Yes
No
34
141
145
435
0.72 0.47 – 1.12 0.13
Frequent drinking
of Cola
Yes
No
86
86
229
347
1.52 1.06 – 2.16 0.017
Frequent drinking
of sour milk
(Laban) with
lunch
Yes
No
115
57
328
252
1.55 1.07 – 2.25 0.016
Frequent drinking
of juice
Yes
No
49
123
133
442
1.32 0.89 – 1.98 0.15
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Table 2: Blood related disorders and anemia in school children, Riyadh, Saudi Arabia
Health
problem
presence Status Odds
Ratio
95% Conf.
Interval
P
Anemic Healthy
Personal
history of
hereditary
blood
disorder
Yes
No
8
143
14
558
2.23 0.84 – 5.8 0.10
Family
history of
hereditary
blood
disorder
Yes
No
4
128
3
526
5.48 1.02 – 31.21 0.01
History of
blood
transfusion
Yes
No
3
151
1
578
11.48 1.06 – 288.4 0.008
Current
blood
disorder
Yes
No
6
156
2
592
11.38 2.00 – 115.9 0.002
Past history
of IDA
Yes
No
18
131
24
544
3.11 1.57 – 6.17 0.0005
Family
history of
IDA
Yes
No
20
129
25
545
3.38 1.74 – 6.54 0.00005
Table 3: Results of logistic regression analysis
Variable Adjusted
Odds Ratio
95% Conf. Interval P
Drinking cola with lunch 1.36 0.94 – 1.99 0.108
Drinking sour milk ( laban)
with lunch
1.48 1.00 - 2.19 0.050
Family history of anemia 2.42 1.18 – 4.94 0.015
NB. The model explains 79.2% of occurrence of anemia.
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Dietary Practice and Physical Activity in Children with Down Syndrome
and Their Siblings in Saudi Arabia
Badreldin A Mohamed1*
, Adel A Alhamdan1, Manal M Samarkandy
2
1Department of Community Health Sciences, College of Applied Medical Sciences, King
Saud University, Riyadh, Saudi Arabia. 2 Manal M. Samarkandy, Senior Dietitian, Sultan Bin
Abdulaziz Humanitarian City, Riyadh, Kingdom of Saudi Arabia.
*Corresponding Author: Dr. Badreldin A Mohamed. Email: [email protected]
ABSTRACT
Background: Feeding difficulties and inappropriate nutrition are common problems among
children with Down Syndrome (DS). Objective: The aim of this study is to investigate the
dietary practice and physical activity among children with DS. Methodology: The study
groups were pre-pubertal DS boys and girls, aged 5 to 12 years clinically and cytogenetically
proven to be suffering from DS. Healthy siblings, closest in age to the DS children were used
as a control group. Breast feeding, eating difficulties, fast food intake, and physical activity
were measured for both groups. Results: During infancy period, 36.4% of the DS children
were bottle fed, compared to only 5.5% of the normal siblings. Nearly half of the breast-fed
DS children were fed for duration of less than 6 months. The percentage of the DS children
experiencing dietary difficulties is significantly higher compared to the siblings. Concerning
physical activity, 73.1% of DS children did not exercise as compared to 44.2% of the control
siblings. Conclusion: Controlling feeding practices and encouraging Down syndrome
children to participate in physical activity either through support from parents or through
designing special programs and facilities and are two avenues that can be used for obesity
prevention.
Key words: Down Syndrome, Feeding Difficulties, Obesity.
Mohamed BA, Alhamdan AA, Samarkandy MM. Dietary Practice and Physical Activity in
Children with Down Syndrome and their Siblings in Saudi Arabia. Canad J Clin Nutr 2013;
1(1): 35-46.
INTRODUCTION
Down‘s syndrome (DS) is characterized by
mental and growth retardation associated
with genetic anomalies. DS is affecting
approximately 1 in 800 live births without
predilection for race or socioeconomic
class (1). In Kingdom of Saudi Arabia
(KSA), the incidence of DS births is
around 1.8 for every 1000 babies born
alive (2). In Arab countries it ranges from
1.93–3.5/1000 live birth (2). Overall, the
incidence worldwide ranges from 1.25–
1.67/1000 live birth (3). Feeding
difficulties and inappropriate nutrition are
common problems among children with
Down‘s syndrome (4, 5). Little is known
about the causes of feeding problems in
infants with DS. These may be associated
with low muscle tone, which also affects
the strength, mobility and range of motion
of the oral muscles and can result in weak
sucking, swallowing, lip closure, and
tongue protrusion, and gastroesophageal
reflux (5, 6). The combination of reduced
oral space and low muscle tone can result
in tongue protrusion (5). True
macroglossia can sometimes occur in
infants with Down syndrome, which
results in additional problems with
breathing, chewing and later on with
speech development. Narrowed nasal
passages and increased respiratory
secretions interfere with nasal breathing
and oral feeding in infants with Down
syndrome. As a result of the early feeding
problems in infants with Down syndrome,
and the emotional responses of parents to
Page 35-46
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the often unexpected diagnosis of Down
syndrome, early mother-infant attachment
may be disrupted and breast feeding is
often not possible (7).
Feeding disorders in children with Down
syndrome may have important long-term
health consequences, including growth
deficits and decreased performance on
tests of academic and cognitive
performance. Some studies estimate that
up to 80% of children with DS have
difficulties related to food or feeding (7-9).
The attainment of feeding milestones in
DS is also delayed by 10–35% depending
on the age of assessment (10).
Furthermore, a delay in the age of
achievement of motor milestones and the
poor gross motor performance of children
with DS may limit physical activity during
infancy and childhood and may further
decrease physical activity levels during
childhood (4, 11, 12). The feeding practice
and physical activity for children with DS
is not well defined particularly in Saudi
Arabia. To the best of our knowledge this
is the first study to assess the feeding
problems and physical activity in DS
children of Saudi Arabia.
SUJECTS AND METHODS
Al-Nahda Schools for DS and the DS
Charitable Association are the only two
schools for DS children in Riyadh city,
Saudi Arabia. The DS children in these
schools are distributed in class rooms
according to their chronological ages. The
approval to conduct the study was
obtained from the school board of these
two schools. One hundred and eight
families were enrolled in the study.
Consent of all families was obtained, and
the study objective was fully explained to
them. The study group included pre
pubertal DS boys and girls (n=108)
clinically and/or cytogenetically proven to
be ailing with DS. Healthy siblings, closest
in age to the DS children were used as a
control group (n =113). Some of the
siblings were twins. The reason for using
siblings as controls in the study was to
ensure quite similar environmental
backgrounds. All the DS children included
in our samples were living with their
parents and had at least one sibling; all
siblings of DS children were living in the
same house. The study was conducted
during the period of February-May 2011.
Thirteen illiterate mothers and 10 mothers
with elementary education that were not
able to fill the questionnaire and were
personally interviewed by the observer in
the school class rooms. The history of
infant feeding among DS children and the
siblings was obtained including type of
feeding and duration of breast feeding.
Nutrition feeding problems were recorded
for the DS children and the siblings, such
as difficulties in using utensils, chewing
and swallowing difficulties, food rejection
and refusal. Physical activity status for the
DS children and matched siblings were
collected from their parents. Food
frequency questionnaire was used to
evaluate dietary habits. The parents were
interviewed for daily details of food
consumed by their children.
Data entry and analysis was carried out
using SPSS 18. Results were presented in
number (n) and in percentage (%), and
were presented as mean values ± standard
deviation (SD). For testing statistical
difference between the DS children and
siblings, and Chi-Square test were used. P-
value less than 0.05 (P<0.05) was
considered statistically significant.
RESULTS
Table 1 illustrates that the mean age is
comparable between DS children and their
siblings. DS children were significantly
shorter and had a higher BMI than their
siblings. The DS children weight less than
their siblings, but the difference did not
reach the significant level. Table 2 shows
history of infant feeding of DS children
and their siblings. The main interesting
results were that during infancy period,
36.4% of DS children were bottle fed
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compared to only 5.5% of siblings. Almost
half of the breast-fed DS children were fed
for duration of less than 6 months
compared to 36.5% of the breast-fed
siblings. The percentage of DS cases that
were not encouraged by the hospital to be
breast fed (35.4%) was greater than the
siblings (15.8%). The delay in introducing
solid foods was markedly higher in the DS
children compared to the siblings.
The percentage of DS children
experiencing difficulties in using utensils
and chewing/swallowing was almost ten
times higher than the control siblings
(Table 3). The percentage of DS children
who experienced food rejection was
almost twice the percentage of those
siblings and the percentage of DS children
who experienced vomiting after meals was
almost three times higher than the siblings.
About one third of DS children did not eat
with their families as compared to only
15% of siblings.
Table 4 represents, the percentage of
mothers preparing meals for DS children
was lower compared to the siblings, but
the difference did not reach the significant
level. The frequency of eating fast food
was lower in the DS compared to the
siblings. The barrier for conducting
physical activity among DS children were
(dislike of parents to physical activity,
weather condition, lack of facilities or
space, lack of time, and embarrassment),
and it was reported that 73% of the DS
children did not exercise as compared to
44.2% of siblings, and in the group of
children who exercised, only 13.8% of the
DS children spent more than 30 minutes in
exercising as compared to 79.4% of
siblings.
Table 5 shows the frequency of
consumption of some food items for the
DS children and siblings. The main
interesting result was that the weekly
consumption of meat was lower in the DS
cases as compared with the siblings. Also
fruits and vegetables consumption was
lower in the DS children compared with
the siblings. In respect to the consumption
of dairy products, the consumption of
whole milk was lower in the DS children
compared to the siblings, while the
consumption of low fat or skimmed milk
was higher in the DS children as compared
with the siblings. No significant difference
was detected between DS children and
their siblings for 1-3 times consumption
for all items (χ2= 7.66, P = 0.57), for 4-6
times consumption (χ2= 31.83, P = 0.0002)
and rarely (χ2= 67.09, P = 0.0001), a
significant difference was observed
between DS children and their siblings.
DISCUSSION
Improved medical care has played a role in
improving health quality and longevity of
DS children. In USA, the average age
mortality has increased from 25 years in
1983 to 49 years in 1997, with
approximately 44% surviving to age 60
years and 13% to age 68 years (13, 14).
Longer life expectancy imposes the need
to address dietary intake and feeding
difficulties faced by DS cases. In this
study, a high rate of bottle feeding in
infancy was observed with 36.4% of DS
children bottle fed compared to only 5.5%
of the siblings. This may be attributed to
the lack of breast feeding encouragement
from hospitals which may have led to the
result that DS children being more
frequently bottle fed as compared to the
siblings. Furthermore, poorer motor
function of the mouth and generalized
muscular hypotonia can contribute to less
breastfeeding (6, 15, 16). Decreased
muscle tone is associated with problems
starting sucking, a poor lip seal, slow
sucking and swallowing reflex and
uncoordinated suck/swallow/breathing
pattern. These conditions may contribute
to coughing, choking, aspiration, milk
escaping through the nose which may
result in incomplete feeding (17). Our
results showed that DS children are breast
fed on average in a less duration compared
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to the siblings. Breast feeding is initiated
in less than 50 % of newborns with DS
(18). DS infants have poor sucking ability
which makes establishment of breast
feeding more difficult, since they have
muscles that are poorly developed, thus
making it difficult to position the infant
during breast feeding, which will require
longer breastfeeding sessions. DS children
may also have problems in their mouth,
such as a too-large tongue or a flat palate,
which can affect the depth of latch on the
breasts (16, 18), this poor sucking will
discourage the mother from breastfeeding
as it takes a great deal of patience to teach
the baby to suck properly (and strongly) to
obtain a milk ejection reflex and to
stimulate the milk (6). In our study, Down
syndrome babies were less frequently
breastfed (64.6%) compared with their
siblings (84.2%) during hospital
admission. Previous studies reported that
the main reasons cited by mothers were
infants‘ illness, frustration and depression.
It was shown that the feeling of
depression, grief, guilt or disbelieve can
make a new mother question whether she
should keep the baby or let alone nurse
him (19).
DS children in this study were introduced
to solid foods at a much later stage
compared to the siblings, which is in
agreement with other findings (8, 9).
Feeding difficulties like food rejection,
chewing and swallowing are common in
children with DS (22-24). In our study,
more than half of DS children were having
difficulties in using utensils, 33% had
chewing problems and almost three fourth
of them had some kind of food refusal.
Some authors attributed this feeding
difficulty to low muscle tone, reduced oral
space, presence of heart defects, slow
sucking reflex, slow swallowing reflex,
low birth weight, choking, and narrowed
nasal passage and increased respiratory
secretion (2,4,5,9). It was reported that
feeding problems in infants with Down
syndrome change as they grow older (10).
The infants may experience problems with
transition from breast/bottle feeding to cup
feeding, and from liquids to solids which
can result in inadequate lip closure, poor
chewing ability and choking. Regarding
food frequency consumption, the main
interesting results were that the daily
consumption of meat like lamb, chicken
and fish was lower in the DS children as
compared to the siblings, and fruits, juices
and vegetable daily consumption was
lower in DS children compared to the
siblings. This is in agreement with
Hopman et al., who reported that children
with Down syndrome consume a
substantial amount of products that
requires less mastication (22). It was
suggested that fruits and vegetables are
rejected or not offered to DS children (10).
The present study showed that some
parents were isolating their DS children
from other family members, as it was
found that the percentage of DS children
not sharing meals with the family was
significantly higher as compared with their
siblings. Furthermore, the percentage of
the mothers preparing meals for their DS
children was lower compared to siblings.
Several studies reported that DS mothers
feel anxious, frightened, guilty, angry and
in rare cases, suicidal (23 -26). Other
major observation seen in DS children is
less time exercising. International research
has shown that one of the major influences
on children with DS is parental
involvement and support in physical
activity (27, 28). Previous studies on
physical activity in Saudi Arabia showed
that inactivity prevalence was 97.3% in
Riyadh, with about 70% of preschool
children, about 60% of elementary and
96.1% of married being physically inactive
(29,30). Poor weather has been identified
as an environmental barrier to being
physically active. In Riyadh the weather is
a typical desert climate, being very hot in
summer and very cold in winter, beside
apartments are small and inadequate areas
are available to play at.
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Work leaves no time for physical activity.
Parents come late from work, work double
shifts or have social and family obligations
beside in Saudi culture; women are not
allowed to go out unless she is
accompanied by the husband or a very
close relative. A very strong barrier is the
presence of grief, even shame or
embarrassment for having a DS child (25,
28).
CONCLUSION
The presence of a sibling as a control
group to the DS children decreases the
potential for confounding by
environmental and genetic factors, and
also decreases the recruitment bias of
using healthy controls. The results
suggest that parents can play a key role
in the participation of children with DS
in physical activity as this may be one
avenue for obesity prevention. Children
with DS need specially designed
program and facilities. Another avenue
is controlling feeding practice. Mothers
of DS children should be trained and
given advice to make decision regarding
feeding options. Attention should be
given to the age at which solid food is
introduced as late introduction can be
harmful to oral-motor development and
may be responsible for developing
malnutrition.
Conflicts of Interest
The authors indicated no potential or
actual conflict of interest pertaining to this
study.
Authors' Contributions
All authors made full contribution to data
acquisition, interpretation of results,
drafting and revising the final manuscript.
All authors read and approved the final
manuscript.
Study Limitations
Sample size number and the shortage in
records regarding medical condition status
for DS children were the major limitations.
Acknowledgements
The authors deeply extended their
appreciation to the parents of the enrolled
children for dedicated effort to complete
this study.
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Table 1: Age and anthropometric assessment of study subjects
Parameter
DS children
Mean ± SD
Siblings
Mean ± SD
P- value
Age (years)
Boys 8.2 ± 1.7 8.9 ± 1.4 0.115
Girls 7.9 ± 1.5 8.1 ± 1.6 0.523
Weight (kg)
Boys 22.2 ± 7.7 26.1 ± 7.8 0.054
Girls 20.4 ± 6.3 21.5 ± 4.9 0.921
Height (cm)
Boys 108 ± 9.9 124 ±12.9 0.001
Girls 105.75 ± 8.3 115.1 ± 10.1 0.001
BMI (kg/m2)
Boys
Girls
19.1 ± 4.1
18.5 ± 3.1
16.9 ± 3.4
16.3 ± 1.9
0.013
0.039
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Table 2: Prenatal nutrition of study subjects
Prenatal Nutrition DS Children Siblings
P - Value n % n %
History of infant feeding
Only breast feeding
Breast fed + Formula milk
Bottle feeding
23 21.5 42 38.2
0.0001 45 42.1 62 56.4
39 36.4 6 5.5
Duration of breast feeding
Less than 6 months
6 – 12 months
More than 12 months
33 48.5 38 36.5
0.02 22 32.4 33 31.7
13 19.1 33 31.7
Hospital encouragement of breast feeding
No
Yes
35 35.4 16 15.8 0.002
64 64.6 85 84.2
Age of introduction of solid food
4 months
5 months
6 months
7 months or more
11 11.5 56 53.3
0.0001 25 26 34 32.4
19 19.8 12 11.4
41 42.7 3 2.9
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Table 3: Difficulties associated with eating meals and food refusal of study subjects
Eating Meals Practice
DS Children Siblings
P –Value
n % n %
Difficulties in using Utensils
No 62 57.4 108 95.6 0.0001
Yes 46 42.6 5 4.4
Vomiting after meals
No 81 75 104 92 0.0006
Yes 27 25 9 8
Chewing/swallowing difficulties
No 72 67 110 97.3 0.0001
Yes 36 33 3 2.7
Food rejection
No 30 28 73 65
0.0001
Yes 74 72 40 35
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Table 4: Trends of eating and physical activity of the study subjects
Trends of Eating and Physical
Activity DS Children Siblings
P-Value
n % n %
Eating meals with the family
0.0005 No 38 35 17 15
Yes 70 64.8 96 85
Meal preparation
0.275 Mothers 65 60 76 67
Others 43 40 37 33
Times/week of eating fast food
1 64 59.3 51 45.1 0.006
≥ 2 44 40.7 62 54.9
Physical exercise
No 79 73.1 50 44.2 0.001
Yes 29 26.9 63 55.8
Duration (minutes)
< 30 25 86.2 13 20.6
0.001 ≥ 30 4 13.8 50 79.4
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Table 5: Weekly consumption of selected food items of study subjects
Food Items
Frequency of consumption
DS Siblings
1 - 3 4 - 6 Rarely 1 - 3 4 - 6 Rarely
Meat 55 (51) 2(1.8) 51 (47.2) 70 (61.9) 33(29.2) 10(0.09)
Chicken 93 (86.1) 13 (12) 13 (12) 2 (1.9) 81 (71.7) 15 (13.3) 1 (0.9)
Fish 93 (86.1) 1 (0.9 14 (13) 94 (83.2) 1 (0.9) 8 (7.1)
Egg 92 (85.2) 11 (10.2) 5 (4.6) 95 (84.1) 15 (13.3) 3 (2.7)
Whole milk 62 (57.4) 15 (13.9) 31 (28.7) 75 (66.4) 31 (27.4) 7 (6.2)
Low fat milk/skimmed 47 (43.6) 44 (40.7) 17 (15.7) 31 (27.4) 32 (28.3) 50 (44.2)
Cheese 86 (79.6) 19 (17.6) 3 (2.8) 94 (83.2) 18 (15.9) 1 (0.9)
Rice/macaroni 96 (88.9) 11 (10.2) 1 (0.9) 95 (84.1) 17 (15) 1 (0.9)
Fresh vegetables 68 (62.9) 18 (16.7) 22 (20.4) 73 (64.6) 31 (27.4) 9 (8)
Fresh fruits 75 (69.5) 16(14.8) 17 (15.7) 81 (71.7) 32 (28.3) 0
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Generation of Insulin Producing Cells using Mesenchymal Stem Cells
Derived from Bone Marrow of New-Zealand White Rabbits
Abdelaziz A. Mohamed
1*, Manal M. Saad
1, Sherif H. Abdeen
2, Mona K. Marei
1
1Tissue Engineering Laboratories, Faculty of Dentistry, Alexandria University, Egypt.
2Department of Zoology, Faculty of Science, Mansoura University, Egypt.
*Corresponding Author: Dr. Abdelaziz Mohamed. Email: [email protected]
ABSTRACT
Background: The utilization of stem cell trans-differentiation into insulin-producing
cells (IPCs) would provide potential promising therapy for diabetes mellitus (DM).
Objective: The study was aimed to investigate the differentiation potential of rabbit‘s
bone marrow-derived cells into insulin producing cells. Methods: Bone marrow-derived
mesenchymal stem cells (MSCs) were obtained from three New-Zealand male white
rabbits and propagated in a primary culture for 14 days in low glucose Dulbecco's
Modified Eagle's Medium (DMEM), harvested and subjected to another three passages
encompassing 21 days. After that, MSCs were functionally defined by their ability to
differentiate into osteoblasts. This was achieved by incubation with the DMEM
containing 10-7
M dexamethasone, 10 mM β-glycerophosphate and 50 µl/ml of ascorbic
acid. Osteogenic differentiation was followed up at days 2, 4, 7 and 9 by staining cells
with alizarin red S and vonKossa. Results: It was found that the onset of differentiation
was at day 7 and continued at day 9. On the other hand, another patch of MSCs were
induced into insulin-producing cells by two step incubation. The first with high glucose
serum-free DMEM containing 0.5 mmol/L β-mercaptoethanol for three days and the
second follows by incubation with the same medium containing 10 mmol/L
nicotinamideinstead of β-mercaptoethanolfor 18 days. Trans-differentiation was followed
up at days 4, 9, 14 and 21. It was found that the cells have trans-differentiated into
insulin-producing cells starting from day 14 and continued in the subsequent days as
judged by their affinity to stain with diphenylthiocarbazone (dithizone or DTZ) at days
14 and 21. Conclusion: The results would provide some insights of using rabbit's bone
marrow as a source of MSCs with their differentiation potentials. This might help for the
development of a future stem cell therapy for diabetes as well as several other human
diseases.
Key words: Mesenchymal Stem Cells, Insulin-producing Cells, Diabetes Mellitus
Mohamed AA, Saad MM, Abdeen SH, Marei MK. Generation of Insulin Producing Cells
using Mesenchymal Stem Cells Derived from Bone Marrow of New-Zealand White Rabbits.
Canad J Clin Nutr 2013; 1(1): 47-66.
Page 47-66
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INTRODUCTION
Stem cells are undifferentiated cells
which have the ability to renew
themselves through mitotic cell division
and differentiate into a diverse range of
specialized cell types (1). Of these cells,
mesenchymal stem cells (MSCs) have a
large capacity for self-renewal while
maintaining their multipotency. MSCs
display multiline age differentiation
potentials into a variety of cells such as
osteoblasts, adipocytes and chondrocytes
as well as myocytes and possibly
neuron-like cells (2). They are capable
of suppressing immune responses and
offer therapeutic potential for achieving
transplantation tolerance (3).
Accordingly, MSCs have been
considered as an appropriate source for
cell and gene therapy tools for treatment
in a number of injuries, congenital and
degenerative diseases including; spinal
cord injury (4), osteogenesis imperfecta
(5), stroke (6), parkinsonism (7) and
diabetes mellitus (8).
Diabetes mellitus refers to a group of
chronic metabolic diseases characterized
by hyperglycemia due to defects in
insulin secretion, insulin action, or both
(9).Type I, insulin-dependent, diabetes is
the result of autoimmune destruction of
insulin-producing pancreatic β-cells. On
the other hand, in type two or non-
insulin-dependent diabetes, insulin
production is inadequate mainly because
of the peripheral insulin resistance and
subsequent β-cell apoptosis. Diabetes
and its devastating effects, which include
retinopathy, nephropathy, stroke and
heart attack, afflict more than 194
million people worldwide. According to
the World Health Organization, these
numbers will be more than double by
2030 (10, 11).
Survival of patients with insulin-
dependent diabetes relies on recurring
insulin delivery, which does not cure the
disease or prevent diabetes-associated
maladies. Although, Type 2 diabetes can
be managed through a combination of
diet, exercise and prescription of drugs,
almost 30% of the affected people will
require frequent administration of
insulin. Therefore, the development of
therapies to replace insulin regimens is
highly desirable. To that end, islet
transplantation has afforded promising
results, with some patients experiencing
insulin independence for more than 5
years after the initial procedure (12).
Ongoing procedural improvements are
underway to increase the time span of
liberation from insulin and reducing the
side effects due to immunosuppressant.
However, the scarcity of available donor
tissues hinders wide application of
pancreas/islet transplantation. Thus, the
hope stands in finding renewable sources
of islet β-cells such as pancreatic β-cell
lines, embryonic stem cells (ESCs),
adult progenitor cells (APCs),
regenerating native islet cells (13) and
MSCs (14).
From all of the previously mentioned
literatures, it was therefore of interest to
carry out experiments investigating the
differentiation potential of rabbit's bone
marrow-derived stem cells into insulin-
producing cells as a first step for their
future use in islet transplantation
purposes.
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MATERIALS AND METHODS
Abbreviations
The following abbreviations are used;
Adult progenitor cells (APCs), deionized
distilled water (ddH2O), diabetes
mellitus (DM), dimethyl sulfoxide
(DMSO), diphenylthiocarbazone
(dithizone or DTZ), Dulbecco's
Modified Eagle's Medium (DMEM),
embryonic stem cells (ESCs), fetal
bovine serum (FBS), hours (hr), insulin I
and II, glucose transporter-2 (Glut-2),
insulin-producing cells (IPCs), intra-
muscular (IM), mesenchymal stem cells
(MSCs), minutes (min), mononuclear
cells (MNCs), pancreatic duodenal
homeobox-1 (Pdx-1) and phosphate
buffer saline (PBS).
Animal work
All animal experiments were performed
according to the guidelines of the
National Institutes of Health (NIH) for
laboratory animal use (15). All
procedures applied in this study were of
no pain category (category C).
Aspiration bone marrow-derived cells
Bone marrow aspiration was performed
according to the method of Horan et al.
(16).Three male New-Zealand white
rabbits (obtained from the research farm,
Faculty of Agriculture, Alexandria
University) were anesthetized by intra-
muscular (IM) injection with 5 mg/kg
xylazine as a preanaesthetic medication.
After 5 min, animals were intra-
muscularly injected with 30 mg/kg
ketamine-HCl. All surgical procedures
were performed in a biological safety
cabinet (Nuaire biological safety class II,
T-Telestar, Spain) with surgery room
disinfected overnight by UV light. The
fur of the thigh was shaved and skin
disinfected. Skin incision was made to
expose the rabbit's femur. A hole was
drilled in the femur using a surgical
rose-head bur. A sterile plastic aspiration
needle containing 8 µl heparin/ml
sample was used. The marrow sample
was kept in a sterile package till
transferred to the cell culture laboratory.
The surgical wound was sutured and the
rabbit was taken back to the animal care
unit. All animals tolerated the surgical
procedures for bone marrow aspiration.
No significant changes in body weight,
no postoperative infections were
observed.
Cultivation media
All buffers, media and their supplements
were purchased from BioWhittkers®
Lonza, Verviers, Belgium unless
otherwise noted. These media included:
Basal medium
[Low glucose Dulbecco's Modified
Eagle's Medium (DMEM) with 4.5
mmol glucose/L and supplemented
with10% (v/v) fetal bovine serum
(FBS),1% L-glutamine,10 IU/ml
penicillin/streptomycin and 20 mM
HEPES]. Ostogenic differentiation
medium [Low glucose DMEM with4.5
mmol glucose/L and supplemented with
10% FBS, 1% L-glutamine, 1%
penicillin/streptomycin, 20 mM
HEPES,10 mM β-
glycerophosphate(Sigma, USA),50
µg/ml ascorbic acid (Sigma, USA)
and10-7
M dexamethasone (Sigma,
USA)].
First step trans-differentiation medium:
Serum-free high glucose DMEM with 25
mmol glucose/L and supplemented with
20 mM HEPES,1% L-glutamine,1%
penicillin/streptomycin and 0.5 mmol/L
β-mercaptoethanol (Sigma Aldrich Co.,
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Germany). Second step trans-
differentiation medium: Serum-freehigh
glucose DMEM with 25 mmol glucose/L
and supplemented with 20 mM HEPES
buffer,1% L-glutamine,1%
penicillin/streptomycin and10 mmol/L
nicotinamide (Sigma Aldrich Co.,
Germany).
Media preparation
The powder supplements of the media
were dissolved in deionized distilled
water (ddH2O) obtained from Barnstead
water deionization system (Barnstead-
Thermolyne, USA). In case of using
another dissolvent, it was sterilized by
membrane filtration through 0.22 μm
microbiological filter system (TPP-
Europe, Switzerland). After adding the
supplements, the pH of the medium was
adjusted at 7 and medium was then
sterilized by membrane filtration. A
sterility test was performed for 3 days at
37C. Medium contamination was
detected depending on the color change
of the phenol red, which gives a yellow-
orange color through the change in pH to
acidic value as a function of the
microbial growth. A sample was also
examined microscopically after passing
the sterility test. All media were stored at
4C until being used.
Isolation of rabbit's bone marrow-
derived mesenchymal stem cells
The method of Sun et al., (17) was used
with minor modifications. Bone marrow
samples of about 1.5 to 2 ml were
aspirated from each rabbit and
transferred to the cell culture laboratory
in a sterile package. Inside a biological
safety cabinet class II (Thermo electron
corporation, Germany) samples were
diluted with a double volume of the
basal medium, collected by
centrifugation at 390 g for 7 min at room
temperature and washed twice with
phosphate buffer saline, pH 7.4 (0.0067
M PBS without calcium and
magnesium).
The samples which have clots or bone
marrow tissue were filtered through 200
µm filter (Sigma Aldrich Co., Germany)
using PBS for washing and liberation of
the trapped cells in the tissue. Bone
marrow mononuclear cells (MNCs) were
then collected by centrifugation, washed
twice with the basal medium and
resuspended in one ml of the same basal
medium, counted (10 l of cells + 10 µl
of 0.4% methyl violet + 180 µl glacial
acetic acid) and tested for viability using
hemocytometer. MNCs were then
seeded in polystyrene coated T-flasks at
a density of 5.5 x 106cells/cm
2and
incubated at 37oC, 5% Co2 and 95%
humidity. Except for the first four days
which were required for cell adhesion,
the cells were fed twice a week by
washing with pre-wormed PBS then
adding fresh medium. The cells were
allowed to proliferate till reaching the
100% confluence in 14 days (the
primary culture).
Only the cells which attach to the
polystyrene surface were allowed to
grow while suspended ones were
discarded during washing. Cell
morphology was followed up daily using
a phase contrast inverted microscope
(NIKON-Japan) using (SIS) software
system for capturing and analysis of
images. All cultures were independently
repeated for three times.
Confluent monolayer of cells were
harvested by trypsinization using
trypsin/EDTA buffered solution 6 ml of
0.5% trypsin, 200 mg/L versene EDTA
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(Gibco/Invitrogen, Germany) at 37oC for
10 min. The suspended cells were
rapidly neutralized with a double volume
of the basal medium to stop the action of
trypsin. The cells were then collected by
centrifugation, washed twice with pre-
wormed PBS, counted and tested for
viability. The cells were then reseeded in
fresh medium at a density of 1400 cells
per cm2 in a new cell culture T-flasks.
The cells were allowed to grow for three
subsequent passages of 7 days each.
After passage three, MSCs were
subjected to osteogenic differentiation
and trans-differentiation into insulin-
producing cells (18).
Estimation of viable cell concentration
Viable cell concentration was
determined using trypan blue exclusion
method (19). Ten l of cells were diluted
to 1:2 in 0.4% trypan blue stain. The
hydrophilic trypan blue diffuses through
cell membrane of the dead cells. Hence,
the viable cells appear bright while the
unviable ones appear blue. Cell viability
was determined according to the
following equation: Cell viability =
Total number of viable cells/Total cell
count ×100
Cryopreservation of bone marrow-
derived cells
At the end of each culture, a separate
patch of cells were trypsinized and
collected for cryopreservation (20). The
cells were cryopreserved at a density of
1×106 cells/ml in freezing medium; basal
medium with 25% FBS and 5% v/v
dimethyl sulfoxide (DMSO). The cells
were then stored at -156ºC in cryo-vials
(Nunc, Wiesbaden, Germany) in the
vapor phase of a liquid nitrogen locator
(Cryo Biological Storage System
Locator 4 plus thermolyne, USA).After
several pilot trials, cryopreservation of
cells was optimized in 5% DMSO as a
cryoprotectant. This protocol yielded the
highest cell viability of 69% upon
revitalization. In order to revitalize the
cells, cryogenic-vials were warmed in a
water bath at 37oC for 2 min and
resuspended rapidly in FBS, centrifuged
for 5 min, washed twice with PBS,
counted, tested for viability and
resuspended in the basal medium.
Counting and testing viability were done
before and after cryopreservation as a
routine procedure.
Characterization of rabbit's bone
marrow-derived MSCs
Rabbit's bone marrow-derived MSCs
were characterized by their induction
into osteogenic differentiation using the
method of Nadriet al.,(21). The cells
were incubated with the osteogenic
differentiation medium at the end of
passage three, especially, when they
have reached 80-90% confluency. The
cultures, in 6-well plates, last for two
weeks with cells fed twice a week. Cell
morphology was followed up daily. To
detect the onset of osteogenic
differentiation, cells were stained with
alizarin red S and von Kossa at days 2,
4, 7 and 9.
Alizarin red S staining of the
differentiated osteoblasts
Calcium depositions of osteoblasts were
detected through its reaction with
alizarin sulphate with scarlet to red color
indicating positive results (22). For
staining, the cells were washed with pre-
warmed PBS, fixed in 4% formaldehyde
for 30 min. The fixative was then
removed and the cells were washed
using distilled water. The alizarin red S
stain pH 4, (2% alizarinsulphonate;
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LobachemieCo., India) was added to
cover all the cells for approximately 5
min at room temperature. The stain was
then discarded and the cells were washed
again with distilled water to remove the
excess of stain then air dried. Red
patches in the tested cultures were
examined microscopically. Cells
propagated in the basal medium were
included as control cultures.
vonKossa staining of the differentiated
osteoblasts
vonKossa staining was applied to
confirm the osteogenic differentiation of
MSCs (23). Like the staining protocol of
alizarin red S, the cells were washed
with pre-warmed PBS, fixed for with 4%
formaldehyde 30 min and washed with
distilled water. The cells were then
incubated with 1% aqueous silver nitrate
solution (Fisher scientific-UK) in a clear
glass coplin jar placed under a 60-100
watt light bulb for 1 hr. After that, the
cells were carefully washed with
distilled water to eliminate all the debris
of silver nitrate and incubated with 5%
sodium thiosulfate for 5 min. The
solution was discarded and the cells
were washed again with distilled water
and air dried. The progress of the
reaction was followed up visually. The
staining intensity of the brown to black
color was a reference for the presence of
calcium produced by the differentiated
osteoblasts.
Trans-differentiation of MSCs into
insulin-producing cells
At the end of passage three, especially
when MSCs have reached 80-90%
confluence, the cells were induced into
insulin producing cells through two
steps. The first step included the
incubation of the cells with the 1ststep
trans-differentiation medium for three
days. This was followed by a careful
wash with pre-warmed PBS and
incubation with the 2nd
step trans-
differentiation medium for 18 days. All
over the two steps, the cells were fed
twice a week (17).
Staining of insulin-producing cells
with dithizone
Dithizone (DTZ), a zinc-chelating agent,
is known to selectively stain pancreatic β
cells by crimson red color. In the
secretory granule of a mature insulin-
producing cell, every 6 insulin molecules
are coordinated by a Zn atom giving the
red color. For staining, the cells were
incubated with DTZ stain (Lobachemie
Co., India; 10 mg/ml DTZ in DMSO
diluted to 1:100 in the basal medium) for
30 min. The cells were then carefully
washed with pre-wormed PBS for three
times. The staining result was monitored
under an inverted microscope. After 5
hours, the stain was completely
disappeared and the cells were able to
grow successfully (24).
Data analysis
Statistical analyses were performed with
one-way ANOVA followed by SPSS
software version 10 (SPSS Science,
Chicago, IL, USA) analysis. Data (mean
± SD) were considered statistically
significant at a value of P < 0.05.
ANOVAtest was applied to compare the
growth kinetics during the different time
points of the expansion period i.e. the
primary culture and the first two
passages.
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RESULTS
Isolation of bone marrow-derived
mesenchymal stem cells
Isolation of bone marrow-derived MSCs
required a primary culture of 14 days
and three subsequent passages of 21
days. This can be summarized as
follows; bone marrow samples of 1.5 - 2
ml were processed for isolation of
mononuclear cells (MNCs) giving rise to
the mean numbers of cells 3.9×107.
MNCs were then seeded in a primary
culture at a density of 5.5×105 cells/cm
2
giving a yield of 15.6×103 cells/cm
2 at
the end the primary culture (day 14).
Whereas, the number of cells seeded in
passage one and two was 1.4×103
cells/cm2 and the number of cells yielded
was 8.4×103 and 7.2×10
3cells/cm
2 for
passages one and two, respectively. The
cells were allowed to grow in passage
three similar to that of passages one and
two with one difference of being
differentiated or trans-differentiated at
the 100% confluency of passage three
without transfer to a next passage (Table
1). Except for day zero of the primary
culture, comparison of the growth
kinetics of all culture during the
expansion period (the first 5 weeks)
revealed that all cultures were
significantly grow (P < 0.05) starting
from day 2 after reseeding.
In the primary culture, MSCs were
allowed to adhere to the polystyrene
tissue culture flask surface in the first
four days without media change.
Whereas, at day five all of the co-
cultured red blood corpuscles (RBCs)
and cell debris were discarded with the
washing step prior to the media change.
At day five, MSCs showed an
anchorage-dependent growth with their
attachment confirmed via the emergence
of expanded cytoskeleton processes. In
the following days, cells proliferate with
increased cell to cell contact giving rise
to cell colonies. By the end of the
primary culture, at day 14, the cell
proliferation reached about 90%
confluence. Thus, the cells were
trypsinized and reseeded in another
culture (Figure 1).
In passage one and unlike the primary
culture, the cells adhere in few hours and
overnight incubation was sufficient to
make the cells to completely adhere in
day 1. However in day 2, the cells
started to contact with each other. In the
subsequent days, the cells proliferated,
forming colonies and their morphology
changed to the spindle-shape. The cells
reached the 100% confluence in only 7
days (Figure 2). After that, the cells were
collected by trypsinization and reseeded
in a new cell culture flask for another
passage. The number of cells at the end
of passage one was 8.2×103 cells/cm
2
with doubling time of 21.6 hr. The
viability after harvesting was 98%.
However in passage two, the cells
showed similar manner of cell growth.
They showed substratum adherence,
migration, cell-cell contact, colony
formation and confluence. The cell yield
of passage two was 7.2×103 cells/cm
2
and doubling time was 17.63 hr.
Characterization of MSCs by
osteogenic differentiation
Cells were incubated in conditioned
medium of dexamethasone, β-
glycerophosphate and ascorbic acid.
They were following up daily with an
inverted microscope. The cells were
stained with alizarin red S and von
Kossa stains in days 2, 4, 7 and 9 to
determine the onset of osteogenic
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differentiation. All tested cultures
showed positive results starting from day
7. However, controls showed negative
staining all over the four time points.
On the other hand, the morphology of
the cells under the stress of osteogenic
differentiation showed the spindle-shape
in the tested cultures. The controls
showed some aspect of over confluent
appearance. The difference in cell
morphology between the tested and
control cultures during the first few days
till day 7 was not clear but with staining
the discrimination was possible (Figure
3).
Trans-differentiation of MSCs into
insulin-producing cells
MSCs were induced into insulin-
producing cells via two steps. The first
step included the incubation of cells with
high glucose serum-free DMEM
containing β-mercaptoethanol. Upon
trans-differentiation, the cells showed
aggregated colonies. The first step of
differentiation was extended to 3 days
then the second step follows at day 4 by
replacing β-mercaptoethanol with
nicotinamide. At day 4, the colonies
were formed and developed in the
subsequent days. At day 14, the
morphology of cells was changed to the
rounded to oval shape and continued
with this morphology in days 19 and 21
(Figure 4).
The dithizone (DTZ) staining was
applied to test the production of insulin
at different time points including days 4,
9, 14 and 21. While, the tested cultures
showed an affinity to the DTZ stain
(crimson red color) starting from day 14
and continued in day 21, the controls
showed negative results all over the time
of the experiment (Figure 5).
DISCUSSION Mesenchymal stem cells are
multipotentstem cells that can
differentiate into a variety of cell types
(25). Bone marrow-derived MSCs, also
named colony-forming fibroblastic cells
(26), marrow stromal stem cells (27) and
mesenchymal progenitor cells (17), have
been isolated and characterized from
many species including: rats, cats, dogs,
baboons and rhesus monkeys, rabbits,
pigs, goats and sheeps (21). MSCs have
many advantages including: the ease of
isolation, the extensive multi-lineage
differentiation potential (18, 28), the
hypo-immunogenic property which
modulate the lymphocytic functions, the
possibility of allogenic transplantation,
the capability of systemic transplantation
for generalized diseases as well as the
local implantation for the local tissue
defects. MSCs can also be used as a
vehicle for genes in gene therapy
protocols or to generate transplantable
tissues and organs in tissue engineering
protocols. Accordingly, MSCs are
among the first stem cell types to be
introduced in the clinic and several
encouraging clinical trials are under way
to study the efficacy and long-term
safety of therapeutics based on MSCs
(29, 30).
Several recent studies have demonstrated
the feasibility of generating insulin-
producing cells obtained from progenitor
cells of various cellular sources,
including the pancreas, liver and
intestinal epithelium, as well as, the
pluripotent embryonic stem cells of
mouse and human origin. However, even
with the conceptual advances offered by
these findings, some obstacles, such as
the immune rejection and autoimmunity
against newly formed cells derived from
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pancreatic stem cells, still remain.
Despite their promising potential, it may
also prove difficult to obtain enough
autologous adult stem cells from these
organs. To overcome these limitations,
the possibility of using rabbit bone
marrow derived cells was explored as a
source of insulin-producing cells under
specific in vitro culture conditions. Bone
marrow has been known for years to
represent a safe and abundant source for
large quantities of adult stem cells (13).
In the present study, the source of MSCs
was the bone marrow of New-Zealand
white rabbits. This animal model was
chosen due its availability, the ease of
handling and the ease of choice between
in and out-bred. In case of aspiration of
bone marrow samples from mice or rats,
the animal is often killed before
aspiration. Contrarily, there is no need to
kill the rabbit to aspirate a bone marrow
sample with the advantage of repeating
aspiration within 8 weeks (16).
Several techniques have been developed
to obtain pure cultures of MSCs by the
reduction or elimination of non-MSCs
from bone marrow cultures (31). This
was achieved, in the present study, by
the application of a prolonged expansion
step through which all of the bone
marrow-derived cells pass in a primary
culture for 14 days and three subsequent
passages of 21 days. During this time,
only MSCs, due to their adherent
property, were retained in the culture
while all of the other non-adherent cells
were eliminated by washing during
media change. Moreover, the selective
medium and the polystyrene-coated
tissue culture flasks enhanced the
adhesion properties of the MSCs (21).
Cultures of MSCs is usually
contaminated by different types of non-
MSCs adherent cells like monocytes and
macrophage (32) and as MSCs are more
responsive to trypsin, they were purified
in the present study with an optimized
concentration of trypsin/EDTA (17).
Unlike the primary culture when the
cells needed 14 day to reach the 100%
confluency, the behavior of the cells
changed in the subsequent passages as
they reached the 100% confluency in
only 7 days. This could be owing to the
gradual selection of a learned
mesenchymal cell clones with
proceeding passages (33).
One of the hallmarks of MSCs is their
multi-potency, defined as the ability to
differentiate into several mesenchymal
lineages including; bone, cartilage,
tendon, muscle, marrow stroma and
adipose tissue. Usually, the tri-lineage
differentiation into bone, adipose tissue
and cartilage is taken as a criterion for
the multi-potentiality of these cells (34).
In the current study, MSCs were
differentiated into osteoblasts using a
conditioned medium containing
dexametasone, ascorbic acid and β-
glycerophosphate. The differentiation
was followed up at different time points
including days 2, 4, 7 and 9 through
staining with alizarin red S and von
Kossa stains. The onset of osteogenic
differentiation was at day 7 as judged by
the positive staining affinity of the
calcium depositions of the osteoblasts
with the two stains. These results
confirmed the mesenchymal stem
lineage of the processed cells
(35).
Upon trans-differentiation, the presence
of insulin was evidenced using the
dithizone stain (DTZ) which is a zinc
chelating agent. It does not require prior
fixation and stains insulin molecules
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either in the cells or in the media.DTZ
disappears after 5 hr leaving live cells
able to complete their life cycle (24, 36).
The onset of trans-differentiation was
followed up at different time points
including; days 4, 9, 14 and 21. It was
found that a complete trans-
differentiation was obvious in day 21
while partial trans-differentiation was
observed in day 14. In contrast, there
were no signs of trans-differentiation at
days 4 and 9. Despite DTZ is a vital
stain, the staining intervals were chosen
minimal to decrease the stress applied on
the cells at every staining time.
On the other hand, the microscopic
examination for the trans-differentiation
revealed aggregations like clusters of
insulin producing cells with a diameter
ranging from 100 to 150µm. These
clusters appeared from day 2 of
differentiation and continued to develop
till day 12 where the cells acquired the
spindle-shape. This morphology was
changed to the rounded and oval shapes
at day 14 which may be considered as a
sign for the meso-endodermal
differentiation (37).
There are two key steps in culture
conditions that appear important for
inducing the trans-differentiation of
MSCs cells into insulin-producing islet-
like cells. First, the transfer of cells from
an expansion period in low-glucose
medium to differentiation in high-
glucose medium until certain genes, such
as pancreatic duodenal homeobox-1
(Pdx-1), insulin I and II, glucose
transporter-2 (Glut-2), and islet amyloid
polypeptide, become detectable. Second,
in order for the MSCs cells to become
glucose responsive, further
differentiation and maturation are
required through either in vitro culture
with cell promoting factors, such as
nicotinamide, mercaptoethanol or
transplantation of the cells into diabetic
animals (17, 38). It is well known that
glucose is a growth factor for cells. It
promotes cell replication in vitro and in
vivo and increases insulin content of the
cell (39).
Nicotinamide is a poly (ADP-ribose)
synthetase inhibitor known to
differentiate and increase cell mass in
the cultured human fetal pancreatic cells
(40). It protects the cells from
desensitization induced by the prolonged
exposure to large amounts of glucose. It
have also been demonstrated that
nicotinamide promoted the formation of
fetal porcine islet-like cell clusters and
increased the rates of pro-insulin
biosynthesis in these clusters. Moreover,
the stimulatory effects of nicotinamide
on insulin production and content by
fetal porcine islet-like cell clusters result
from neo-formation of cells through
differentiation (41). Another study
described how nicotinamide-treated
islets derived from the pancreatic
progenitor cell had more insulin and
secreted significantly more insulin than
cultures treated with glucose alone (42).
The present study used the low glucose
medium for cell expansion and for
induction to insulin-producing cells the
medium was changed to high glucose
and this was the first key step in trans-
differentiation. The second key step was
achieved through culturing with the
media containing β-mecaptoethanol then
nicotinamide as cell promoting factors.
In conclusion, the present data suggest
potential uses of MSCs from rabbit's
bone marrow in induction into insulin-
producing cells. This provides hope for a
future development a stem cell therapy
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for diabetes as well as several other
human diseases and injuries.
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Table 1. Bone marrow-derived cell growth during culture
Total number of living cells
(Mean cells / cm2 ± SD) × 10
3
Primary
culture
Day 0 Day 5 Day 7* Day 9* Day 14*
550 ± 88.8 5.1 ± 0.8 7.77 ± 0.76 11.37 ± 1.01 15.67 ±
0.67
Passage
one
Day 0 Day 1 Day 2* Day 4* Day 7*
1.4± 0 1.67 ±
0.21 2.93 ± 0.15 5.23 ± 0.31 8.4 ± 0.2
Passage
two
Day 0 Day 1 Day 2* Day 4* Day 7*
1.4± 0 1.63 ± 0.15 2.3 ± 0.53 4.23 ± 0.31 7.2 ± 0.6
Passage
three
Day 0 Reached the 100% confluency after 7 days.
Characterization by osteogenic differentiation.
Trans-differentiation into insulin-producing cells. 1.4± 0
* Significant cell growth (P < 0.05) compared to the beginning of culture with the
exception of day zero of the primary culture where cultures were compared to the
day 5.
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Figure 1. Photomicrographs of MSCs during the primary culture. Days of follow up
included; (A) day 4, (B) day 5, (C) day 6, (D) day 7, (E) day 9 and (F) day 14. Black
arrow in A refers to a red blood corpuscle and whites arrows in A and B refer to the
adherent MSCs.
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Figure 2. Photomicrographs of MSCs during passage one. Days of follow up
included. (A) Day one and (B) day three, with arrows referring to cell-cell contact.
(C)and (D) are representing the culture at days 4 and 6, respectively. (E) represents the
morphology of the mesenchymal stem cell colony and (F) represents two proliferating
colonies in their way to adhere with arrows representing cell movement.
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Figure 3. Photomicrographs of MSCs at day seven during osteogenic differentiation. (A)and(B) are representing the control and tested cultures, respectively, stained with
alizarin red S. (C) and (D) are representing similar control and tested cultures,
respectively, stained with von Kossa. The orange to red patches in B and the brown to
black patches in D indicate the osteogenic differentiation.
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Figure 4.Photomicrographs of MSCs during the trans-differentiation into insulin-
producing cells. Days of follow up included; (A, B) day 2, (C, D) day 14 and (E, F) day
19. (A, C) are representing the control cultures and (B, D, E, F) are representing the
tested cultures. The control cultures showed an over confluency (arrows). The change in
cell morphology of the tested cultures from the spindle-shape to the oval or rounded-
shape was noted from day 14 and continued to day 19.
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Figure 5. Photomicrographs of dithizone (DTZ) stained MSCs during the trans-
differentiation into insulin-producing cells at day 14 (A, B) and day 21 (C, D). (A, C)
are representing the control cultures and (B, D) are representing the tested cultures. The
control cultures showed an over confluency with negative staining. While, the tested ones
showed the positive staining (crimson red patches).
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The Role of Folate on Colorectal Cancer in the Arabian Gulf
Cooperation Council Countries: An Overview
Mostafa I. Waly,1,4*
, Yahya M. Al-Farsi 2,5
, Allal Ouhtit3
1Department of Food Science and Nutrition, College of Agricultural and Marine Sciences;
2Department of Family Medicine and Public Health,
3Department of Genetics, College of
Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman. 4Department of
Nutrition, High Institute of Public Health, Alexandria University, Egypt. 5Department of
Epidemiology, School of Public Health, Boston University, USA
*Corresponding Author: Dr. Mostafa Waly. Email: [email protected]
ABSTRACT
Driven by the boom of wealth brought by oil discovery and production, the high rate of
urbanization and a steady increase in the per capita income, during the past years, has
improved the socio-economic status of the people in the Arabian Gulf Cooperation
Countries (GCC). This radical economic change has been accompanied by drastic
changes in their lifestyle and food consumption patterns. During the past years, the
regular consumption of traditional foods is being replaced with more Western-style and
ready-made foods. In addition to adopting a sedentary life style in daily life and other
related activities. According to National Health Survies in the GCC countries, high daily
caloric intake, refined carbohydrates and protein were associated with increased risk of non-
communicable diseases including colorectal cancer (CRC). The rate of CRC among GCC
countries is in the rise; however, there is dearth of research exploring it. In particular,
there is lack of research about role of folate on occurrence of CRC despite the recent
flourishing scientific research papers from other parts of the world.
Key words: Colorectal Cancer, Folate, Gulf Cooperation Countries.
Waly MI,Al-Farsi YM, Ouhtit A. The Role of Folate on Colorectal Cancer in the Arabian
Gulf Cooperation Council Countries: An Overview. Canad J Clin Nutr 2013; 1(1): 67-73.
INTRODUCTION
Cancer is considered a leading cause of
death worldwide, accounting for 7.6
million of all deaths from a total of 58
million deaths reported in year 2005 and
the (WHO) estimates that there will be
20 million new cases and 12 million
deaths from cancer alone by the year
2020 (1). Furthermore the WHO
reported that in Western countries, the
rate of colorectal cancer (CRC) has
increased dramatically as compared to
other types of cancers, and this increase
was attributed to westernization in food
choices and dietary pattern as well as
adopting a sedentary lifestyle (1). The
Arabian Gulf Cooperation Council
(GCC) countries include the following
six countries: Oman, United Arab
Page 67-73
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Emirates, Saudi Arabia, Qatar, Bahrain,
and Kuwait (2).
The GCC countries have witnessed rapid
change in many aspects of life during the
last 5 decades because of the boom of
wealth that coincided with the discovery
and production of oil (3). This boom has
transformed these countries from being
traditional nomadic societies to become
affluent metropolitan cities in a very
short time. This rapid change resulted in
an immense effect of the life style of
people, and their social life. This is quite
notable with the proliferation of western
pattern of lifestyle especially in nutrition
and physical inactivity (4). The rapid
socio-economic transition might also
have affected the pattern of cancer in
these countries. It has been quite notable
that incidence rates of cancer have
increased in other countries that went
through rapid industrialization because
of the lifestyle risk factors including
diet, physical activity, obesity which
appears to play an important role in the
etiology of the disease (5).
Recent reports indicate that migrant
populations moved from countries of
low CRC and incidence to the West
adopted the high CRC incidence trend of
the new country (6-8). These
observations suggest that changes in diet
and lifestyle might contribute to the
incidence of CRC, and therefore
research had focused in identifying the
dietary pattern and lifestyle
characteristics that might contribute to
primary prevention of CRC. The
international experts from the recent
World Cancer Research Fund Report,
2008, concluded that CRC is a major
public health problem and modernization
in food choices, sedentary life style and
increased life expectancy are the major
factors that might synergize with
genetics for the epidemic of CRC
worldwide (9).
It is timely to conduct research studies to
elucidate the underpinning risk factors of
cancer, in general, and colorectal cancer,
in particular, in the GCC countries. In
the GCC countries, there are few
published reports about the dietary
pattern and lifestyle characteristics of
CRC among adults. Generally, it has
been noted that the rate of CRC among
GCC countries is considered relatively
low compared to most of western
countries. Nonetheless, the pattern is in
the rise (10). In Oman, CRC ranked third
after breast cancer and stomach cancer
(11). Similar pattern has been observed in
Qatar and Saudi Arabia where it ranked
second after breast cancer, and in both
countries it constituted for 9% of the
newly diagnosed cases (12). In a
comparative review among Arab
countries, it has been noted that the rates
of CRC among Bahrain and Kuwait were
higher than other Arab countries (10).
Sporadic studies about CRC in the GCC
countries do exist. They are mainly
cross-sectional epidemiological studies
that describe the pattern of annual
change of cancer rates in general, and
among them CRC is noted (13). Fewer
studies are case-control studies that
explored underlying risk factors (14). To
our best knowledge, studies that explore
the relation between folate and CRC in
the GCC countries have not been yet
reported. The following sections provide
an overview of the molecular
mechanisms of the role of folate in
occurrence of CRC.
There are several established dietary risk
factors for CRC, largely related to folate
and/or vitamin B12 deficiency (15, 16),
diets from animal sources that are low in
fibre and high in fat (17-19). Meanwhile,
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allium vegetables, fruits, pulses and
foods containing selenium protect
against CRC cancer (20-22). Non dietary
risk factors for CRC include, decreased
physical activity (23), obesity ,a body
mass index (BMI) of greater than or
equal to 30 kg/m2 (24, 25), genetic
susceptibility (26, 27), alcohol (28, 29),
smoking (30), and exposure to
environmental carcinogens that may lead
to proliferation and malignant
transformation of colorectal cells (31,
32).
Folate and vitamin B12 deficiency induce
carcinogenesis in susceptible persons,
via mechanisms that involve cell
signaling, cell division and DNA
methylation. The protective effect of
folate and vitamin B12 is attributed to its
one carbon folate metabolism, including
the methionine cycle that is regulated by
ubiquitous enzyme, methionine synthase
(MS). The mechanism involves the
necessity of 5-methyltetrahydrofolate (5-
CH3-THF) as a methyl donor and
vitamin B12 as a cofactor for MS that
regulates the homocysteine (HCY)
remethylation to methionine and
synthesis of S-adenosylmethionine
(SAM), the universal biochemical
methyl donor for all biological
methylation reactions, including DNA
methylation (33).Numerous studies have
indicated that under conditions of low
dietary intake of folate and vitamin B12,
the methyl supply is low and
consequently the MS activity is low
concomitant with low SAM levels and
DNA hypomethylation, a leading cause
of mutagenesis and abnormal expression
of oncogenes, which have been
implicated in different types of
carcinogenesis (34-36).
As illustrated in Figure 1, folate-
dependent methionine cycle modulates
HCY availability for the transsulfuration
into cysteine. Homocysteine (HCY) is
converted to methionine by methionine
synthase enzyme (MS), which utilizes
vitamin B12 as a cofactor and acquires a
methyl group from, 5-
methyltetrahydrofolate (5-CH3-THF)
which is then converted to
tetrahydrofolate (THF). Methionine is
further converted to S-
Adenosylmethionine (SAM) through the
activity of methionine
adenosyltransferase. SAM is the major
methyl donor for all methyltransferases
enzymes, which add methyl groups to
various acceptor molecules such as
DNA, RNA, phospholipids and proteins.
SAM is then converted to S-
Adenosylhomocysteine (SAH), which is
then reversibly converted to HCY in a
reaction catalyzed by SAH-hydrolase.
HCY is either re-methylated back to
methionine or transsulfurated to
glutathione (GSH), the major cellular
antioxidant.
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Figure 1: Simplified schematic diagram of the folate-dependent HCY methylation
and transsulfuration pathway
Folate-dependent transulfuration
pathway is the precursor for de-novo
synthesis of reduced glutathione (GSH),
a tripeptide of glutamic acid, cysteine,
and glycine. GSH is the major
intracellular antioxidant and it undergoes
oxidation to the disulfide form (GSSG),
oxidized form, when scavenging reactive
oxygen species (ROS) that are highly
unstable molecules. In healthy cells and
tissues, more than 90% of the total
glutathione pool is in the reduced form
(GSH), and less than 10% exists in the
disulfide form (GSSG), and a reduced
GSH/GSSG ratio is an indication of
oxidative stress (37, 38). Oxidative
stress is a condition under which the
intracellular antioxidant (GSH),
antioxidant enzymes (glutathione
peroxidase, superoxide dismutase, and
catalase), and dietary antioxidants
(vitamin C, selenium, β carotene and
vitamin E) are not counterbalancing the
ROS, and subsequently induce cellular
damage which is involved in the
pathogenesis of cancer. Vegetables and
fruits are good sources of antioxidants
that provide a protective effect against
the ROS-mediated DNA and lipids cell
membrane structures damage in
proliferated cells (39, 40).
In conclusion various Western studies
have revealed that CRC carcinogenesis
is modifiable in accordance to certain
dietary factors with potential anticancer
properties. Such studies are needed to be
conducted in the Arabian Gulf region, in
order to address the intake of bioactive
food components in the diet consumed
by vulnerable groups at risk for CRC.
Addressing the physical activity is an
asset to develop a multidisciplinary
approach for the primary prevention of
CRC among high risk population. In the
Arabian Gulf region, primary prevention
of CRC is feasible through intervention
programs such as; establishing a
biochemical profile for early diagnosis
of CRC and adopting long-term behavior
modifications in food choices, dietary
pattern and physical activity.
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Should Children with Autism Continue Taking Folic Acid Supplement? Mostafa I. Waly,
1,2*
1Department of Food Science and Nutrition, College of Agricultural and Marine Sciences, Sultan
Qaboos University, Muscat, Oman 2Department of Nutrition, High Institute of Public Health,
Alexandria University, Egypt
*Corresponding Author: Dr. Mostafa Waly. Email: [email protected]
Dear Reader,
Elevated levels of homocysteine have been linked with autism. Despite evidence that
folic acid supplementation reduces the homocysteine level. There is a need for clinical
trials to specifically study the role of folic acid in the primary and secondary prevention
of autism. Sporadic evidence from childhood practices that there is a benefit for folic acid
supplementation for autistic children and those patients are encouraged to take folic acid
as a medication. Meta-analysis studies are needed to study the cause-specific effect of
folic acid deficiency and/or hyperhomocysteinemia on the autism incidence.
Waly MI. Should children with autism continue taking folic acid? Canad J Clin Nutr 2013;
1(1): 74.
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