Anxiety and depression among teachers, doctors and bank officers in district Rahim Yar Khan

Background: Anxiety and depression among professionals is increasing due to multiple reasons

Objective: To determine the level of anxiety and depression among teachers, bankers, and doctors in district Rahim Yar Khan

Methodology: This was a crosssectional study conducted by using convenient sampling technique. The study subjects were teachers, bankers, and doctors working in government schools, hospitals and public or private banks. The sample size was 446. We used a validated Urdu version of Hospital Anxiety Depression Scale. Anxiety was defined as a feeling of worry, nervousness, or unease about something with an uncertain outcome. Depression was defined as a state of low mood and aversion to activity that can affect person's thought behavior, feelings, and sense of well being. According to HADS, person's scoring >= 11/22 is said to be in state of anxiety obliged depression

Results: Total respondents from the three categories were 446 including, 235 teachers, 117 doctors and 94 bank officers. Results showed that none of the group has a case of anxiety or depression according to these criteria. However, considering the level of anxiety and depression score, the level of score was higher in bankers as compared to that in other groups, and the difference was significant.[p<0.05]

Conclusion: This study showed that none of the three professional groups, teachers, doctors, and bankers in Rahim Yar Khan were suffering from anxiety or depression and female bankers have relatively higher level of anxiety and depression scores

Drug-drug interactions; penicillins, cephalosporins and quinolones in indoor patients

Introduction: This research paper is based on a study conducted on the in-door patients at a teaching hospital in Gujrat, Pakistan, in order to check for the frequency with which Penicillins, Quinolones and Cephalosporins are being used together and in combinations with other drugs and the drug-drug interactions that occur due to these combinations and their impacts on the patients

Objectives: [1] To check the frequency with which Penicillins, Quinolone and Cephalosporins are being used in different combinations in patients. [2] To determine their drug-drug interactions. [3] Impact on patients due to these interactions. [4] Reasons for prescription of mismatched combinations by clinicians. Study Design: 270 random prescriptions were collected from different wards of DHQ hospital, Gujrat. These prescriptions were then analyzed for drug interactions among the above mentioned group of drugs, with the help of soft ware program named The Medical Letter Adverse Drug Interaction Program. Setting: Aziz Bhatti Shaheed Hospital [DHQ], Gujrat, Pakistan. Period: Prescriptions were collected over the period of 3 months

Conclusions: Prescribing antibiotics for different indications in indoor patients is unavoidable. However, it is the duty of the clinician to monitor the patient when he is using two or more drugs together. This study recommends the use of drug-drug interaction detecting software in hospitals, so that, the level of patients' safety may be enhanced

Correction of iron deficiency anemia in pregnancy and its effects on superoxide dismutase

Iron deficiency anemia [IDA] affects not only the hematological parameters but also disturb the oxidative balance of body. In pregnancy, this is much more considerable as oxidative stress is considered to be one of the physiological changes during this period. This study aims to observe the effect of daily iron supplement on oxidative stress in pregnancy. In this study, 30 pregnant women with IDA were treated with daily oral iron supplements for 12 weeks. After 12 weeks hemoglobin [Hb], hematocrit, serum ferritin concentration [SFC] and superoxide dismutase [SOD] activity were measured and compared with pre-supplement levels. A significant increase in all the parameters was observed after treatment [p<0.05]. When post supplemental values of SFC and SOD were compared with control group comprising of 10 non anemic pregnant women, they were significantly low [p<0.05]. Our results indicate that oxidative stress in pregnancy associated with IDA decreases with daily iron supplements but fail to reach normal pregnant levels. This supports iron over load theory in daily iron supplements and suggests that oxidative stress increases if pregnancy is associated with iron deficiency

Pharmacodynamic study on acute hypotensive activities of Carissa carandas extract in normal rats

This study aims to evaluate the effect of Carissa carandas extract on cardiovascular function of normal rats. Intravenous bolus injection of this extract in the doses of 5 mg kg[-1]-45 mg kg[-1], produced dose dependent reduction in arterial blood pressure [p<0.001]. The 45mg/kg dose caused a 50.75% +/- 2.71 decrease in MABP which was highly significant with P value< 0.0005 when compared with its controls. Significant reduction in heart rate frequency was observed after CC injection at a dose of 45 mg kg[-1] [p<0.001]. The results were comparable with Acetylcholine 10[-4] M. The receptor activity performed for which Atropine 10[-4]M was administered I.V. and then the extract [45mg/kg] was administered. A highly Non Significant fall in Mean Arterial Blood pressure was observed 1.51% +/- 0.22 [P>0.05].It was concluded that the Carissa carandas Ethanol extract possess potent acute hypotensive effect in normal rats. It stimulates the muscarinic receptors located on the endothelial cells of the vasculature. This stimulation results in the release of endothelial-derived relaxing factors [EDRFs] or nitric oxide that diffuses to vasculature smooth muscles and causes their relaxation

Comparison of serum sodium before and after use of reduced osmolarity ors solution in children with acute water diarrhea

Background: Oral rehydration salt [ORS] solution has reduced childhood deaths from diarrhea. Recent studies suggest that ORS solutions with reduced osmolarity may be more effective. However, there is concern about hyponatremia with reduced osmolarity ORS. Objectives: To compare the serum sodium level before and after the use of reduced osmolarity ORS solution in children with acute watery diarrhea [AWD]

Patients and Methods: This comparative cross sectional study was conducted in the Department of Paediatrics Unit-I, King Edward Medical University/ Mayo Hospital, Lahore from March to August 2009. Sample was collected by non probability purposive sampling. After consent, a total of 100 children of age 2 to 60 months, consistent with clinical case definition of AWD [passage of 3 or more loose stools/day with duration of less than 14 days] were enrolled. Those children with severe dehydration or having clinical evidence of systemic infection were excluded from the study. Each child was offered reduced osmolarity ORS solution. Serum sodium level was measured before and 6 hour after use of ORS. Data was entered in SPSS 17 and paired sample t-test was applied to compare serum sodium level before and after use of ORS

Results: Mean serum sodium level before and 6 hour after use of reduced osmolarity ORS solution was 133+/-3.4mEq/L and 133+/-2.9mEq/L, respectively. There was statistically insignificant change in serum sodium level after use of reduced osmolarity ORS solution.[p value 0.173] Similar results were found for subgroups of age and gender

Conclusion: Reduced osmolarity ORS solution has no statistically significant risk of hyponatremia in children with AWD

Evaluation of typhidot [IgM] in early and rapid diagnosis of typhoid fever

Typhoid fever is widely recognized as a major public health problem in developing countries. A simple, reliable and rapid diagnostic test is needed for clinicians especially in areas where laboratory services are limited. To evaluate sensitivity and specificity of typhidot [IgM], a serological test to identify IgM antibodies against salmonella typhi. This was a prospective study. Northern Institute of Medical Sciences [NIMS] and Ayub Teaching Hospital Abbottabad. 1[st] November 2009 to 31[st] August 2010. A total of 100 patients with clinically suspected typhoid fever were studied and divided into three main groups as A, B and C, with definite typhoid fever, typhoid suspects plus non-typhoidal illnesses and healthy controls respectively. Blood culture and typhidot [IgM] tests were conducted for all subjects included in the study. The validity of typhidot [IgM] test has been evaluated by determining the sensitivity, specificity, positive and negative predictive values. In our study, majority [75%] were males and [25%] females with M to F ratio of 3:1. The mean age of study group was 26.31 +/- 11.8 [SD] years. Among 100 clinically diagnosed typhoid fever patients, 19 had positive blood culture for S.typhi and 71 were typhidot [IgM] positive. Out of 19 culture positive patients, 18 [94.73%] were true typhidot [IgM] positive, which was also falsely positive in 05 [20.83%] among 24 non- typhoidal febrile controls. None of the healthy controls was positive for typhoid [IgM] test. The sensitivity, specificity, negative and positive predictive values of typhidot [IgM] test using blood culture as gold standard were 94.73%, 90%, 97.72% and 78.26% respectively for patients having typhoid fever. Typhidot [IgM] test is a simple, reliable, rapid and valid diagnostic tool for typhoid fever especially in areas where laboratory services are limited

Comparison of urdu version of strengths and difficulties questionnaire [SDQ] and the child behaviour check list [CBCL] amongst primary school children in Karachi

To compare CBCL [Child Behaviour Check Llist] Urdu, with the validated Urdu version of Strengths and Difficulties Questionnaire [SDQ] used as "gold standard" among school children in Karachi, Pakistan, and to develop local cutoffs for CBCL using SDQ as a gold standard. A cross-sectional study. Schools of Karachi metropolitan area from January to December 2006. The Strengths and Difficulties Questionnaire [SDQ] and Child Behaviour Check List [CBCL] was completed by parents of 5-11 years old primary school children in Karachi. Appropriate cutoff points for total problem, internalizing and externalizing scales were obtained for CBCL. A total of 556 parents filled out both the SDQ Urdu version as well as CBCL. Scores from the parent rated total SDQ scores were highly correlated with the total CBCL scores [r=0.589]. The local cutoffs derived for CBCL were considerably lower than USA norms. Slightly higher cutoff for males was found as compared to females for the total CBCL scores. Like the original English version, the Urdu version of CBCL and SDQ are both equally valid assessment tools to be used for both clinical and research purpose in Pakistani settings, where Urdu is widely spoken and understood

Retrosternal goitre, presentation and treatment outcome

To assess the clinical presentation, surgical out come and complications of retrosternal goitre [RSG]. A descriptive retrospective study. Departments of Ear Nose Throat and Head and Neck Surgery, Fatima Hospital Baqai Medical University and Civil Hospital Dow University of Health Sciences Karachi, between January 2002 to March 2008. Twenty seven patients of both gender and different ages of retrosternal goitre who under went for thyroidectomy between January 2002 to March 2008 were studied regarding their clinical presentation, and surgical outcome. Only two [7.4%] of our patients were presented with acute air way obstruction. Six [22.2%] patients were complained of dsypnoea only in supine posture, dysphagia and hoarseness were noticed in 3[11.1%] and 1 [3.7%] patients respectively while fifteen [51.5%] were asymptomatic apart from the obvious neck swelling. Total thyroidectomy was performed in twenty two [81.4%] cases and lobectomy with isthemectomy was done in five [18.1%] patients. CT scan was done in seven [25.9%] cases. Majority of our cases i.e. twenty five [92.6%] were benign while malignancy was noted in only two [7.4%] cases. Complications noted was haematoma formation in one [3.7%], recurrent laryngeal nerve injury in four [14.8%], hypoparathyroidism [transient] was recorded in three [11.1%] patients, and wound infection was observed in two [7.4%] patients. There was no mortality pre and post-operatively and no case of permanent hypoparathyroidism was noted where as only one patient had permanent unilateral recurrent laryngeal nerve injury. Retrosternal goitre is often asymptomatic and thyroidectomy is the treatment of choice with very low mortality and morbidity

Impact of working status on their lives: a survey of working women at a teaching hospital in Karachi, Pakistan

To study the impact of working status on the lives of working women. A questionnaire based cross sectional survey was conducted at the Family Practice Center, Aga Khan University Hospital, Karachi, Pakistan, from July to December 2006. The Questionnaire included data on the demographic profile of the patient and questions in line with study objectives. Ethical requirement including the administration of written informed consent and the provision of confidentiality were ensured. SPSS computer software was used for data analysis. Two hundred working women were interviewed. The mean age was 29.05 years. A majority was married [53.5%] with more than grade XII education [67%]. Sixty three [31.5%] women were working due to need and eighty three [41.5%] were finding it difficult to carry out home responsibilities because of it. Extra understanding and support was received from family by 155 [77.5%] and 115 [57.5%] women respectively. One hundred twenty three [61.5%] women felt they did not have enough time for themselves. The status of working women is better than non-working women according to 123 [61.5%] respondents. Financial benefits outweigh other disadvantages according to 105 [52.5%] respondents. Marriage prospects of working women and their children are better than non-working women and their children according to eighty one [40.5%] and eighty [40%] respondents respectively. Confidence in working women is higher than non-working women according to 142 [71%] respondents. Eighty one [40.5%] respondents feel that working women's financial independence has negative impact on theirs husband's self esteem. Working women find it difficult to carryout their home responsibilities. There is need for further studies on how to improve the working conditions and home situation for working women in our society

Hemoglobin status of pregnant women visiting tertiary care hospitals of Pakistan

To determine the status of haemoglobin levels in pregnant women who visited tertiary care hospitals of various cities in Pakistan for their antenatal care from January 1 to April 30, 2007. This was a descriptive cross-sectional multi-centre study This study was conducted at the Aga Khan University Hospital [AKUH], Karachi, Civil Hospital, Karachi [CHK] and Nawabshah Medical College Hospital [NMCH], Nawabshah. Copies of medicinal prescriptions given to pregnant patients attending the antenatal clinics were collected from January 1 to April 30, 2007. Reports or results of hemoglobin concentrations were also obtained from the patients. A total of 1709 pregnant women were recruited. Majority 1145[67%] were from the age group of 25 to 34 years and 1555[91%] had some degree of anemia. The number of women with moderate to severe anemia [hemoglobin levels < 8 or 8-9.9 gm/dl, respectively] was significantly higher in CHK and NMCH compared to AKUH [p < 0.001]. Whereas mild anemia [hemoglobin levels 10-10.9gm/dl] or normal hemoglobin levels was significantly higher at AKUH [p < 0.001]. Moderate anemia [hemoglobin levels of 8-9.9gm/dl] was statistically more frequent in second and third trimester, while mild anemia [hemoglobin levels of 10-10.9gm/dl] was more in first trimester of pregnancy. The distribution of severe anemia however; was not different is the three trimesters. About 90-92% subjects received iron/vitamin/mineral supplements irrespective of the hemoglobin status of the woman. Prevalence and severity of anemia in pregnant subjects attending the tertiary care hospitals of Pakistan is exceptionally high. Current findings highlight the anemia in pregnancy as a priority area of concern

Awareness about reproductive health and rights among students of a public university in karachi, Pakistan: a cross sectional study

To determine the knowledge, attitude and practices of Karachi University students about reproductive health and rights. Cross sectional study. A survey was conducted from February to May 2005 to determine the understanding and knowledge related to reproductive health and rights among the students of the department of Biochemistry, University of Karachi, Pakistan. A pre-coded questionnaire was developed and pre-tested. The questionnaire was introduced to those students, who agreed to participate in the study. Data collected was double entered and analyzed on SPSS and Epi-info latest version. Fifty five percent [55%] of participants believed the reproductive rights to be as important as other human rights. About 80% of participants thought that proper birth spacing can improve maternal and child health but very few Pakistani women have birth spacing rights. Quality of life of women and men can be improved by knowing their reproductive rights in view of 71% and 63% of respondents respectively. Although one third of participants claimed to be aware of their reproductive rights but majority were unable to identify what exactly comes under the domain of reproductive rights. Majority knew that appropriate use of contraception and birth spacing can have positive impact on maternal and child health. The study recommends that awareness sessions should be conducted at all levels of society and more efforts should be made to improve reproductive health and increase awareness and the implementation of reproductive rights

Comparision between bed side testing of blood glucose by glucometer vs centralized testing in a tertiary care hospital

To determine the accuracy, turnaround time and cost effectiveness of bedside monitoring of blood glucose levels by non-laboratory health care workers and centralized testing of blood glucose by automated analyzer in a tertiary care hospital. The study was conducted in Section of Chemical Pathology, Department of Pathology and Microbiology and Section of Endocrinology Department of Medicine, Aga Khan University and Hospital Karachi, from April 2005 to March 2006.One hundred and ten patients were included in the study. The blood glucose levels were analyzed on glucometer [Precision Abbott] by finger stick, using Biosensor Technology. At the same time venous blood was obtained to analyze glucose in clinical laboratory on automated analyzer [SYNCHRON CX7] by glucose oxidase method. We observed good correlation between bed side glucometer and laboratory automated analyzer for glucose values between 3.3 mmol/L [60 mg/dl] and 16.7 [300 mg/dl]. A significant difference was observed for glucose values less than 3.3 mmol/L [p=0.002] and glucose values more than 16.67 mmol/l [p=0.049]. Mean Turnaround time for glucometer and automated analyzer were 0.08 hours and 2.49 hours respectively. The cost of glucose testing with glucometer was 48.8% lower than centralized lab based testing. Bedside glucometer testing, though less expensive does not have good accuracy in acutely ill patient with either very high or very low blood glucose levels

Otogenic intracranial complication

Two patients one male of 25 years the other a girl of 10 years old presented to us with purulent ear discharge, severe hcadache and nausea/vomiting and amastoid abscess in one of them of few days duration. Otoscopy revealed purulent foul smell discharge filling the ipsilateral ears with X-ray mastoid showing a cavity due to bone erosion. Incision and drainage of mastoid abscess followed by radical mastoidectomy in one and radical mastoidectomy straight away in the other were performed with complete eradication of disease and chlesteatoma was achieved clinically. But within 16 hour in the young girl and after 12 days in the 25 years old male again both cases presented in emergency with sever headache, nausea/vomiting and disorientation. CT scan of both the cases revealed right temporal lobe abscess. The girl was already in ICU and the male was re- admitted for the drainage of abscesses under care of neurosurgeon and follow up was done in both the departments for four months

Causes of unilateral proptosis and its management

To evaluate the common ENT diseases causing proptosis. A retrospective analysis. Department of ENT and Head and Neck Surgery Civil Hospital and Jinnah Postgraduate Medical Centre Karachi [JPMC] during September 1995 to September 1998. This study is based on 25 patients admitted in the ENT dept. of Civil Hospital and JPMC Karachi during the period of three years. RESULTS: Out of25 cases 15 were female and 10 were males of 13 to 62 years of ages carrying different pat hologies e.g 8 cases of fungal sinusitis, 6 of nasal polyps, 2 of inverted papilloma, 2 cases of carcinoma maxilla, 3 of carcinoma ethmoid sinus, 2 of angio fibroma, one case of mucocele forontal sinus and one patient of T.B granuloma of maxillary sinus. All 25 patients treated surgically via different approaches like lateral rhinotomy, Jansen Horgan ethmoidectomy and Weber Furgusson approach. Malignant cases also received radio, and chemotherapy, while patients of fungal sinusitis kept on antifungal treatment orally in post operative period. Proptosis caused by sinonasal pathologies once diagnosed must be treated promptly to get the best results. Radiations should be avoided if possible to prevent the loss of vision

Transitional cell carcinoma of the nasal cavity

A 40 years old female presented with left nasal obstruction, sneezing and watery discharge for the last three months. Clinically left proptosis and widening of the nasal bridge was obvious while the left nasal cavity was full of multiple greyish grapes like polypoid masses which were painless and did not bleed on manipulation. CT scan revealed soft tissue mass occupying the left nasal cavity, maxilla, infra temporal fossa, ethmoid, sphenoid and the orbit. The mass was excised in toto through left Lateral Rhinology approach and histology examination revealed it to be a transitional cell carcinoma

Unilateral nasal obstruction caused by sino-nasal neoplastic lesions

To report pattern of unilateral nasal obstruction caused by sino-nasal neoplasms seen in two teaching hospitals in Sindh, Pakistan. A case series. Ear, Nose and Throat [ENT] departments of Jinnah Postgraduate Medical Centre, Karachi and People's Medical College, Nawabshah between June 1995 to June 1998. This study included 51 patients who presented with unilateral nasal obstruction persistantly for more than eight weeks. A proforma was designed to note the complaints, pinpoint the cause and look at the outcome of the treatment and prognosis. Thus, a detailed history of patients was undertaken through clinical examination, laboratory investigations e.g. blood profile, urine analysis, radiological [common and special] imaging, biopsy and histopathology. Neoplastic lesions of the nose and paranasal sinuses were found in 51 patients. This included 16 [31.37%] females and 35 [68.62%] males with an average age of 37 years. Benign lesions were 19 [37.25%] and 32 [62.75%] were malignant including single case of schwanoma, two cases of squamous papilloma and three patients with fibrous dysplasia while inverted papilloma was seen in six and nasopharyngeal angiofibroma in seven patients. Commonest malignant lesion was squamous cell carcinoma seen in 30 [58.82%] patients. Maxillary sinus was involved in 30 cases and 2 of them were arising from the ethmoid sinus and nasal cavity, and were found to be adenocarcinoma. For benign lesions, wide surgical approach was adopted and except one case of inverted papilloma which reccurred, rest were cured completely. Radical and oncologically sound surgical resection combined with radiation therapy remained the treatment of choice for all the malignant lesions. Local recurrence was seen in two cases. Only one patient died after 8 months due to distant metastasis. Two patients were lost to follow up after 25 months. Neoplastic lesions especially the benign tumors, promptly treated via wide surgical approach, mostly cure the lesion with negligible complication or no recurrence. Malignant lesions of the nose and sinuses are very often diagnosed in advanced T-stages [intracranial or intraorbital extentions] due to non-specific symptoms and have a poor overall prognosis even in the advances in surgical techniques, radiation therapy and new chemotherapeutic agents

Surgical management of juvenile nasopharyngeal angiofibroma, with and without pre-operative embolization. A comparative analysis

To compare the outcome of surgical excision of juvenile nasopharyngeal fibroma [JNF] with and without pre-operative embolization. A descriptive study. Conducted at departments of Otolaryngology of Peoples Medical College, Nawabshah and Jinnah Post Graduate Medical Centre Karachi between Jan: 1997 to Dec:1999. 23 cases with high clinical and radiological [C.T scan] indices of suspicion of nasopharyngeal angiofibroma were included in this study. Patients were divided into two groups [A and B]. Group A comprising of 10 patients who underwent pre-operative embolization. Group B comprising of 13 patients underwent surgery without preoperative embolization. 1. To compare pros and cons between surgical procedures with and without pre-operative embolizaion. 2. To compare the chances of recurrence after excision of JNF with and without embolization. Group A indicated 1- Significant reduced blood loss [average 200cc]. 2-Recurrence - 3 cases. 3- facial numbness - 1 case. 4- Total cost incurred Rs: 15000. Group B 1- Average blood loss of 2000cc. 2- Recurrence-nil. Surgical excision of INF with pre-operative embolization has an advantage of much reduced blood loss during surgery but the rate of recurrence is almost nil in patients who underwent excision of JNF without pre-operative embolisation

HIV-1 western blot assay: What determines an indeterminate status?

BACKGROUND: The Western blot assay is the gold standard for the detection of antibodies to human immunodeficiency virus type 1 (HIV-1). However, indeterminate Western blot reactivity to HIV-1 proteins may occur in individuals, who may not be infected with HIV. AIM: This retrospective study was aimed to determine the diagnostic value of the interpretation criteria in relation to commercial kits for HIV-1 diagnosis. METHODS AND MATERIALS: A total of 556 serum/plasma specimens collected from high-risk population attending our HIV clinic from 2000-2004 were tested by three different western blot kits: NEW LAV BLOT I (n=244), HIV BLOT 2.2; (n=112), Genetic Systems HIV-1 (n=237). And the results of western blot strips were analyzed using the various interpretation criteria: WHO/NACO, CDC/ ASTPHLD, ARC, FDA, CRSS and JHU. Some specimens were run on more than one kit. RT-PCR assay was performed on 5 specimens, which were indeterminate with LAV BLOT I. RESULTS: The discrepancy in LAV BLOT I positive results were between 157(64)-176(72), and indeterminate results were between 44(18) to 63(25). No such variations were observed in genetic systems. There are some HIV negative (by PCR) specimens were indeterminate in LAV BLOT I revealing the kit more sensitive and less effective for diagnostic purpose. CONCLUSION: The genetic systems kit is superior to other kits we analyzed and its results are concordant with HIV-1 PCR results. To report, the choice of western blot commercial kit is paramount important than the use of particular interpretation criteria for the diagnosis of HIV-1.

Womens' beliefs and practices regarding food restrictions during pregnancy and lactation: a hospital based study

Maternal diet is an important determinant of outcomes of pregnancy. Malnutrition during pregnancy and its consequences maximally affect the health and long-term outcomes of the population. Low birth weight accounts for almost 30% of all births; with maternal malnutrition as a dominant risk factor. This study aims to investigate the existing beliefs and practices regarding food restrictions during pregnancy and lactation and also to assess whether there is any relationship with education level of the respondent and their beliefs and practices. A cross-sectional survey was conducted at Community Health Center [CHC] of The Aga Khan University Hospital, Karachi from July- September 2000. Four hundred adult female respondents, who came to the outpatient services as a patient or as an attendant, were interviewed after taking verbal consent. A self administered pre-coded and pre-tested questionnaire was filled by the respondent. More than three fourths of respondents were literate. Twelve% believed in restricting some food item during pregnancy and about 25% believed the same during lactation. No statistically significant association was found between belief about food restriction during pregnancy or during lactation and education level of the respondent. Undue food restrictions during pregnancy and lactation do exist in our culture. To assess the true picture we need to conduct larger studies in the community. The information obtained from the studies will help us in addressing these issues for improvement of nutritional knowledge and dietary practices and to avoid undue food restrictions