Abstract
Objective:
The aim of our study was to assess the association of eating habits with the dietary patterns of people with diabetes.
Methods:
This cross-sectional study was conducted at National Institute of Diabetes and Endocrinology (NIDE), Dow University Hospital in Karachi, Pakistan. A total 301 patients aged >18 with type 2 diabetes came to Outpatient department were recruited. Structured questionnaire was used to assess general characteristics, Anthropometric measurements, biochemical markers, and dietary intake.
Results:
A total of 301 patients with type 2 diabetes mellitus were included in this study. The average age of patients was 51.6 (SD ± 11.1) years which ranged from 21 to 80 years whereas the average BMI was 27.2 kg / m2 (SD ± 5.6). Overall, 42% of patients were found to often have less than 1 serving of fruit, and 45% had less than 3 servings of vegetables daily. Of all, 77 (26%) patients often distributed carbohydrates all over the day. Results revealed that HbA1c was higher in those patients who took more than 3 roti (approximately each roti weight 60-80 g) (P-value < .001) and full plate rice approximately 300 to 355 g cooked weight in a whole day (P-value < .001) as compared to those patients whose intake of roti was 3 or less than 3 and rice was a half plate. Moreover, out of 301 patients, 102 were found physically active (52% females and 48% males), while 199 were not active. Pain in legs and lack of motivation were common barrier to physical activity.
Conclusion:
Our study revealed that patients’ fruits and vegetable intake was not optimum, diet was not balanced and the quantity of starchy carbohydrates was not controlled which may affect their HBA1C levels. Proper counseling and awareness about the importance of a balanced diet and portion control in diabetes are needed.
Keywords: Dietary pattern, roti consumption, rice consumption, type 2 diabetes
Introduction
The prevalence of diabetes is a growing concern worldwide, affecting all age groups. In the year 2000, the global prevalence of diabetes was 2.8%, and it is expected to increase to 4.4% by the year 2030. 1 In Pakistan, around 19 million adults were predicted to be living with diabetes in the year 2019, and 8.5 million of them were undiagnosed and at risk for diabetes. 2 According to another research conducted in collaboration with the Pakistan health research council, the prevalence of diabetes was 26.3% in the age group of 19 years and older.
The treatment of type 2 diabetes requires more than just pharmacotherapy; it also involves lifestyle modifications. Lifestyle changes such as healthy eating habits and regular physical activity are crucial in controlling blood sugar levels. 3 A balanced diet with an appropriate combination of fruits, vegetables, and high-fiber foods rich in nutrients, vitamins, and minerals is essential for individuals with type 2 diabetes. 4 Meal planning for individuals with type 2 diabetes should take into consideration age, gender, and activity level to provide a balanced and healthy diet. 5 Studies have shown that many people with type 2 diabetes consume fewer servings of fruits and vegetables than recommended and have an excessive intake of meat products. 6 This highlights the need for education and awareness regarding healthy food choices for individuals with type 2 diabetes. For instance, one study conducted in Islamabad suggested the need to educate individuals with diabetes regarding the glycemic index of foods as part of their dietary management. 7
Maximizing the benefits of sugar control through diet requires people with diabetes to have knowledge of their food choices and portion control, as diabetes is a progressive disease that requires regular counseling. 8 Overweight and obesity are prevalent in diabetes, and dietary counseling should focus on food choices that improve insulin sensitivity. 8 Healthcare professionals must be aware of the food choices and preferences of people with diabetes to provide effective dietary counseling that encourages positive lifestyle habits. By understanding their dietary choices, healthcare professionals can give tailored advice and recommendations to individuals with diabetes to help them manage their condition effectively.
The study aims to assess the dietary choices of people with diabetes, their portion sizes, and the reasons for not engaging in physical activity. Additionally, the study intended to evaluate the frequency of unhealthy food choices among people with diabetes. This information could help healthcare professionals in providing tailored dietary counseling and support to people with diabetes to help them manage their condition more effectively.
Methodology
This cross-sectional study was conducted at the National Institute of Diabetes and Endocrinology (NIDE) a tertiary care diabetes center in Karachi Pakistan from November 2021 to May 2022. People with type 2 diabetes attending the outpatient department of NIDE were included in the study. This study included a sample of 301 patients of both genders using non-probability consecutive sampling, and a structured questionnaire was used for data collection, consisting of 4 sections. Data was collected from dietitians.
The first section of the questionnaire included the general characteristics of the patients such as occupation, age, gender, and ethnicity. The second section included a food frequency questionnaire used for nutritional assessment which was taken after literature review. 9 Registered dietitian asked each study participant about the frequency and amount of consumption from different food groups, including cereal, fruit, vegetable, meat, milk, and fats and oil. Additionally, the frequency of consumption of unhealthy food choices was determined. Measuring cups and spoons, pictures of cooked food, and models of food items were used to estimate participant portion sizes of food from different food groups and unhealthy food items.
The third section contained the laboratory investigation values like HBA1C, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride. At the same time, the fourth section assesses the physical activity levels among patients. It was asked from each participant their physical activity levels where the patient was considered physically active if they are doing a moderate level of physical activity 150 minutes per week.
Data was collected after taking signed informed consent from all the patients in the Urdu Language. The study was approved by the Institutional Review Board (IRB) Dow University of Health Sciences (Ref: IRB-1898/DUHS/Approval/2021/).
Inclusion criteria
Diagnosed with diabetes >6 months of diabetes.
Exclusion criteria
Patients with complications of diabetes in which food intake is compromised.
Statistical analysis
Descriptive statistics were reported in terms of frequency and percentage for qualitative variables whereas median and inter-quartile range (Q1 − Q3) for quantitative variables. The normality of continuous variables was checked by the Shapiro-Wilk test. Mann-Whitney U test and Chi-square test were applied to check median and proportional differences in dietary patterns and consumption of protein and fat of diabetic patients between genders. P-value ⩽ .05 were considered to be statistically significant. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 26.
Results
A total of 301 patients with type II diabetes mellitus were included in this study. The average age of patients was 51.6 (SD ± 11.1) years which ranged from 21 to 80 years whereas the average BMI was 27.2 (SD ± 5.6). The median weight (77vs 69 kg, P-value < .001) and height (167vs 160 cm, P-value < .001) of males were higher as compared to females although BMI didn’t show such differences. Among male patients, 49 (36%) were graduate and among females 25 (15%) did graduation. Almost an equal proportion of male patients were professional/businessmen 49 (36%) and retired/jobless 48 (36%) whereas 144 (87%) females were housewives. Similarly, an equal proportion of the male patients were Sindhi 48 (36%) and Urdu speaking 46 (34%), and around half of the females 81 (49%) were Urdu speaking (Table 1).
Table 1.
Demographics and anthropometric measures of type II diabetic patients (n = 301).
| Characteristics | Male | Female | P-value* |
|---|---|---|---|
| (n = 135) | (n = 166) | ||
| Age (years) | 52.0 (45.0-62.0) | 50.0 (45.0-57.0) | NS |
| Weight (kg) | 77.0 (68.0-86.0) | 69.0 (59.0-77.0) | <.001 |
| Height (cm) | 167.6 (165.0-172.7) | 160.0 (157.5-165.0) | <.001 |
| BMI (kg/m2) | 26.7 (23.7-30.1) | 26.4 (23.6-30.1) | NS |
| Waist circumference (cm) | 38.0 (36.0-40.0) | 38.0 (35.0-40.0) | NS |
| Duration of diabetes (years) | 7.0 (3.0-12.5) | 5.0 (2.0-10.0) | NS |
| Education | |||
| Uneducated | 23 (17.0) | 40 (24.1) | <.001 |
| Metric | 28 (20.7) | 61 (36.7) | |
| Intermediate | 18 (13.3) | 30 (18.1) | |
| Graduate | 49 (36.3) | 25 (15.1) | |
| Post graduate | 17 (12.6) | 10 (6.0) | |
| Occupation | |||
| Professional/Businessman | 49 (36.3) | 11 (6.6) | <.001 |
| Retired/Jobless | 48 (35.6) | 8 (4.8) | |
| House maker/Housewife | 9 (6.7) | 144 (86.7) | |
| Skilled labor | 29 (21.5) | 3 (1.8) | |
| Ethnicity | |||
| Sindhi | 48 (35.6) | 40 (24.1) | .024 |
| Punjabi | 9 (6.7) | 18 (10.8) | |
| Balochi | 10 (7.4) | 4 (2.4) | |
| Pakhtoon | 14 (10.4) | 15 (9.0) | |
| Urdu speaking | 46 (34.1) | 81 (48.8) | |
| Other | 8 (5.9) | 8 (4.8) | |
Abbreviation: BMI, Body Mass Index.
Median (Q1 − Q3) and n (%) are reported.
P-value calculated by Mann Whitney test and Chi-square test.
It was reported that 107 (79%) male and 137 (82%) female patients rarely/never skipped their breakfast moreover 86 (64%) male and 121 (73%) female patients rarely/never had more than 4 meals a week from outside. Ninety-two (68%) male and 126 (76%) female patients usually/often ate whole grain products a day. Overall, 42% of patients usually/often had less than 1 serving of fruit a day and 45% had less than 3 to 4 servings of vegetables a day. Only 15 (5%) of patients; 10 (7%) male and 5 (3%) female patients usually/often drank soft/sweet drinks regularly whereas 13 (10%) male and 13 (8%) female patients added salt on the table. Of all, 77 (26%) patients usually/often distributed food choices of carbohydrates all over the day (Table 2).
Table 2.
Nutritional history and dietary pattern of type II diabetic patients (n = 301).
| Characteristics | Total | Male | Female | P-value* |
|---|---|---|---|---|
| (n = 135) | (n = 166) | |||
| Skipping breakfast | ||||
| Usually/often | 37 (12.3) | 19 (14.1) | 18 (10.8) | NS |
| Sometimes | 20 (6.6) | 9 (6.7) | 11 (6.6) | |
| Rarely/never | 244 (81.1) | 107 (79.3) | 137 (82.5) | |
| Eating ⩾4 meals from restaurants/outside a week | ||||
| Usually/often | 50 (16.6) | 29 (21.5) | 21 (12.7) | NS |
| Sometimes | 44 (14.6) | 20 (14.8) | 24 (14.5) | |
| Rarely/never | 207 (68.8) | 86 (63.7) | 121 (72.9) | |
| Eating whole grain products a day | ||||
| Usually/often | 218 (72.4) | 92 (68.1) | 126 (75.9) | NS |
| Sometimes | 32 (10.6) | 14 (10.4) | 18 (10.8) | |
| Rarely/never | 51 (16.9) | 29 (21.5) | 22 (13.3) | |
| Eating ⩾1 servings of fruit a day | ||||
| Usually/often | 28 (42.5) | 57 (42.2) | 71 (42.8) | NS |
| Sometimes | 101 (33.6) | 46 (34.1) | 55 (33.1) | |
| Rarely/never | 72 (23.9) | 32 (23.7) | 40 (24.1) | |
| Eating ⩾3 servings of vegetables a day | ||||
| Usually/often | 136 (45.2) | 66 (48.9) | 70 (42.2) | NS |
| Sometimes | 112 (37.2) | 43 (31.9) | 69 (41.6) | |
| Rarely/never | 53 (17.6) | 26 (19.3) | 27 (16.3) | |
| Eating or drinking ⩾1 serving of milk products a day | ||||
| Usually/often | 116 (38.5) | 52 (38.5) | 64 (38.6) | NS |
| Sometimes | 69 (22.9) | 30 (22.2) | 39 (23.5) | |
| Rarely/never | 116 (38.5) | 53 (39.3) | 63 (38.0) | |
| Eating desserts or sweet things regularly | ||||
| Usually/often | 49 (16.3) | 26 (19.3) | 23 (13.9) | NS |
| Sometimes | 59 (19.6) | 23 (17.0) | 36 (21.7) | |
| Rarely/never | 193 (64.1) | 86 (63.7) | 107 (64.5) | |
| Drinking fruit juices | ||||
| Usually/often | 24 (8.0) | 15 (11.1) | 9 (5.4) | NS |
| Sometimes | 54 (17.9) | 23 (17.0) | 31 (18.7) | |
| Rarely/never | 223 (74.1) | 97 (71.9) | 126 (75.9) | |
| Drinking soft drinks/sweet drinks regularly | ||||
| Usually/often | 15 (5.0) | 10 (7.4) | 5 (3.0) | NS |
| Sometimes | 44 (14.6) | 18 (13.3) | 26 (15.7) | |
| Rarely/never | 242 (80.4) | 107 (79.3) | 135 (81.3) | |
| Added salt at the table | ||||
| Usually/often | 26 (8.6) | 13 (9.6) | 13 (7.8) | NS |
| Sometimes | 25 (8.3) | 8 (5.9) | 17 (10.2) | |
| Rarely/never | 250 (83.1) | 114 (84.4) | 136 (81.9) | |
| Distribute carbohydrates all over the day | ||||
| Usually/often | 77 (25.6) | 36 (26.7) | 41 (24.7) | NS |
| Sometimes | 60 (19.9) | 29 (21.5) | 31 (18.7) | |
| Rarely/never | 164 (54.5) | 70 (51.9) | 94 (56.6) | |
| Amount of roti whole day | ||||
| ⩽3 | 82 (27.2) | 33 (24.4) | 49 (29.5) | NS |
| >3 | 219 (72.8) | 102 (75.6) | 117 (70.5) | |
n (%) are reported. Usually/often (5 or more than 5 days), Sometimes (less than 5 days), Rarely/never (once a month).
P-value calculated by Chi-square test.
It was found that 99 (73%) male and 111 (67%) female patients ate red meat and chicken more than 2 times a week also 103 (76%) male and 131 (79%) female patients had daal lentils usually/often. Eating fried food and excess saturated fat were usually/often adopted by 53 (18%) and 64 (21%) patients, respectively. It was noted that gender differences were not significantly related to the nutritional history, dietary pattern, and consumption of proteins and fats of type II diabetic patients (Table 3).
Table 3.
Consumption of proteins and fats of type II diabetic patients (n = 301).
| Characteristics | Total | Male | Female | P-value* |
|---|---|---|---|---|
| (n = 135) | (n = 166) | |||
| Eating beef or red meat, chicken >2 times a week | ||||
| Usually/often | 210 (69.8) | 99 (73.3) | 111 (66.9) | NS |
| Sometimes | 68 (22.6) | 26 (19.3) | 42 (25.3) | |
| Rarely/never | 23 (7.6) | 10 (7.4) | 13 (7.8) | |
| Daal lentils frequency | ||||
| Usually/often | 234 (77.7) | 103 (76.3) | 131 (78.9) | NS |
| Sometimes | 45 (15.0) | 23 (17.0) | 22 (13.3) | |
| Rarely/never | 22 (7.3) | 9 (6.7) | 13 (7.8) | |
| Choosing higher fat meats instead of lean meat | ||||
| Usually/often | 68 (22.6) | 31 (23.0) | 37 (22.3) | NS |
| Sometimes | 29 (9.6) | 14 (10.4) | 15 (9.0) | |
| Rarely/never | 204 (67.8) | 90 (66.7) | 114 (68.7) | |
| Using regular processed meats | ||||
| Usually/often | 35 (11.6) | 18 (13.3) | 17 (10.2) | NS |
| Sometimes | 17 (5.6) | 8 (5.9) | 9 (5.4) | |
| Rarely/never | 249 (82.7) | 109 (80.7) | 140 (84.3) | |
| Eating fried foods | ||||
| Usually/often | 53 (17.6) | 30 (22.2) | 23 (13.9) | NS |
| Sometimes | 68 (22.6) | 24 (17.8) | 44 (26.5) | |
| Rarely/never | 180 (59.8) | 81 (60.0) | 99 (59.6) | |
| Eating excess saturated fat (ghee, butter) | ||||
| Usually/often | 64 (21.3) | 32 (23.7) | 32 (19.3) | NS |
| Sometimes | 43 (14.3) | 18 (13.3) | 25 (15.1) | |
| Rarely/never | 194 (64.5) | 85 (63.0) | 109 (65.7) | |
| Taking excess oil | ||||
| Usually/often | 118 (39.2) | 56 (41.5) | 62 (37.3) | NS |
| Sometimes | 57 (18.9) | 25 (18.5) | 32 (19.3) | |
| Rarely/never | 126 (41.9) | 54 (40.0) | 72 (43.4) | |
n (%) are reported. Usually/often (5 or more than 5 days), Sometimes (less than 5 days), Rarely/never (once a month).
P-value calculated by Chi-square test.
Median differences in blood parameters were assessed between gender and the total amount of roti and rice. Results revealed that HbA1c was higher in those patients who took more than 3 roti (approximately each roti weight 60-80 g) (8.6%vs 7.1%, P-value < .001) and full plate rice (approximate300-355 g cooked weight) in a whole day (8.7%vs 8.0%, P-value < .001) as compared to those patients whose intake of roti was 3 or less than 3 and intake of rice was the half plate. Levels of HDL were higher in female patients (39vs 34 mg/dL, P-value < .001) as compared to male patients (Table 4).
Table 4.
Blood parameters of type II diabetic patients by gender, total amount of roti and rice in whole day (n = 301).
| Characteristics | Gender | Total amount of roti | Total amount of rice | |||
|---|---|---|---|---|---|---|
| Male | Female | ⩽3 roti | >3 roti | Half plate | Full plate | |
| (n = 135) | (n = 166) | (n = 82) | (n = 219) | (n = 193) | (n = 108) | |
| HbA1c (%) | 8.0 (7.0-10.0) | 8.2 (7.0-10.0) | 7.1 (6.6-9.0) | 8.6 (7.1-10.3) | 8.0 (6.8-9.9) | 8.7 (7.7-10.0) |
| P-value* | NS | <.001 | .007 | |||
| Triglyceride (mg/dL) | 155.0 (116.5-228.5) | 160.0 (135.5-226.0) | 162.0 (131.0-249.0) | 155.0 (118.0-222.2) | 162.0 (128.0-244.0) | 151.0 (113.0-208.0) |
| P-value* | NS | NS | NS | |||
| LDL (mg/dL) | 111.0 (83.0-140.0) | 124.0 (96.0-146.5) | 117.0 (95.5-142.5) | 121.0 (88.0-146.0) | 117.0 (92.0-140.0) | 128.0 (92.2-149.0) |
| P-value* | NS | NS | NS | |||
| HDL (mg/dL) | 34.0 (30.0-39.0) | 39.0 (34.0-45.0) | 36.0 (32.0-45.2) | 36.0 (31.0-41.0) | 36.0 (31.0-42.0) | 36.5 (31.2-42.7) |
| P-value* | <.001 | NS | NS | |||
Abbreviations: HDL, high density lipoproteins; LDL, low density lipoproteins.
Median (Q1 − Q 3 ) is reported.
P-value calculated by Mann Whitney test.
There were 102 (34%) patients who were physically active, out of those 53 (52%) were males and 49 (48%) were females. Of those patients who were not physically active 199 (64%) reported that pain in legs and lack of motivation was the most common barriers to physical activity (Figure 1).
Figure 1.
Physical activity status and its barriers by gender.
Discussion
This study has been done to assess the nutritional intake of people with type 2 diabetes as a proper balance diet has a major role in controlling blood sugars. 9 Thus, this study aimed to assess the dietary choices of people with diabetes, their portion sizes, and reasons for not doing physical activity, in addition, to finding out the frequency of unhealthy food choices among people with diabetes.
In our study, 79% of male and 82% of female patients rarely/never skipped their breakfast, and 64% of male and 73% of female patients rarely/never had more than 4 meals a week from outside and it was found from another study that glucose variability has been shown in people with type 2 diabetes who skipped breakfast. 10 It is noteworthy that only a small percentage of patients drink soft or sweet drinks regularly, and fewer add salt on the table.
Around 68% of male and 76% of female patients usually/often ate whole grain products a day. Moreover, in the current study, 76% of male and 79% of female patients had lentils usually/often, that is the majority of them were consuming high-fiber cereal. Similarly, a study reported that whole grain and legume incorporation as a part of the diet in diabetic patients has proven to improve sugar control and decrease cardiovascular risk. 11 Another study proved that consuming plant-based fibers in the diet reduces the risk of type 2 diabetes. 12 As these foods decrease blood pressure, insulin resistance, weight gain, and systemic inflammation all lead to type 2 diabetes.13-15
Although In our study good thing is that eating fried food and excess saturated fat were usually/often adopted by 18% and 21% of patients, respectively if we observe oil intake for making gravies and cooking food 39.2% of people have habitual using much oil during cooking and most of the studies show that higher levels of total fat in the diet result in greater whole-body insulin resistance. 16
If we see roti( the main staple food in Pakistan) and rice consumption 219 patients were eating more than 3 roti (approximately each roti weight 60-80 g) and 108 patients were eating an excessive quantity of rice(300-355 g cooked weight) and, HbA1c was higher in those patients who took more than 3 roti (8.6%vs 7.1%, P-value < .001) and full plate rice in a whole day (8.7%vs 8.0%, P-value < .001) as compared to those patients whose intake of roti was ⩽ 3 and intake of rice was a half plate. It was obvious from other studies that there is an association between high carbohydrate intake from starchy foods and metabolic disorders. And it confirmed that high total carbohydrate intake is positively associated with hyperlipidemia and MetS. 17
Although there is no ideal percentage of carbohydrates from total calories for people with diabetes, research showed that a low carbohydrate diet had shown improvement in blood sugar levels. 18
Although in our study majority of people were eating roti prepared from whole grains it’s important to control the glycemic load (the number of carbohydrates) of total carbohydrates taken.
The glycemic index does not indicate the amount of carbohydrate it delivers excluding fiber. That’s how Glycemic load is used to classify food by measuring both the number of carbohydrates and their effect on blood sugar level. 19
Evidence shows. Glycemic Index along with quantifying the amount of carbohydrate present in the food has been found to have a beneficial effect on glycemic control. 20
Furthermore, in the current study 42%, 45%, and 38% of patients were taking 1 or more than 1 serving of fruit a day, ⩾3 servings of vegetables a day, and ⩾1 serving of the milk group usually (more than 5 times a week) respectively. A balanced diet includes all food groups in adequate amounts including the greater portion from the cereal and grains group, followed by fruits and vegetables, meat and poultry, dairy and fats while sugar shares the smallest portion unfortunately in Pakistani households, there is an imbalance in proportions of food group giving least importance to the fruits and vegetable that is ultimately leading to malnutrition among masses. To minimize malnutrition risk it is important to diversify diet with adequate food group proportions 21
And dietary guidelines for people with diabetes also emphasize when counting carbohydrates for glycemic control fruits and vegetables and low-fat milk must be a part of the diet along with whole grain cereals, bean and lentils. 18
Adults with metabolic syndrome have low levels of antioxidants in the blood with low consumption of fruits and vegetables that increase the risk of oxidative stress, which may play a role in the development of diabetes, emerging research showed that fruits and vegetables have an antioxidant effect and their consumption is helpful for people with diabetes. 22
Furthermore, the current study noted that gender differences were not significantly related to the nutritional history, dietary pattern, and consumption of proteins and fats among type 2 diabetic patients. But if we see meat consumption among the study population 22.6% were taking sometimes 2 or <2 servings of chicken and lean meat. Research shows that in diabetes substituting carbohydrates with high Biological value protein (considering kidney function) and unsaturated fats are effective in glycemic control. 23
If we see other dietary habits like only, 77 (26%) patients usually/often distributed choices of carbohydrates all over the day, and it was shown from other studies that even distribution of carbohydrates and protein among meals have a beneficial effect on sugars control. 22
Furthermore, it has also been reported through various researches that glycemic control could be improved and mortality risk could be decreased in type 2 diabetic patients through physical activity.23-25 However, in the current study, only a small proportion of the population was doing physical activity (34%). And those patients who were not physically active (64%) reported that pain in their legs and lack of motivation were the most common barriers to physical activity.
Conclusion
This study has been conducted to assess the dietary habits of people with diabetes and we found that people were not taking appropriate portions from the fruit and vegetable group which are the main source of fiber, vitamins, and minerals, and were not distributing carbohydrates food throughout the day which may be the reason of uncontrolled blood sugars. Therefore, it is essential that proper dietary counseling should be done with people with diabetes which emphasizes on optimum amount of servings from each food group.
Footnotes
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions: Thamina Rashid: Concept, design, Literature search, collection and assembly of data, interpretation of data, Drafting the article, writing the manuscript. Hina Afnan: Concept, design, Critical revision of the article for important intellectual content and approved the manuscript. Akhter Ali Baloch: Literature search, drafting the article, writing the manuscript. Saba Mughal: Analysis & interpretation of data. Mohammad Hasan: Drafting the manuscript, Data collection. Muhammad Umar Khan: Data collection, writing the manuscript.
Consent to Participate: Written informed consent was obtained from patients.
Data Availability Statement: All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.
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