Metabolic syndrome in Saudi women with low bone mineral density

Year & Volume - Issue: 
Authors: 
Essra Aldawood, Mubashir Zafar
Article type: 
CID: 
e0412
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Abstract: 
Background ― Metabolic syndrome (MetS) is the world's major public health problem. Objectives ― Assessment of metabolic syndrome impact on bone mineral density (BMD) among Saudi menopausal women in Eastern Province – Saudi Arabia. Material and Methods ― It’s a case control study and 380 menopausal Saudi women were selected through stratified random sampling; they are divided into 190 cases with osteoporosis and 190 without osteoporosis. BMD at the total hip were determined using dual-energy X-ray absorptiometry (DEXA). The T score was calculated, the relationship between the risk factors of MetS and bone mineral density were analyzed by statistical methods. Results ― Prevalence of MetS was substantially higher among osteoprotic women. The MetS is significantly correlated with bone mineral density (r=0.08, P=0.05). The occurrence of MetS was associated with increased osteoporosis among Saudi women (B=0.004; 0.05) after adjustment of confounders. The presence of obesity (component of MetS) was significantly associated with increased odds of Bone marrow density among women (OR 2.56, 95% CI, 2.22–3.44, P=0.030) after adjustment of confounders. Conclusion ― MetS was significantly associated with an osteoporosis in Saudi women.
Cite as: 
Aldawood E, Zafar M. The relationship between metabolic syndrome and bone mineral density among menopausal Saudi women: case control study. Russian Open Medical Journal 2020; 9: e0412.

Introduction

The prevalence of metabolic syndrome (MetS) is expanding at an alarming rate in developed and developing nations throughout the world [1]. MetS is a cluster of the most dangerous heart attack risk factors including raised fasting plasma glucose, abdominal obesity, high cholesterol and high blood pressure [2]. Epidemiologic researches indicate that metabolic syndrome is a major risk factor for various number of chronic diseases mainly cardiovascular disease and type II diabetes [3]. According to the International Diabetes Federation (IDF) it is estimated to have MetS in around 20-25% of the world’s adult population and are twice as probable to die from and three times as likely to have a heart attack or stroke compared to individuals without the syndrome [3]. A survey published in 2018 shows that the prevalence of MetS in Saudi Arabia was found to be 39.8% (34.4% in men and 29.2% in women) and 31.6% (45.0% in men and 35.4% in women), according to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) and IDF criteria, respectively [4]. Moreover, per International Osteoporosis Foundation (IOF), osteoporosis affects an estimated 200 million people worldwide which is responsible for more than 8.9 million fractures yearly, resulting in an osteoporotic fracture every 3 seconds.

The high prevalence for both diseases prompts a need to understand the relationship between the two conditions. Epidemiological studies achieve inconclusive outcomes on the relationship between bone health and MetS, whereby this relationship is beneficial, adverse or non-significant [5]. conducted a cross-sectional study to determine the association among menopausal Korean women between risk factors of MetS and bone mineral density (BMD). The findings showed that MetS risk factors did not differ significantly, while waist circumference showed a significant association with body surface area (BSA) (r=-0.242, P<0.001), BSA (r=0.186, P<0.01) and bone mineral content (BMC) (r=0.161, P<0.05) correlated significantly with diastolic blood pressure in correlation test. This result was similar to a cross sectional study conducted by [6] that included 2007 participants (1045 males and 962 females) over 50 years of age who were examined by a preventive examination agency in urban Taiwan to examine the link between MetS and osteoporosis among Taiwanese middle-aged and elderly participants. A population-based survey in China consisting of 9930 Chinese adolescents aged 40 years or older in the district of Chongming, Shanghai was performed to assess the connection between MetS and osteoporotic fracture between middle-aged and elderly Chinese [7].

Although MetS and osteoporosis were earlier thought to be two unrelated diseases, latest studies have shown that both conditions share several genetic, nutritional and hormonal factors [8]. While the relationship between cardiovascular disease and osteoporosis has been widely studied, the specific association between MetS, a powerful risk factor for cardiovascular disease, and osteoporosis has not been discussed so extensively and several studies have shown inconsistent outcomes [9-15].

The prevalence of metabolic syndrome has increased in Saudi Arabia, forcing such a need to determine the causal factors that led MetS among aged population. Life expectancy also rises, which raises Saudi women's risk of osteoporosis. Only limited studies have focused on explaining the relationship between MetS and BMD in Saudi Arabia, these studies cover all populations including expatriated which did not determine the actual problem among Saudi women. Also, these studies are cross sectional studies which did not determine the temporality (causal association). This research will also be the first case-control study undertaken in Saudi Arabia in order to determine a possible causal relationship between the two conditions. Furthermore, only Saudi females will be included as survey respondents estimating the real issue among Saudi women.

Objectives: The aim of this study is to determine the relationship between MetS and BMD among Saudi menopausal women in Eastern Province – Saudi Arabia.

 

Material and Methods

Study setting and participants

Study setting: The study was conducted at Safwa General Hospital, one of the Eastern Province's main government facilities consisting of nearly 30 beds and serving approximately 150-200 patients daily in the outpatient departments (OPD). And also, patients were included from one of the biggest primary healthcare centers in Qatif that serve about 80-100 patients daily.

Study participants: All menopausal women (age 45-75 years old) who had got BMD scans by Dual-Energy X-ray Absorptiometry (DEXA) and were diagnosed as osteoporotic as cases and without osteoporotic as control by their physicians who visits the hospital for regular checkup

Menopausal status is defined as cessation of menstruation for at least 1 year.

 

Study design

It is a case control study.

For cases: Inclusion criteria: all menopausal women age (45-75 years old) who in their general physician visits had been advised of a bone mineral density (BMD) scan owing to their being at risk associated with bone loss and were diagnosed with osteoporosis with MetS. Exclusion criteria: perimenopausal women, participants with liver or renal diseases, inflammatory diseases, vascular diseases or with evident endocrine disorders or drug treatment with possible effect on bone metabolism like bisphosphonate, or estrogen replacement therapy.

For controls: Inclusion criteria: all menopausal women age (45-75 years old) who were free of osteoporosis with MetS Exclusion criteria: perimenopausal women, being above 75 years of age or on estrogen replacement therapy. Hormonal replacement therapy is defined as the therapeutic use of hormones typically to increase diminished levels in the body.

 

Sample size and sampling technique

Sample size: Sample size was calculated by WHO sample size calculator for health studies based on 95% confidence level, relative precision 0.25, probability to exposure given to disease 0.6, probability to exposure given to no disease 0.4 and anticipated Odd Ratio is 1.5, the sample size is 380 for this study. Divide the sample size as 190 participants for cases and 190 for control and participants were selected through stratified random sampling.

 

Data collection tool and technique

Structured questionnaire was used. The questionnaire is divided into four section first sociodemographic characteristic including smoking habit, physical exercise, exposure to sunlight and family history of MetS, anthropometric measurement, Biochemical measurement including FBG, RBG, lipid profile and DEXA measurement.

 

Anthropometry, blood sample and analysis

Height and weight were measured using an automatic anthropometer in participants wearing light clothing and no shoes. Body mass index (BMI) was calculated as body weight (in kilograms) divided by height (in meters squared) and then classified according to WHO classes: Normal (18.50–24.99 kg/m2), Overweight (25.00–29.99 kg/m2) , Obese (≥30 kg/m2), The waist circumference was measured at the midpoint between the lowest rib and the upper iliac crest using a tape measure on exhalation.

Blood pressure was measured using an automatic blood pressure monitor after resting for 10 minutes in a sitting position before measurement as the average of 2 consecutive measurements after at least 5 minutes of sitting.

Blood sample after 8-12 hours fasting was collected for the measurement of fasting blood sugar, high density lipoprotein cholesterol, and triglycerides.

 

Criteria for diagnosis of metabolic syndrome

Participants were diagnosed with MetS using the criteria set in the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) which states MetS being present if at least three of the following five components are present.

1. Central obesity: waist circumference (WC) ≥102 cm (males), ≥88 cm (females).

2. Hyperglycemia: fasting blood sugar (FBS) ≥100 mg/dl

3. Hypertriglyceridemia: serum triglycerides (TG) ≥150 mg/dl

4. Serum HDL-cholesterol (HDL-C) <50 mg/dl

5. Systolic blood pressure (SBP) ≥130mmHg and/or diastolic blood pressure (DBP) ≥85 mmHg.

 

Criteria for diagnosis of osteoporosis

The bone mineral density of the total hip were measured using dual-energy X-ray absorptiometry (DEXA). The T score was calculated, and the diagnosis of osteoporosis were made according to the World Health Organization (WHO) criteria

·           T-score between −1 and −2.5 is indicative of osteopenia

·           T-score of −2.5 and below reflects osteoporosis

·           T-score of −1 and above is considered normal T-Score Tertiles

·           Data were divided into T-score tertiles with tertile1 having the lowest T-score and tertile 3 having the highest T-score.

 

Ethical consideration

Ethical approval were obtained from Imam Abdulrahman Bin Faisal University Research Ethical Review Board. Permission were taken from the hospital. Informed consent were obtained from all subjects who agree to participate in the study before the interview. Participation is voluntary, and participants are free to withdraw at any time without any explanation. The confidentiality and privacy of the subjects were maintained and there were no financial benefit to either the subjects or the researcher.

 

Statistical analysis

All Statistical analysis were performed with SPSS windows version 23. Continuous data were presented as mean ± standard deviation (SD). Statistical significance between the groups were evaluated using Students t-test while categorical data were compared by Chi square test. Correlation between MetS and BMD were determined by Pearson’s correlation test. A Confident Interval (CI) of 95% and a P-value of less than 0.05 (two-sided) was consider statistically significant. Multinomial logistic regression were performed using the T-score tertile as a dependent variable (with lowest tertile as reference) and full MetS or its individual components (present vs. absent) as independent variables. Different models were formed with model “a” as univariate, and all other models were adjusted accordingly for + age (model “b”), + BMI (model “c”), + other components of MetS (model “d”) and + risk factors associated with bone loss like type II diabetes mellitus.

 

Results

Table 1 shows the socio-demographic characteristics of study participants. The mean age of all subjects is 63.8±7.1 years. The data shows a statistically significant difference in age categories between women with osteoporosis compared to their counterparts, i.e. those with osteoporosis are older (P<0.001).

 

Table 1. Socio-demographic characteristics of study participants (n=380)

P- value

Control

(n=190)

Cases

(n=190)

Characteristics

Sr. No

 

62.15±7.12

65.45±7.24

Age, years

1

 

<0.001

 Age categories

2

59 (63.9%)

59 (36.1%)

45-60 years

 

131 (43.7%)

131 (56.3%)

61-75 years

 

51.35±3.94

51.70±4.97

Age at menopause, years

3

Marital status

4

0.530

8 (53.3%)

8 (46.7%)

Single

 

141(51.4%)

141 (48.6%)

Married

41 (44.6%)

41 (55.4%)

Widowed& Divorced

Education level

5

0.423

76(46.7%)

76 (53.3%)

Illiterate

 

67(50%)

67 (50%)

Intermediate

47(55.3%)

47 (44.7%)

High School& University

Occupation

6

0.214

173 (49%)

173 (51%)

Housewife

 

17 (60%)

17 (40%)

Employed

 

Exposure to Sunlight

7

0.467

110 (48.4%)

110 (51.6%)

<1 time

 

80 (52.2%)

80 (47.8%)

>1 time

 

Veil Type

8

0.873

20 (46.2%)

20 (53.8%)

Covering hair only

 

108 (50.7%)

108 (49.3%)

Eyes shown only

 

62 (50%)

62 (50%)

Full cover

 

Physical Activity

9

0.016

85 (42.1%)

85 (57.9%)

<1 time

 

66 (58.3%)

66 (41.7%)

1-2 times

 

39 (53.2%)

39 (46.8%)

>3 times

 

Smoking

10

0.837

103 (50.5%)

103(49.5%)

Never smoke

 

87 (49.4%)

87 (50.6%)

Ever smoke

 

Family History of Met

11

0.334

145 (48.6%)

145 (51.4%)

Yes

 

45 (54.4%)

45 (45.6%)

No

 
Data are given as the mean ± SD or as the number of subjects with percentages given in parentheses, as appropriate. Categorical data were compared by χ2 test. BMD, bone mineral density.

 

There is no statistical significance in baseline characteristics between all participants except for physical activity. Physical inactivity is more prevalent among women with osteoporosis than those without osteoporosis (57.9% vs. 42.1, P=0.016). Whereas more women without osteoporosis are exercising 1-2 times per week more than their counterparts with osteoporosis (58.3% vs. 41.7%, P<0.05). 

Table 2 shows the difference in anthropometric and biochemical parameters of all participants. Women with higher BMI have significantly less cases of osteoporosis compared to their counterparts (58% vs. 42%, P=0.001). In addition, participants with higher Serum TG have significantly higher cases of osteoporosis compared with their counterparts (P<0.001). Moreover, women with lower mean levels of HDL-C have significantly less cases of osteoporosis compared to their counterparts (P<0.001).

 

Table 2. Anthropometric and biochemical characteristics of study participants (n=380)

Sr. No

Characteristics

Control (n=190)

Cases (n=190)

P-value

1

Mean height, cm

153.20±9.57

155.46±7.08

-

2

Mean Weight, kg

69.71±16.76

78.05±16.86

-

3

Mean WC, cm

 

Normal (WC<88cm)

43 (58.1%)

43 (41.9%)

0.086

 

Obese (WC ≥88cm)

147 (47.6%)

147 (52.4%)

4

BMI, kg/m2

31.26±22.33

32.15±6.37

-

5

BMI class

 

Normal

30 (67.2%)

31 (32.8%)

0.001

Under weight

2 (100%)

0

Overweight

61 (52.8%)

62(47.2%)

Obese

97 (42%)

97 (58%)

6

Mean SBP, mmHg

 

Normal (<130mmHg)

154 (50.2%)

154 (49.8%)

0.896

 

High (≥ 130mmHg)

36 (49.3%)

36 (50.7%)

7

Mean DBP, mmHg

 

Normal (<85mmHg)

44 (51.7%)

44 (48.3%)

0.714

 

High( ≥ 85mmHg)

146(49.5%)

146 (50.5%)

8

Level of triglyceride (TG)

 

Normal (< 90 mg/dl)

78 (41%)

78 (59%)

0.000

 

Borderline (90-129 mg/dl)

54 (40.4%)

54 (59.6%)

 

High (>129 mg/dl)

58(71.3%)

58 (28.7%)

9

Level of high-density lipoprotein (HDL)

 

Normal (> 45 mg/dl)

129 (43%)

129 (57%)

0.000

 

Borderline (40– 45 mg/dl)

29 (64.9%)

29 (35.1%)

 

Low (< 40 mmol/L)

32 (64.6%)

32 (35.4%)

10

Fasting blood sugar

 

Normal (< 100 mg/dl)

41 (50.6%)

41 (49.5%)

0.744

 

Borderline (100–125 mg/dl)

79 (51.9%)

79(48.1%)

 

High >125 mg/dl)

70 (47.5%)

70 (52.5%)

11

T-score

 

T1 (Lowest)

50 (100%)

50 (0%)

0.000

 

T2

93 (47.8%)

93 (52.2%)

 

T3 (Highest)

47 (0%)

47 (100%)

Data are given as the mean ± SD or as the number of subjects with percentages given in parentheses, as appropriate. Categorical data were compared by χ2 test. WHO criteria: a T-score between −1 and −2.5 is indicative of osteopenia, while a T-score of −2.5 and below reflects osteoporosis; a T-score of −1 and above is considered normal. 

 

Table 3 shows the prevalence of MetS in participants with tertile according to the T-score (L1-L4 spine). The lowest T-score (least BMD represents the tertile 1 and the highest T-score represents the tertile 3. The prevalence of the five components is more or less similar in different tertiles of T-score and this is seen in both groups. The data does not show significant statistical difference in either groups.

 

Table 3 Prevalence of metabolic syndrome (MetS) components in tertile of T-score (n=380)

Sr.

no

Components of Metabolic Syndrome

Cases (n=190)

Control (n=190)

T1

T2

P-value

T2

T3

P-value

1

Obesity

50.7%

42.5%

0.340

53.2%

64.8%

0.211

2

Hyperglycemia

52.5%

47.5%

0.675

49.7%

50.3%

0.357

3

Low HDL level

55.3%

44.7%

0.372

54.7%

45.3%

0.403

4

Hypertension

 

 

Systolic (SPB)

55.2%

44.8%

0.318

47.3%

52.7%

0.052

Diastolic (DPB)

44.4%

55.6%

0.245

48.6%

51.4%

0.744

5

Hypertriglyceridemia

57.5%

46.8%

0.340

54.5%

45.5%

0.727

Categorical data were compared by χ2 test. WHO criteria: a T-score between −1 and −2.5 is indicative of osteopenia, while a T-score of −2.5 and below reflects osteoporosis; a T-score of −1 and above is considered normal. P-value <0.05 significant.

 

Table 4 shows the results of the correlation between MetS and BMD in both groups. A very weak negative correlation was observed between BMD and SBP (r=-0.072), TG (r=-0.069) and HDL (R=-0.065) in women with osteoporosis , and between BMD and WC (r=-0.091), TG (r=-0.025) and HDL (r=-0.061) in their control counterparts. No statistical significance was found in either group (P-value >0.05).

 

Table 4 Correlation between bone mineral density and features of the metabolic syndrome in 380 postmenopausal women

Sr.No

Variables

BMD cases

BMD controls

 

 

T score

T score

 

 

r (P-value)

r (P-value)

1

WC, cm

0.082 (0.050)

-0.091 (0.213)

2

SBP, mmHg

-0.072 (0.320)

0.141 (0.052)

3

DBP, mmHg

0.084 (0.247)

0.024 (0.746)

4

FBS, mmol/L

0.030 (0.677)

0.067 (0.360)

5

TG, mmol/L

-0.069 (0.342)

-0.025 (0.729)

6

HDL, mmol/L

-0.065 (0.375)

-0.061 (0.406)

Pearson correlations. WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, fasting blood glucose; TG, triglycerides; HDL-C, high-density lipoprotein cholesterol. 

 

Table 5 shows the association of socio-demographic characteristics with osteoporosis. All the socio-demographic characteristics were associated of osteoporosis but none of them were statistically significant.

 

Table 5 Associations of osteoporosis with metabolic syndrome other risk factors among women in Dammam

Risk Factors

Cases (n=190) N, %

Control (n=190) N, %

Unadjusted risk Estimate OR (95% CI)

P-value

Adjusted Risk Estimate OR (95% CI)

P-value

Age

45-60 years

59.5 (36.1%)

76 (40%)

0.439 (0.281-0.686)

0.000

0.128 (0.050-.327)

0.000

61-75 years

130.5 (56.3%)

114 (60%)

0b

0b

0b

0b

BMI

Normal

44 (23.2%)

20 (10.5%)

0b

0b

0b

0b

Overweight

65 (34.2%)

58 (30.5%)

0.509 (0.270-0.962)

0.038

1.087 (0.398-2.964)

0.871

Obese

81 (42.6%)

112 (58.9%)

1.329 (1.180-1.600)

0.000

2.569 (2.224-3.445)

0.030

Marital status

Single

7 (3.7%)

8 (4.2%)

0.704 (0.234-2.120)

0.532

0.400 (0.059-2.716)

0.348

Married

137 (72.1%)

145 (76.3%)

0.760 (0.465-1.243)

0.274

0.797 (0.355-1.789)

0.582

Widowed

46 (24.2%)

37 (19.5%)

0b

0b

0b

0b

Education

Illiterate

81 (42.6%)

71 (37.4%)

1.412 (0.843-2.368)

0.190

0.702 (0.222-2.227)

0.548

Intermediate

67 (35.3%)

67 (35.3%)

1.238 (0.729-2.102)

0.429

0.865 (0.306-2.447)

0.785

University

42 (22.1%)

52 (27.4%)

0b

0b

0b

0b

Occupation

Employed

14 (7.4%)

21 (11.1%)

0b

0b

0b

0b

Unemployed

176 (92.6%)

169 (88.9%)

1.562 (0.769-3.172)

0.217

1.686 (0.345-8.228)

0.519

Veil type

Hair only

21 (11.1%)

18 (9.5%)

0b

0b

0b

0b

Eyes shown

107 (56.3%)

110 (57.9%)

0.834 (0.421-1.652)

0.602

0.713 (0.214-2.372)

0.581

Full cover

62 (32.6%)

62 (32.6%)

0.857 (0.417-1.763)

0.675

0.348 (0.097-1.248)

0.105

Physical activity

< 1time

99 (52.1%)

72 (37.9%)

1.566 (0.912-2.690)

0.104

1.041 (0.358-3.027)

0.941

1-2 times

55 (28.9%)

77 (40.5%)

0.813 (0.462-1.432)

0.475

0.685 (0.236-1.988)

0.487

>3 times

36 (18.9%)

41 (21.6%)

0b

0b

0b

0b

Smoking

Ever

88 (46.3%)

86 (45.3%)

1.043 (0.697-1.562)

0.837

0.541 (0.265-1.108)

0.093

Never

102 (53.7%)

104 (54.7%)

0b

0b

0b

0b

Odds ratio with 95% confidence interval. BMI, body mass index. The reference category is: T1. b: this parameter is reference category. 

 

Table 6 shows the association of metabolic syndrome characteristics with osteoporosis in multiple regression analysis. Triglyceride is the only component of metabolic syndrome were statically significant associated with osteoporosis. Every unit change of triglycerides the -0.004 unit decreased in the osteoporosis.

 

Table 6 Multiple regression analysis of the effect of metabolic syndrome risk factors on T-score

Risk Factors

B

SE

β

p-value

WC

0.000

0.002

0.014

0.78

SBP

0.001

0.005

-0.014

0.05

DBP

0.006

0.008

0.043

0.44

TG

0.004

0.001

-0.194

0.00

HDL

0.002

0.005

0.019

0.72

FBS

0.001

0.002

0.023

0.66

B, unstandardized beta; SE, standard error; β, standardized beta; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure; TG, triglyceride; HDL-C, high density lipoprotein cholesterol; FBS, fasting blood sugar. 

 

Discussion

The study results revealed osteoporosis was significantly associated with a metabolic syndrome in Saudi women. This association was unbiassed of other covariates.

Metabolic syndrome (MetS) is a group of cardiovascular hazards which have been clustered under one umbrella because they exist together much more often than would be expected by probability. This result is consistent with other studies results [16-18]. Moreover, some universal mechanisms for both illnesses have been related. For example, low HDL levels are considered preemptive risk factors for osteoporosis, and it also have been suggested to progress of MetS [19-22].

This study results found that metabolic syndrome components prevalence was more in osteoporosis patients compare to non-osteoporosis patients. These results were consistent with other studies results, previous studies have revealed that higher blood pressure in osteoporosis patients with increased chance of bone loss [23]. Furthermore, low HDL level was observed among those who have osteoporosis [24]. Case control study was conducted, result found that high blood pressure was major contributor to bone loss [25]. other components of MetS is TG level, our study found that high level in osteoporosis patients and definitely, TG level increase with age.

This study also found that WC and obesity is strongly associated with MetS. This result consistent with other study results. Even Though the pathophysiological systems connecting obesity to osteoporotic fracture have not been well recognized, it is plausible to consider disproportionate growth of visceral fat could affect in a higher emission of proinflammatory cytokines, with a harmful outcome on bone [26-28].

Physical activity was also associated with osteoporosis in this study results. This results contrast of other study results. Previous study found that those who have more physical active was less chance of osteoporosis fracture [29]. The reason for this conclusion is the when person more active which increased the bone mineral replacement and good for health.

The study results also found that those women who cover the body had more association of osteoporosis. The reason for this association is that sunlight is important predictor for bone mineral. This result is consistent with other study results [30-31].

This study had few limitations. First, this study recruited only two centres, therefore it is difficult to generalize the findings to women. Second, ages of the study subjects were limited to those in their 75s, results for oldest post-menopausal women were not analyzed. Third, bone-metabolism-associated factors such as vitamin D, blood levels of calcium, eating behavior, smoking, alcohol consumption all of which may affect BMD of menopausal women, were not examined in this study, which may confound the explanation of the results of this study.

 

Conclusion

This study found that presence of MetS was significantly associated with osteoporosis Saudi women. Further experimental studies were needed to generating the strong evidence.

 

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments, or comparable ethical standards.

 

Conflict of interest

None declared.

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About the Authors: 

Essra Aldawood – BDS, MPH, Dental Surgeon, Primary Health Care Centre, Ministry of Health, Al-Jubail, Saudi Arabia. https://orcid.org/0000-0002-8697-6463
Mubashir Zafar – MBBS, MBA, FCPS, Assistant Professor, Family and Community Medicine Department, College of Medicine, University of Hail, Hail, Saudi Arabia. https://orcid.org/0000-0002-7440-0635

Received 2 April 2020, Accepted 6 October 2020 
© 2020, Aldawood E., Zafar M.    
© 2020, Russian Open Medical Journal 
Correspondence to Mubashir Zafar. E-mail: researchmubshir@outlook.com. 

DOI: 
10.15275/rusomj.2020.0412