Journal of the American College of Nutrition
ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
Urban–Rural Differentials in Overweight and Obese Individuals with Diarrhea in Bangladesh Sumon Kumar Das MBBS, Mohammod Jobayer Chisti MMed, Mohammad Abdul Malek MSc, Lana Vanderlee, Mohammed Abdus Salam MBBS, Tahmeed Ahmed PhD, Pradip Kumar Bardhan MD, Abu Syed Golam Faruque MPH & Abdullah Al Mamun PhD To cite this article: Sumon Kumar Das MBBS, Mohammod Jobayer Chisti MMed, Mohammad Abdul Malek MSc, Lana Vanderlee, Mohammed Abdus Salam MBBS, Tahmeed Ahmed PhD, Pradip Kumar Bardhan MD, Abu Syed Golam Faruque MPH & Abdullah Al Mamun PhD (2014) Urban–Rural Differentials in Overweight and Obese Individuals with Diarrhea in Bangladesh, Journal of the American College of Nutrition, 33:6, 459-465, DOI: 10.1080/07315724.2013.875412 To link to this article: http://dx.doi.org/10.1080/07315724.2013.875412
Published online: 11 Nov 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=uacn20 Download by: [Dalhousie University]
Date: 12 November 2015, At: 15:46
Original Research
Urban–Rural Differentials in Overweight and Obese Individuals with Diarrhea in Bangladesh Sumon Kumar Das, MBBS, Mohammod Jobayer Chisti, MMed, Mohammad Abdul Malek, MSc, Lana Vanderlee, Mohammed Abdus Salam, MBBS, Tahmeed Ahmed, PhD, Pradip Kumar Bardhan, MD, Abu Syed Golam Faruque, MPH, Abdullah Al Mamun, PhD International Centre for Diarrheal Disease Research, Dhaka, BANGLADESH (S.K.D., M.J.C., M.A.M., M.A.S., T.A., P.K.B., A.S.G.F.); School of Public Health and Health Systems, University of Waterloo, Waterloo, CANADA (L.V.); School of Population Health, University of Queensland, Brisbane, AUSTRALIA (S.K.D., A.A.M.)
Journal of the American College of Nutrition 2014.33:459-465.
Key words: Bangladesh, diarrhea, obesity, overweight, rural, urban Objective: The study aimed to determine urban and rural differences in overweight and obesity (OO) with diarrhea regarding subjects’ sociodemographic, clinical characteristics, etiology, and antimicrobial susceptibility. Methods: Relevant information from 2000 to 2011 were extracted from the data archive of the Diarrheal Disease Surveillance System of urban Dhaka (1248, 4.5%) and rural Matlab (615, 3.4%) hospitals of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). Results: The proportion of OO significantly increased in both urban (3–7%; chi-square for trend p < 0.001) and rural (1–6%; p < 0.001) areas over the study period. In multivariate modeling, monthly income more than US$100 (odds ratio [OR] = 54.44, 95% confidence interval [CI], 25.37–116.82, p < 0.001), high wealth quintile (OR = 18.23, 95% CI, 8.63–38.49, p < 0.001), access to sanitary toilet (OR = 3.07. 95% CI. 1.76–5.26. p < 0.001), boiled drinking water (OR = 2.77, 95% CI, 1.09–7.05, p = 0.032), antimicrobial use before hospitalization (OR = 4.99, 95% CI, 2.85–8.74, p < 0.001), fever (OR = 0.14, 95% CI, 0.37, 0.50, p < 0.001), watery stools (OR = 5.59, 95% CI, 2.11–14.80, p < 0.001), dehydrating diarrhea (OR = 5.17, 95% CI, 2.54–10.52, p < 0.001), intravenous saline infusion after hospitalization (OR = 2.65, 95% CI, 1.28–5.49, p = 0.009), and Salmonella infection (OR = 0.20, 95% CI, 0.50–0.83, p = 0.027) remained significantly associated with urban OO individuals. At least 88% of Shigella isolates were susceptible to ciprofloxacin in both urban and rural areas; for mecillinum it was 90%. Ciprofloxacin had the least detected resistance for Vibrio cholerae (0%) and trimethoprim-sulfamethoxazole (TMP-SMX) showed the greatest resistance (Dhaka 86%; Matlab 98%). Susceptibility for Salmonella showed ampicillin (95%), chloramphenecol (100%), ciprofloxacin (95%), ceftraxone (93%), TMP-SMX (95%) at both sites. Conclusion: Urban OO with diarrheal illnesses was significantly different from that in rural areas, including antimicrobial susceptibility.
INTRODUCTION
creased disease burden due to noncommunicable and chronic diseases [1]. Increases in regional and global prevalence of overweight and obesity substantially impact the public health burden not only in developed but also in developing countries [2]. Evidence suggests that overweight and obesity are more dominant in urban areas; however, rural residents are also at risk. In several contexts, proportions are higher in rural than urban population
The epidemiological transition is causing a gradual shift in disease patterns in developing countries. Improvements in public health practices, such as nutrition and hygiene, are contributing to a shift from infectious, communicable diseases to chronic, noncommunicable diseases. Increasing attention is being paid to overweight and obesity as significant contributors to the in-
Address correspondence to: Abu Syed Golam Faruque, Centre for Nutrition and Food Security (CNFS), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, BANGLADESH. E-mail: [email protected] Abbreviations: BMI = body mass index, CI = confidence interval, CLSI = Clinical Laboratory Standards Institute, DDSS = Diarrheal Disease Surveillance System, ERC = Ethical Review Committee, ETEC = enterotoxigenic Escherichia coli, HDSS = Health and Demographic Surveillance System, icddr,b = International Centre for Diarrheal Disease Research, Bangladesh, OR = odds ratios, RRC = Research Review Committee, SD = standard deviation, SPSS = Statistical Package for Social Sciences, TMP-SMX = trimethoprim-sulfamethoxazole, WHO = World Health Organization.
Journal of the American College of Nutrition, Vol. 33, No. 6, 459–465 (2014) C American College of Nutrition Published by Taylor & Francis Group, LLC 459
Journal of the American College of Nutrition 2014.33:459-465.
Urban–Rural Overweight and Obese with Diarrhea [3–6]. This may be due to differences in socioeconomic characteristics, lifestyle patterns, and food habits between rural and urban areas [4,7,8]. Nevertheless, urban–rural similarities have also been documented [7]. Often individuals suffer from chronic and infectious disease simultaneously. Diarrhea caused by various enteropathogens, such as rotavirus, enterotoxigenic Escherichia coli (ETEC), Vibrio cholerae, and Shigella remains a major public health problem globally [9–12]. Vast literature has examined the relationship between diarrheal disease and malnutrition [13,14]; however, evidence-based information about diarrheal disease among overweight and obese individuals is grossly lacking, including urban and rural differences. Due to excess subcutaneous fat it is often difficult to assess dehydration status among overweight and obese individuals with diarrhea. Urban–rural differentials always bear public health implications, especially for planning of different interventions for prevention of many public health challenges, and overweight and obesity is a major concern. The International Center for Diarrhoeal Disease Research Bangladesh (icddr,b) maintains aroundthe-clock diarrheal disease surveillance in urban Dhaka and rural Matlab, which paves the way to ascertain such differentials. Thus, the present study aims to determine the urban–rural differentials with regard to sociodemographics, clinical and etiological diversity, and antimicrobial susceptibility among overweight and obese individuals in Bangladesh.
Matlab Hospital Matlab Hospital, located approximately 55 km south of Dhaka, was selected as the rural study site. Matlab Hospital was established in 1963 and provides free treatment to 12,000–15,000 diarrhea patients annually. The Health and Demographic Surveillance System (HDSS) was established 40 years prior and has collected continuous demographic information on a population of more than 200,000. The HDSS collects information on vital events such as birth, death, marriage, and migration (in and out) thrice yearly. All diarrhea patients coming for the HDSS were enrolled in the DDSS irrespective of age, sex, and sociodemographic status.
Definition of Overweight and Obesity Patients were stratified under 3 age strata: (1) children under 5 years of age, (2) preadolescents and adolescents aged 5–19 years, and (3) adults older than 19 years. We defined overweight and obesity following World Health Organization guidelines, using weight-for-height z-score for children under 5 (> + 2.00 SD), body mass index (BMI)-for-age zscore (> + 2.00 SD for preadolescents and adolescents aged 5–19 years, and BMI of >25 kg/m2 for adults older than 19 years [15,16].
Sampling Frame
MATERIALS AND METHODS Study Site, Source of Data, and the Hospital Surveillance System The study included data collected from diarrheal disease surveillance system of 2 hospitals in Bangladesh.
For the present analysis, relevant information from 2000 to 2011 was extracted from the data archive of DDSS and HDSS. During the study period, a total of 27,538 in Dhaka and 18,242 in Matlab Hospital were enrolled in the surveillance systems. Of these patients, 1248 (4.5%) and 615 (3.4%) were found to be overweight or obese from the urban and rural areas, respectively. These individuals were the representative samples for the present analysis.
Dhaka Hospital Dhaka Hospital is located in Dhaka, the capital city of Bangladesh, and was selected as the urban study site. The hospital was established in 1962 by the icddr,b and currently provides free care and treatment to around 140,000 patients each year. The Diarrheal Disease Surveillance System (DDSS) was established at the hospital in 1979 to collect longitudinal data on its patient populations. The DDSS systematically sampled 4% of all patients from 1979 through 1995 and 2% since 1996, adjusted due to an increased number of patients (more than double) while assuming no major changes in the prevalence of different diarrhea etiologies. The DDSS collects information on clinical, epidemiological, and demographic characteristics; the feeding practices of infants and young children; and use of drug and fluid therapy at home by administering a structured questionnaire.
460
Lab Methodology All patients coming from the HDSS area in Matlab were included and their stool specimens were processed in the Matlab Microbiology Laboratory; a 2% subsample from Dhaka Hospital was examined in the central laboratory in Dkaha. Each specimen was aliquoted into 3 serial containers and submitted to the respective laboratories for routine screening of common enteric pathogens such as Vibrio cholerae [17], Shigella spp. [18], Salmonella [18], Campylobacter [18], and rotavirus [19] applying standard methods. Bacterial susceptibility to antimicrobial agents was determined by the disk diffusion method as recommended by the Clinical Laboratory Standards Institute (2010) [20] with commercial antimicrobial discs (Oxoid, Basingstoke, UK). The antibiotic discs used in this study were ampicillin (10 µg), mecillinum
VOL. 33, NO. 6
Urban–Rural Overweight and Obese with Diarrhea (25 µg), nalidixic acid (30 µg), trimethoprim-sulfamethoxazole (cotrimoxazole, TMP-SMX; 25 µg), and ciprofloxacin (5 µg) for Shigella. For Vibrio cholerae, tetracycline (30 µg), TMPSMX (25 µg), erythromycin (15 µg), and ciprofloxacin (5 µg) antibiotic discs were used. For Salmonella they were ampicillin (10 µg), nalidixic acid (30 µg), choleramphenecol (30 µg), TMP-SMX (25 µg), ciprofloxacin (5 µg), and cefreiaxone (30 µg) [20].
Journal of the American College of Nutrition 2014.33:459-465.
Data Analysis Data were analyzed using Statistical Package for Social Sciences for Windows (Ver. 15.2, Chicago, IL) and Epi Info (Ver. 6.0, Stone Mountain, GA). We compared differences in the proportions by Chi-square test. A probability of US$100 Small family size (≤5 mean) Wealth quintile Rich Upper middle Middle Lower middle Poor Sanitary toilet Use boiled water for drinking Antimicrobial therapy before attending the hospital Fever (≥37.8◦ C) Vomiting Duration of diarrhea (>1 day) Watery stools Abdominal pain Dehydration (some or severe) Intravenous rehydration Hospitalization >24 hours V. Cholerae Shigella Rotavirus Salmonella Campylobacter
Urban n = 1248 (%)
Rural n = 615 (%)
Unadjusted OR (95% CI) p Value
265 (21) 983 (79) 590 (47) 1212 (97) 793 (64)
149 (24) 466 (76) 244 (40) 313 (51) 367 (60)
0.84 (0.67, 1.07) 0.161 1.19 (0.94, 1.50) 0.161 1.36 (1.12, 1.67) 0.002 32.48 (22.19, 47.74)
ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
Urban–Rural Differentials in Overweight and Obese Individuals with Diarrhea in Bangladesh Sumon Kumar Das MBBS, Mohammod Jobayer Chisti MMed, Mohammad Abdul Malek MSc, Lana Vanderlee, Mohammed Abdus Salam MBBS, Tahmeed Ahmed PhD, Pradip Kumar Bardhan MD, Abu Syed Golam Faruque MPH & Abdullah Al Mamun PhD To cite this article: Sumon Kumar Das MBBS, Mohammod Jobayer Chisti MMed, Mohammad Abdul Malek MSc, Lana Vanderlee, Mohammed Abdus Salam MBBS, Tahmeed Ahmed PhD, Pradip Kumar Bardhan MD, Abu Syed Golam Faruque MPH & Abdullah Al Mamun PhD (2014) Urban–Rural Differentials in Overweight and Obese Individuals with Diarrhea in Bangladesh, Journal of the American College of Nutrition, 33:6, 459-465, DOI: 10.1080/07315724.2013.875412 To link to this article: http://dx.doi.org/10.1080/07315724.2013.875412
Published online: 11 Nov 2014.
Submit your article to this journal
Article views: 45
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=uacn20 Download by: [Dalhousie University]
Date: 12 November 2015, At: 15:46
Original Research
Urban–Rural Differentials in Overweight and Obese Individuals with Diarrhea in Bangladesh Sumon Kumar Das, MBBS, Mohammod Jobayer Chisti, MMed, Mohammad Abdul Malek, MSc, Lana Vanderlee, Mohammed Abdus Salam, MBBS, Tahmeed Ahmed, PhD, Pradip Kumar Bardhan, MD, Abu Syed Golam Faruque, MPH, Abdullah Al Mamun, PhD International Centre for Diarrheal Disease Research, Dhaka, BANGLADESH (S.K.D., M.J.C., M.A.M., M.A.S., T.A., P.K.B., A.S.G.F.); School of Public Health and Health Systems, University of Waterloo, Waterloo, CANADA (L.V.); School of Population Health, University of Queensland, Brisbane, AUSTRALIA (S.K.D., A.A.M.)
Journal of the American College of Nutrition 2014.33:459-465.
Key words: Bangladesh, diarrhea, obesity, overweight, rural, urban Objective: The study aimed to determine urban and rural differences in overweight and obesity (OO) with diarrhea regarding subjects’ sociodemographic, clinical characteristics, etiology, and antimicrobial susceptibility. Methods: Relevant information from 2000 to 2011 were extracted from the data archive of the Diarrheal Disease Surveillance System of urban Dhaka (1248, 4.5%) and rural Matlab (615, 3.4%) hospitals of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b). Results: The proportion of OO significantly increased in both urban (3–7%; chi-square for trend p < 0.001) and rural (1–6%; p < 0.001) areas over the study period. In multivariate modeling, monthly income more than US$100 (odds ratio [OR] = 54.44, 95% confidence interval [CI], 25.37–116.82, p < 0.001), high wealth quintile (OR = 18.23, 95% CI, 8.63–38.49, p < 0.001), access to sanitary toilet (OR = 3.07. 95% CI. 1.76–5.26. p < 0.001), boiled drinking water (OR = 2.77, 95% CI, 1.09–7.05, p = 0.032), antimicrobial use before hospitalization (OR = 4.99, 95% CI, 2.85–8.74, p < 0.001), fever (OR = 0.14, 95% CI, 0.37, 0.50, p < 0.001), watery stools (OR = 5.59, 95% CI, 2.11–14.80, p < 0.001), dehydrating diarrhea (OR = 5.17, 95% CI, 2.54–10.52, p < 0.001), intravenous saline infusion after hospitalization (OR = 2.65, 95% CI, 1.28–5.49, p = 0.009), and Salmonella infection (OR = 0.20, 95% CI, 0.50–0.83, p = 0.027) remained significantly associated with urban OO individuals. At least 88% of Shigella isolates were susceptible to ciprofloxacin in both urban and rural areas; for mecillinum it was 90%. Ciprofloxacin had the least detected resistance for Vibrio cholerae (0%) and trimethoprim-sulfamethoxazole (TMP-SMX) showed the greatest resistance (Dhaka 86%; Matlab 98%). Susceptibility for Salmonella showed ampicillin (95%), chloramphenecol (100%), ciprofloxacin (95%), ceftraxone (93%), TMP-SMX (95%) at both sites. Conclusion: Urban OO with diarrheal illnesses was significantly different from that in rural areas, including antimicrobial susceptibility.
INTRODUCTION
creased disease burden due to noncommunicable and chronic diseases [1]. Increases in regional and global prevalence of overweight and obesity substantially impact the public health burden not only in developed but also in developing countries [2]. Evidence suggests that overweight and obesity are more dominant in urban areas; however, rural residents are also at risk. In several contexts, proportions are higher in rural than urban population
The epidemiological transition is causing a gradual shift in disease patterns in developing countries. Improvements in public health practices, such as nutrition and hygiene, are contributing to a shift from infectious, communicable diseases to chronic, noncommunicable diseases. Increasing attention is being paid to overweight and obesity as significant contributors to the in-
Address correspondence to: Abu Syed Golam Faruque, Centre for Nutrition and Food Security (CNFS), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, BANGLADESH. E-mail: [email protected] Abbreviations: BMI = body mass index, CI = confidence interval, CLSI = Clinical Laboratory Standards Institute, DDSS = Diarrheal Disease Surveillance System, ERC = Ethical Review Committee, ETEC = enterotoxigenic Escherichia coli, HDSS = Health and Demographic Surveillance System, icddr,b = International Centre for Diarrheal Disease Research, Bangladesh, OR = odds ratios, RRC = Research Review Committee, SD = standard deviation, SPSS = Statistical Package for Social Sciences, TMP-SMX = trimethoprim-sulfamethoxazole, WHO = World Health Organization.
Journal of the American College of Nutrition, Vol. 33, No. 6, 459–465 (2014) C American College of Nutrition Published by Taylor & Francis Group, LLC 459
Journal of the American College of Nutrition 2014.33:459-465.
Urban–Rural Overweight and Obese with Diarrhea [3–6]. This may be due to differences in socioeconomic characteristics, lifestyle patterns, and food habits between rural and urban areas [4,7,8]. Nevertheless, urban–rural similarities have also been documented [7]. Often individuals suffer from chronic and infectious disease simultaneously. Diarrhea caused by various enteropathogens, such as rotavirus, enterotoxigenic Escherichia coli (ETEC), Vibrio cholerae, and Shigella remains a major public health problem globally [9–12]. Vast literature has examined the relationship between diarrheal disease and malnutrition [13,14]; however, evidence-based information about diarrheal disease among overweight and obese individuals is grossly lacking, including urban and rural differences. Due to excess subcutaneous fat it is often difficult to assess dehydration status among overweight and obese individuals with diarrhea. Urban–rural differentials always bear public health implications, especially for planning of different interventions for prevention of many public health challenges, and overweight and obesity is a major concern. The International Center for Diarrhoeal Disease Research Bangladesh (icddr,b) maintains aroundthe-clock diarrheal disease surveillance in urban Dhaka and rural Matlab, which paves the way to ascertain such differentials. Thus, the present study aims to determine the urban–rural differentials with regard to sociodemographics, clinical and etiological diversity, and antimicrobial susceptibility among overweight and obese individuals in Bangladesh.
Matlab Hospital Matlab Hospital, located approximately 55 km south of Dhaka, was selected as the rural study site. Matlab Hospital was established in 1963 and provides free treatment to 12,000–15,000 diarrhea patients annually. The Health and Demographic Surveillance System (HDSS) was established 40 years prior and has collected continuous demographic information on a population of more than 200,000. The HDSS collects information on vital events such as birth, death, marriage, and migration (in and out) thrice yearly. All diarrhea patients coming for the HDSS were enrolled in the DDSS irrespective of age, sex, and sociodemographic status.
Definition of Overweight and Obesity Patients were stratified under 3 age strata: (1) children under 5 years of age, (2) preadolescents and adolescents aged 5–19 years, and (3) adults older than 19 years. We defined overweight and obesity following World Health Organization guidelines, using weight-for-height z-score for children under 5 (> + 2.00 SD), body mass index (BMI)-for-age zscore (> + 2.00 SD for preadolescents and adolescents aged 5–19 years, and BMI of >25 kg/m2 for adults older than 19 years [15,16].
Sampling Frame
MATERIALS AND METHODS Study Site, Source of Data, and the Hospital Surveillance System The study included data collected from diarrheal disease surveillance system of 2 hospitals in Bangladesh.
For the present analysis, relevant information from 2000 to 2011 was extracted from the data archive of DDSS and HDSS. During the study period, a total of 27,538 in Dhaka and 18,242 in Matlab Hospital were enrolled in the surveillance systems. Of these patients, 1248 (4.5%) and 615 (3.4%) were found to be overweight or obese from the urban and rural areas, respectively. These individuals were the representative samples for the present analysis.
Dhaka Hospital Dhaka Hospital is located in Dhaka, the capital city of Bangladesh, and was selected as the urban study site. The hospital was established in 1962 by the icddr,b and currently provides free care and treatment to around 140,000 patients each year. The Diarrheal Disease Surveillance System (DDSS) was established at the hospital in 1979 to collect longitudinal data on its patient populations. The DDSS systematically sampled 4% of all patients from 1979 through 1995 and 2% since 1996, adjusted due to an increased number of patients (more than double) while assuming no major changes in the prevalence of different diarrhea etiologies. The DDSS collects information on clinical, epidemiological, and demographic characteristics; the feeding practices of infants and young children; and use of drug and fluid therapy at home by administering a structured questionnaire.
460
Lab Methodology All patients coming from the HDSS area in Matlab were included and their stool specimens were processed in the Matlab Microbiology Laboratory; a 2% subsample from Dhaka Hospital was examined in the central laboratory in Dkaha. Each specimen was aliquoted into 3 serial containers and submitted to the respective laboratories for routine screening of common enteric pathogens such as Vibrio cholerae [17], Shigella spp. [18], Salmonella [18], Campylobacter [18], and rotavirus [19] applying standard methods. Bacterial susceptibility to antimicrobial agents was determined by the disk diffusion method as recommended by the Clinical Laboratory Standards Institute (2010) [20] with commercial antimicrobial discs (Oxoid, Basingstoke, UK). The antibiotic discs used in this study were ampicillin (10 µg), mecillinum
VOL. 33, NO. 6
Urban–Rural Overweight and Obese with Diarrhea (25 µg), nalidixic acid (30 µg), trimethoprim-sulfamethoxazole (cotrimoxazole, TMP-SMX; 25 µg), and ciprofloxacin (5 µg) for Shigella. For Vibrio cholerae, tetracycline (30 µg), TMPSMX (25 µg), erythromycin (15 µg), and ciprofloxacin (5 µg) antibiotic discs were used. For Salmonella they were ampicillin (10 µg), nalidixic acid (30 µg), choleramphenecol (30 µg), TMP-SMX (25 µg), ciprofloxacin (5 µg), and cefreiaxone (30 µg) [20].
Journal of the American College of Nutrition 2014.33:459-465.
Data Analysis Data were analyzed using Statistical Package for Social Sciences for Windows (Ver. 15.2, Chicago, IL) and Epi Info (Ver. 6.0, Stone Mountain, GA). We compared differences in the proportions by Chi-square test. A probability of US$100 Small family size (≤5 mean) Wealth quintile Rich Upper middle Middle Lower middle Poor Sanitary toilet Use boiled water for drinking Antimicrobial therapy before attending the hospital Fever (≥37.8◦ C) Vomiting Duration of diarrhea (>1 day) Watery stools Abdominal pain Dehydration (some or severe) Intravenous rehydration Hospitalization >24 hours V. Cholerae Shigella Rotavirus Salmonella Campylobacter
Urban n = 1248 (%)
Rural n = 615 (%)
Unadjusted OR (95% CI) p Value
265 (21) 983 (79) 590 (47) 1212 (97) 793 (64)
149 (24) 466 (76) 244 (40) 313 (51) 367 (60)
0.84 (0.67, 1.07) 0.161 1.19 (0.94, 1.50) 0.161 1.36 (1.12, 1.67) 0.002 32.48 (22.19, 47.74)
