XA0404145 RISK FACTORS FOR OBESITY IN CHINESE ADULTS

GuANsHENG MA, M.D.

Institute of Nutrition and Food Safety, Chinese Center for Disease Control and Prevention

1. SCIENTIFIC BACKGROUND AND SCOPE OF TE PROJECT

1.1. Demographic Transition in The World Health Report draws attention to the fact that this is an era of population aging. China is also becoming a society of aging. The total population in China is 12 billion which almost one-fourth of the world population in 1997 [1]. There were more than 0.1 billion population aged 65 and over in 1996, which 6 of the total population in China and about 20% of the total aging population in the world 1].

Along with the development of socioeconomic, improvement of living standard and system, the death rate decreased gradually since 1960 [1] while the life expectancy increased dramatically since 1949. The life expectancy at birth for Chinese people was 35.6 years before 1949. It increased to 68.9 years, 71.0 years in 1985, 1997 respectively 2. However, increases in life expectancy mean little if health expectancy is not assured simultaneously.

1.2. Nutritional and Epidemiological Transitions in China The pattern of food consumption in China has been subject to significant changes in the last 30-40 years. According to the national statistical of food provision, while the consumption of plant foods decreased, consumption of animal foods increased significantly from 1977-1987 [3] and the same trend continues 4 This change is more significant in urban areas as compared with rural areas.

There is also a shift of disease pattern along with the change of dietary pattern. Health statistical data from National Statistics [5] show that in the last four decades, there has been a steep decrease in communicable diseases and simultaneously, a significant increase in degenerative chronic diseases. The mortality rate of acute infectious diseases reduced by 98% between 1957 and 1990, but at the same time, that of cancer, hypertension, coronary heart disease (CHD), and diabetes increased by 240%, 60%, 88%, and 169% respectively. The sum of mortality of cancer, cerebrovascular and cardiovascular diseases now account for about 70% of the total deaths in urban areas, 50% in rural areas in China. All the above data confirm that the transition of the dietary pattern has already affected the health of the Chinese population, especially people in the urban areas.

1.3. Obesity in China China in the early 1980s had the best population distribution of BMIs in the world but major BMI increases are underway, particularly with urbanization. According to results of 1992 China National Nutrition Survey, there were 23. 1% of adults aged 20-45 in urban areas whose BMI bigger than 25 kg/m2. Using the definitions for overweight based on the Body Mass Index 6] almost half of the adult population in Beijing 7] and more than half of the elder

63 population in urban Beijing are overweight [8]. Obesity is now one of the major public health problems in China.

The economic costs of obesity are tremendous. In Australia 9], the direct costs of health care attributable to obesity were A$395 million or 2 per cent of health care costs between 1989- 1990. In Netherlands [10], the estimated direct costs associated with overweight and obesity were one billion Dutch guilders per year or 4 per cent of the total health care costs in 1991 In the U.S. [I 1, the estimated direct costs of obesity were 45.8 billion dollars or 68 per cent of the health care costs in 1990. Although no data available about the direct costs of obesity in China, it should be an astronomical figure.

Many health hazards are associated with obesity 12]. Being obese can induce multiple metabolic abnormalities that contribute to cardiovascular disease, diabetes mellitus, and other chronic degenerative diseases 13 ]. Manson 14] and Lew [ 15] reported that increased risk of all-cause and coronary heart disease mortality were associated with BMI. Study in USA 16] indicated that obese individuals have a four time greater risk of developing hypertension as compared to lean people. Colditz 17] found that early obesity increased risk of developing non-insulin-dependent diabetes mellitus (NIDDM) and 88 to 97 per cent of NIDDM was attributable to their obesity.

The underlying causes of the increasing prevalence of obesity are not well understood, Energy intake and physical activity are thought to be some of the major lifestyle factors that are involved [18, 19]. However, the contribution of each specific factor has not yet been identified. It has been recognized that high levels of body fat cannot have been accumulated without energy intake being unusually high or energy expenditure being unusually low, or a combination of these two options. There have been cross-sectional, prospective and intervention studies in defining factor which primarily determining energy regulation 20-27]. However, the results of these studies are conflicting and have not yet permitted any general consensus over the relative importance of energy intake and energy expenditure in the determination of body fat mass. Further study should be conducted to clarify it.

Because effective measures for treating obesity are lacking, the most effective and economic strategy is to prevent it happens. The risk factors to obesity should be identified in order to develop effective prevention strategies.

2. RESEARCH OBJECTIVES

• To compare the dietary intakes of Chinese adults with normal weight, overweight and obesity. • To compare the physical activity levels and energy expenditure of Chinese adults with normal weight, overweight and obesity. • To identify the risk factors for overweight and obesity among Chinese population. • To provide scientific information for developing obesity prevention strategies.

64 3. STUDY DESIGN

This is a cross-sectional study. One hundred fifty adults were recruited for this study. They were divided into three groups (normal weight, overweight and obesity) according to their 13M[Is.

2 • Normal weight: BNE 18.5-25.0 kg/m • Overweight: BM[I 25.0-29.9 k g/M2 • Obesity: BNH >30.0 kg/M2

4. METHODS

4.1. Body Composition and Energy Expenditure

2-H and 18-0 were used for estimating body composition and total energy expenditure. Using isotope-ratio mass spectrometry according to established protocol performed isotope analyses.

4.2. Physical Activity Physical activity questionnaire was used for collecting physical activity.

4.3. Dietary Intake

Three-day (two weekdays and one weekend day) food weighted method was used. The dietary energy and nutrients intakes were calculated by using the 1991 Chinese Food Composition Table.

4.4. Body Fat Distribution

Standard procedure was followed to measure subjects'weight, height, circumferences of waist, hip and mid thigh. Waist-to-hip and waist-to-thigh ratio were used as the index of fat distribution.

4.5. Serum Insulin and Leptin

Serum insulin and leptin levels were assayed by using Radioimmunoassay.

4.6. Lipid Profile Lipid profile including plasma total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), very low-density lipoprotein VLDL), lipoprotein (a), apolipoprotein (apo) A-I, and apo levels were analyzed in Institute of Nutrition and Food Hygiene by using the established methods.

65 4.7. Blood Pressure

Blood pressure was measured on two study mornings with a random-zero sphygmomanometer. Means of measurements on the two study days were used in the analysis.

4.8. Blood Samples A single fasting blood sample of 20 ml was drawn from each subject's vein for preparation of plasma and serum, which then was stored at 80 OC.

5. SCREENING AND RECRUITMENT

5.1. Screening

Five hundred adults aged 35-52 years from 24 neighborhood committees in 4 urban districts of Beijing were involved for the screen. A questionnaire was administrated for each of them. The screening data was analyzed, 155 subjects from 500 candidates were qualified for the study.

5.2. Data Collection

A 7-day study was conducted involving collecting data on anthropometry, physical activity, and dietary survey in each subject. The general information of the subjects was collected by interview-administered general questionnaire. Body composition was assessed by deuterium oxide dilution technique on study day 1. Physical activity was measured by using the modified VMO 7-day and 1-year questionnaires. Dietary intake was measured by using 3-day food weighted method and food frequency questionnaire. The dietary energy and nutrients intakes were calculated using the 1991 Chinese Food Composition Table. Standard procedure was followed to measure subject's weight, height, circumferences of waist, hip and mid thigh. Blood pressure was measured on the morning of two study days using a standard random-zero mercury sphygmomanometer A single fasting blood sample of 30 ml was drawn from each subject for preparation of plasma and serum. Serum insulin and leptin concentration were analyzed using radioimmunoassay. Lipid profile was analyzed by using standard methods which meet the performance requirements of the lipid standardization program of the CDC.

The dietary survey was carried out at subject's home. All other measurements were conducted in the lab of the institute.

66 5.3. Chemical and physical analysis

5.3. 1. Foodsample

Gross energy content was determined in freeze-dried samples by using a bomb calorimeter. Total fat content was determined in freeze-dried samples by acid hydrolysis.

5.3.2. Body composition

Abundances of deuterium in the isotope dose dilutions and in the urine specimens were analyzed by using isotope-ratio mass spectrometry.

5.3.3. Energy expenditure

Energy expenditure was assessed by modified WHO -year questionnaires.

5.3.4. Blood sample

Lipid profile including TC, TG, HDL, LDL, VLDL, lipoprotein (a), apo A-1, and apo B concentrations were analyzed by using standard methods which meet the performance requirements of the lipid standardization program of the CDC. Serum insulin and leptin levels were measured using radioimmunoassay (RIA).

6 DATA ANALYSIS

All the questionnaires were double checked and coded and then were entered into different databases ad checked logically before analysis.

Values were expressed as mean ± SEM, difference between the three groups was compared using ANOVA analysis; Difference of rate between three groups was compared using X2 -test. Statistic significance was accepted at P<0.05.

7. PRELMINARY RESULTS

7.1. General information

A total of 155 subjects 78 males, 77 females) were included in the study. Their age, gender, height, weight and BNH were shown in Table .

The circumferences of waist, hip and waist/hip ratios of the three groups were shown in Table 2. The waists, hips and waist/hip ratios in obese group were greater than that in overweight and normal weight groups.

67 7.2. Dietary intake The total dietary energy intakes and the percentages of the energy intake of RDA of the three study groups were shown in Table 3 The total energy intakes and the percentages of RDA in overweight and obese groups were significantly greater than that in normal weight group. No significant differences were found between overweight and obese groups.

The fat intakes and percentages of RDA of energy from fat in three study groups were shown in Table 4 The total fat intakes in obese group and overweight group was significant greater than that in normal weight group. However, no significant difference was found between obese and overweight groups. No significant differences were found among three groups for the percentage of energy from fat.

7.3. Physical activity and Energy Expenditure

The time spent on physical activity in normal weight and overweight groups were significant greater that in obesity group. The same trend was found for the energy expenditure by body weight. See Table .

7.4. Body Composition

The percent body fat of normal weight, overweight and obese groups were 29.0%, 33.9% and 39.7%, respectively (Table 6. Significant differences were found between each two groups.

7.5. Blood Pressure

The means of diastolic and systolic blood pressure and hypertension rate of the three groups were shown in Table 7 The hypertension rate in obese group 33.3%) was significantly higher than that in overweight group (I 7.3 %) and in normal weight group (I 1.5 %).

7.6. Lipid Profiles, Insulin and Leptin

The total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein, Apolipoprotein B and Apolipoprotein A-I were listed in Table 810.

The insulin level of obese group was 22.3±13.lmg/dI, significantly higher than that in overweight group (14.5±6.Omg/di) and in normal weight group (11.2±4.3mg/dl) No significant difference was found between overweight and normal weight groups (Table I ).

The leptin in obese, overweight and normal weight groups were 30.6±18.6ng/dI, 18.4±14.7ng/dI, and 9.2±8.Ong/dI, respectively. Significant differences were found between groups (Table 1 1).

7.7. Plasma total homocysteine level and vitainine cofactors

Total homocysteine (tHcy), folate, Vitamin B6 and Vitamin B12 of three groups was shown in Table 12. No significant differences were found among three groups for the means of tHcy, folate, Vitamin B6 and Vitamin 12 (Table 12).

68 REFERENCES

[1] STATE STATISTICAL BUREAU, China Statistical Yearbook 1998, China Statistical Publishing House Beijing. 1999) 105 pp. [2] MINISTRY OF HEALTH, Health Statistical Yearbook 1996. [3] CHEN, C., Dietary guidelines for food and agriculture planning in China, Proceedings of International Symposium on Food, Nutrition and Social Economic Development-, Beijing: China Science and Technology Press, 1991) 40-48. [4] Institute of Health, China Center for Preventive , Proceedings of 1982 National Nutrition Survey, November, 1985, Beijing [5] State Statistical Bureau, People's Republic of China, China Statistical Yearbook 1995, Beijing: China Statistical Publishing House, 1995. [6] MEISLER, J.D., ST, J.S., Summary recommendations from the American Health Foundations's Expert Panel on Healthy Weight, Am J Clin Nutr. 63 1995) 474S- 477S. [7] GE, K.Y., The dietary and nutritional status of Chinese population, People's Medical Publishing House, Vol 1996) 424. [8] Institute of Nutrition and Food Hygiene, Chinese Academy of Preventive Medicine, Nutrition and health status in middle aged and elderly Chinese people living on different dietary pattern, Proceedings of International Symposium on Food Nutrition and Social Economic Development. (I 991) 78-85. [9] SEGAL, L., CARTER, R., ZIV[MET, P., The cost of obesity: the Australian perspective, Pharmacoeconimics. 5 1994) 45-52. [10] SEIDELL, J. C., DEERENBERG,, I., Obesity in Europe: prevalence and consequences for use of medical care, Pharmacoeconimics. 5 1994) 3 844. [11] WOLF, A.M., COLDITZ, G.A., The cost of obesity: The US perspective, Pharmacoeconomics. 5 1994) 34-37. [121 HARLEN, W.R., Epidemiology of childhood obesity: a national perspective, Annals New York Academy of Sciences 1993. [13] DEPARTMENT OF HEALTH AND HUMAN SERVICES. The surgeon general's report on nutrition and health, Washington DC. DHHS [PHS] publication no. 88- 50210 1988). [141 MANSO, J.E., WILLETT, W.C., STAMPFER, M.J. et al. Body weight and mortality in women, N Engl. J. Med. 333 1995) 677-685. [15] LEW, E.A., GAR-FINKLE, L., Variations in mortality by weight among 750,000 men and women, J. Chron, Dis. 32 1979) 563-576. [16] WITTEMAN, J.C.M., WILLET, W.C., STAMPFER, M.J., et al, A prospective study of nutritional factors and hypertension among US women, Circulation. 80 1989) 1320-1327. [17] COLDITZ, G.A., WILLETT, W.C., ROTNITZKYA. & MANSON, J.E., Weight gain as a risk factor for clinical diabetes in women, Ann. Intern. Med. 122(1995) 481-486. [18] MILLER, W.C., LINDEMAN, A.K., WALLACE, J., NIEDERPRLTEM, M., Diet composition, energy intake, and exercise in relation to body fat in men and women, Am J Clin Nutr. 52 1990) 426-430. [19] WILMORE, J.H., Increasing physical activity: alterations in body mass and composition, Am J Clin Nutr. 63 1996) 456S-460S [20] MILLER, W.C., LINDEMAN, A.K., WALLACE, J.M NIEDERPRUEM, D., Diet composition, energy intake, and exercise in relation to body fat in men and women, Am J Clin Nutr. 52 1990) 426-430. [21] DREON, D.M. et al, Dietary fat: carbohydrate ratio and obesity in middle-aged men, Am J Clin Nutr. 47 1988) 995-1000.

69 [22] RONJIEU, I, et al, Energy intake and other determinants of relative weight, Am J Clin Nutr. 47 1988) 406-412. [23] SCHOELLER, D.A., Measurement of energy expenditure in free-living humans by using doubly labeled water, J Nutr. II 1988) 1278-1289. [24] SCHULZ, L.O. SCHOELLER, D.A., A compilation of total daily energy expenditures and body weights in healthy adults, Am J Clin Nutr. 60 1994) 676-68 . [25] KLESGES, R., KLESGES, L.M., HADDOCK, C.K., ECK, L.H., A longitudinal analysis of the impact of dietary intake and physical activity on weight change in adults. Am J Clin Nut. 55 1992) 818-822. [26] DAVIES, P.S.W., DAY, J.M., LUCAS, A., Energy expenditure in early infancy and later fatness, Int J Obesity. 15 1991) 727-73 . [27] VOORRIPS, L., et al, History of body weight and physical activity of elderly women differing in current physical activity, Int J Obesity. 16 1992) 199-205.

70 TABLE 1: GENERAL INFORMATION OF SUBJECTS

Age (yn) Height (cm) Weight ft) DMI 2gL Normal IOverwt Obesity Normal Oveiwt Obesity Normal T!"0=rwt Obesity I Normal Overm Obesity Male Mean 1 43.8 141.8 42.9 170.8 170.9 173.2 66.7 1 79.1 96.5 1 22.8 27.0 32.2 Std 1 3.8 13.8 4.0 4.7 6.1 6.2 6.8 1 7.6 8.2 1 1.8 1.2 2.0 Female Mean 1 43.6 142.2 43.1 159.7 158.3 159.7 56.9 1 69.5 83.3 1 22.2 27.7 32.6 9td 3.4 14.2 1 3.5 6.7 13.8 6.1 7.7 1 3.8 11.4 1 2.0 1.4 3.3 Total Mean 43.7 142.0 1 43.0 165.3 1164.6 166.6 61.8 1 74.3 1 90.0 1 22.5 27.4 32.4 Std 1 36 14.0 1 3.7 8.0 18.1 9.1 8.7 1 7.7 1 11.9 1 1.9 1.3 2.7

TABLE 2 TBE WAIST, H[P AND WAISTJ-1IP RATIO OF TBREE GROUPS

Waist (cm) Hip (cm) Waist/Hip Ratio Normal Overwt Obesity Normal I Overwt Obesity Normal I Overw I Obesi Male N 26 26 26 26 26 26 26 26 26 Mean 82.9 90.6 102.3 93.6 100.0 110.2 0.89 0.91 0.93 Std 5.7 5.3 4.8 3.9 14.1 5.0 0.04 1 0.03 0.05 Female N 26 26 25 26 26 25 26 26 25 Mean 74.0 84.9 94.6 94.1 101.8 111.3 0.79 0.83 0.85 Sid 6.4 3.3 5.5 4.8 14.1 6.9 0.05 0.03 0.04 Total N 72 72 71 1 72 1 72 171 1 72 1 72 71 Mean 78.511 87.8 b 98.5c 1 93.8 a I 100.9b 1 110.70 1 0.84 a 1 0.87 b I0.89b Std -F7.5 5.2 1 6.4 1 4.3 14.2 1 6.0 1 0.07 1 0.05 10.06

71 TABLE 3 AVERAGE DAILY ENERGY INTAKE

Ener Intake cal) %RDA of Ener Intake Normal Overwt Obesity Normal Overwt Obesity Male N 26 26 26 26 26 26 -Mean 2389 2614 2312 88.2 96.9 121.3 Std 846 1904 1721 33.8 62.2 68.0 Female N 26 26 25 26 26 25 -Mean 1601 2214 2342 69.7 95.9 104.9 Std 514 888 1045 25.6 39.4 43.1 Total N 52 52 5 1 52 52 52 Mean 1995a 22 2414 b 78.9 a 96.4ab Std 809 1482 1485 31.1 51.5 57.2-

TABLE 4 AVERAGE DAILY FAT INTAKE

Total Fat Inta (g) % o Energy from Fat Normal Overwt Obesity Normal Overwt Obesity Male N 26 26 26 26 26 26 Mean 132.2 144.0 194.8 50.3 48.8 52.7 Sid 51.0 105.2 128.0 8.3 10.0 9.9 Female N 26 26 25 26 26 25 Mean 87.4 117.2 124.3 49.3 48.8 48.9 Std 30.3 48.6 54.8 8.9 10.0 11.2 Total N 52 52 5 1 52 52 5 1 Mean 109.8a 130.6ab -1766-00-33T-1 49.8a 48.8" 50.8a Std 47.3 82.3 104.4 8.5 10.5 10.1

72 TABLE 5: AVERAGE WEEKLY ENERGY EXPENDED BY PHYSICAL ACTIVITY

Time Spent (minutes) Calories Expended (Kcal) Calorie Expended by Body We ght (kcal g) Normal Overwt Obesity 'Normal Overwt Obesity Normal Overwt Obesity Male N 26 26 26 26 26 26 26 26 26 Median 405.8 442.9 354.1 9441 11621 10897 148.5 149.6 114.6 Q3-Q] 124.7 13.6 216.4 3337 6167 6294 46.8 62.4 1 70.3 Female N 26 26 25 26 26 25 26 26 25 Median 465.4 4817 438.6 9094 9784 11858 164.5 143.0 145.9 Q3-Q] 144.1 200.7 168.6 4146 6016 5104 51.5 95.9 46.8 Total N 52 52 5 1 52 52 5 1 52 52 51 Median 43 2 lab 453.6" 398.6 b 9389a 1054 I b 11818 152.2a 147.9ab 132.7" Q3-Q] 1 140.2 165.7 208.6 3533 6552 6047 56.3 73.1 54.5

TABLE 6 PERCENT BODY FAT OF THE THREE GROUPS

Deuterium Dilution (%) Skinfold Thickness Normal Overwt Obesity Normal Overwt Obesity N 25 25 25 26 26 26 Male Mean 24.4 29.6 31.9 20.3 25.1 31.3 Sid 5.4 3.7 2.3 3.9 3.2 3.0 N 26 15 11 26 26 25 Female Mean 33.5 41.0 43.9 33.6 40.2 42.1 Sid 3.7 3.1 4.0 4.6 1.6 2.0 N 5 1 40 17 52 52 5 1 Total Mean 29.Oa 33.9" 39.7c 26. ga 32.6b 36.6c Sid 6.5 1 6.6 6.8 7.9 8.0 6.0

73 TABLE 7 BLOOD PRESSURE NPvIHG) AND HYPERTENSION RATE

stolic B iastolic Bp - Rate of yperte ion(%) Normal Overwt Obesity Normal Overwt Obesity Normal Overst Obesity Male N 26 26 26 26 26 26 26 26 26 Allean 124 126 134 83 84 89 23.1 23.1 42.3 Sid 15 9 20 9 9 12 Female AT 26 26 25 26 26 25 26 26 25 Mea n 112 124 126 7 6 8 0 8 5 0 13 31.6 Std 8 3 18 7 10 8 Total AT 5 2 5 2 5 1 5 2 52 5 1 5 2 52 5 1 Wean 118a 125' 130b 80a 82a 8 7b 11.5a -17.3b 33.30 Std 13 1 19 8 9 10

TABLE 8: TOTAL CHOLESTEROL AND TRIGLYCERIDE OF TREE GROUPS

Total Cholesterol riglyceride Normal Overwt Obesity Normal Overwt Obesity Male AT 26 26 26 26 26 26 Alean (mgldl) 168.3 176 166 175 207.1 217.5 Sid 28.5 28.6 25.2 138.8 168.9 149.4 Female ?V 26 26 25 26 26 25 Wean (mgldl) 153 161.4 158.3 79.3 131.3 125 Std 26.5 24.1 21.3 30.1 109.1 56.8 Total NT 52 52 51 52 52 51 Yean (mgldl) 160.7 168.7 162.3 127.1 169.2 172.2 td 28.3 27.2 23.5 110.6 145.8 122.1

74 TABLE 9 HIGH DENSITY LIPOPROTEIN AND LOW DENSITY LIPOPROTEIN OF THREE GROUPS

HDL LDL Normal Overwt Obesity Normal Overwt Obesity Male N 26 26 26 26 26 26 Allean (mgldl) 42.6 37 33.7 96.1 106.8 95 Std 12.5 8.4 5.9 27.8 23.6 25.3 Female 26 j 26 25 26 26 25 Alfean (mgldl) 48.2 44.4 42 88.9 93.2 91.3 Sid 7.5 9.3 8.9 24.5 18.4 20.8 Total 52 52 51 52 52 51

Allean (mgldl) 45.4- 1 40.7 b 37.70 92.5 100 93.2 Std 10.6 1 95 8.6 26.2 1 22.1 23

TABLE 10: APOLIPOPROTEIN AND APOLIPOPROTEIN A-I OF THREE GROUPS

Apo ipoprotein B Apolipoprotei A I Normal Overwt Obesity Normal Overwt Obesity Male IV 26 26 6 26 26 6 Mean (mgldl) 81.9 86.2 88.5 136.2 127.5 135.7 Sid 22.7 19.7 16.2 25.2 21.4 14.9 Female N 26 15 1 1 26 15 11 Mean (mgldl) 62.5 69.9 71 141.8 136.1 140.3 Sid 16.2 17.3 14.2 14.6 20.3 25.8 Total ?V 52 41 17 52 41 17 Mean (mgldl) 72.2 80.2 77.2 139 130.7 138.6 Std 21.9 20.2 16.8 20.6 21.1 22.1

75 TABLE I : INSULIN SENSITIVITY AND LEPID CONCENTRATION

Glucose (mg 1) In ulin (mg 1) L ptin (ng 1) Normal Overwt Obesity Normal Overwt Obesity Normal Overwt Obesity -Male Mean 87.2 93.3 104.1 11.3 13.7 22.0 4.8 6.4 22.5 Std 10.1 13.1 29.5 4.2 5.1 13.3 3.9 3.1 21.2 -Female Mean 90.5 96.1 98.8 11.2 15.3 22.7 13.6 30.4 39.0 -Std 8.4 11.9 14.5 4.5 6.7 12.9 8.6 11.6 10.6 Jotal -Mean 88.8 a 94.7 a 101.5 11.2a 14.5a 30.6 b 9.2" 84 30.6c -Std 9.4 12.5 23.3 4.3 6.0 19.6 8.0 14.7 18.6

76 TABLE 12: PLASMA TOTAL HOMOCYSTEINE LEVEL AND VITAMIN LEVELS

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