Nutritional and Metabolic Diseases Commons^™

Adversity In Childhood Is Linked To Mental And Physical Health Throughout Life, Charles A. Nelson, Richard David Scott, Zulfiqar Ahmed Bhutta, Nadine Burke Harri, Andrea Danes, Muthanna Samara

Woman and Child Health

The prevalence of “toxic stress” and huge downstream consequences in disease, suffering, and financial costs make prevention and early intervention crucial, say Charles A Nelson and colleagues.

Researching The Delivery Of Health And Nutrition Interventions For Women And Children In The Context Of Armed Conflict: Lessons On Research Challenges And Strategies From Branch Consortium Case Studies Of Somalia, Mali, Pakistan And Afghanistan, Michelle F. Gaffey, Anushka Ataullahjan, Jai K. Das, Mohammed Shafiq Mirzazada, Moctar Tounkara, Abdirisak A. Dalmar, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: The BRANCH Consortium recently conducted 10 mixed-methods case studies to investigate the provision of health and nutrition interventions for women and children in conflict-affected countries, aiming to better understand the dominant influences on humanitarian health actors' programmatic decision-making and how such actors surmount intervention delivery barriers. In this paper, the research challenges encountered and the mitigating strategies employed by the case study investigators in four of the BRANCH case study contexts are discussed: Somalia, Mali, Pakistan and Afghanistan.
Discussion: Many of the encountered research challenges were anticipated, with investigators adopting mitigation strategies in advance or early on, but others …

Malnutrition And Food Insecurity In Child Labourers In Sindh, Pakistan: A Cross-Sectional Study, Meesha Iqbal, Zafar Fatmi, Kausar S. Khan, Yusra Jumani, Neelma Amjad, Asaad Ahmed Nafees

Community Health Sciences

Background: Child labour is common in low- and middle-income countries. Although child labour is widespread in Pakistan, no data are available on the health of child labourers.
Aims: This study aimed to assess the food security, food intake and nutritional status of child labourers aged 5-14 years working in lower Sindh, Pakistan.
Methods: Child labourers aged 5-14 years working in agriculture, manufacturing industry, hotels and restaurants, domestic work and migrant child labourers working in vegetable markets were recruited using a respondent-driven sampling technique. Sociodemographic and nutrition information was obtained by an interviewer questionnaire. The children's height and weight were measured …

Vitamin D Usage Among Pakistani Population - Too Much Of A Good Thing, Bhagwan Das, Sarah Nadeem

Section of Diabetes, Endocrinology and Metabolism

No abstract provided.

Drivers Of Stunting Reduction In Peru: A Country Case Study, Luis Huicho, Elisa Vidal-Cárdenas, Nadia Akseer, Samanpreet Brar, Kaitlin Conway, Muhammad Islam, Elisa Juarez, Aviva Rappaport, Hana Tasic, Tyler Vaivada, Jannah Wigle, Zulfiqar Ahmed Bhutta

Woman and Child Health

Background: Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016.
Objectives: We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016.
Methods: Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor …

Stunting In Childhood: An Overview Of Global Burden, Trends, Determinants, And Drivers Of Decline, Tyler Vaivada, Nadia Akseer, Selai Akseer, Ahalya Somaskandan, Marianne Stefopulos, Zulfiqar Ahmed Bhutta

Woman and Child Health

Background: Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development.
Objective: This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries.
Methods: We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key …

The Intertwined Relationship Between Malnutrition And Poverty, Faareha Siddiqui, Rehana Salam, Zohra S. Lassi, Jai K. Das

Woman and Child Health

Despite social and economic development, the burden of malnutrition across the globe remains unacceptably high. A vital relationship exists between nutritional status, human capital, and economic standing. Malnutrition adversely affects the physiological and mental capacity of individuals; which in turn hampers productivity levels, making them and their respective countries more susceptible to poverty. A two-way link exists between malnutrition and poverty, creating a vicious cycle with each fueling the other. Malnutrition produces conditions of poverty by reducing the economic potential of the population and likewise, poverty reinforces malnutrition by increasing the risk of food insecurity. The aim of the paper …

Specialized Nutritious Food Combined With Cash Transfers And Social And Behavior Change Communication To Prevent Stunting Among Children Aged 6 To 23 Months In Pakistan: Protocol For A Cluster Randomized Controlled Trial, Gul Nawaz Khan, Sumra Kureishy, Shabina Ariff, Atif Habib, Asra Abeer Usmani, Areeba Mubarik, Masawar Hussain, Naveed Akbar, Pablo Rodriguez De Castro, Alba Cecilia Garzon, Saskia De Pee, Sajid Bashir Soofi

Department of Paediatrics and Child Health

Background: In Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country-43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households.
Objective: The primary objective of this study is to determine the effect …

Effect Of Lipid-Based Nutrient Supplement-Medium Quantity On Reduction Of Stunting In Children 6-23 Months Of Age In Sindh, Pakistan: A Cluster Randomized Controlled Trial, Gul Nawaz Khan, Sumra Kureishy, Shabina Ariff, Arjumand Rizvi, Muhammad Sajid, Cecilia Garzon, Ali Ahmad Khan, Saskia De Pee, Sajid Bashir Soofi, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Chronic childhood malnutrition, or stunting, remains a persistent barrier to achieve optimal cognitive development, child growth and ability to reach full potential. Almost half of children under-five years of age are stunted in the province of Sindh, Pakistan.
Objective: The primary objective of this study was to test the hypothesis that the provision of lipid-based nutrient supplement-medium-quantity (LNS-MQ) known as Wawamum will result in a 10% reduction in risk of being stunted at the age of 24 months in the intervention group compared with the control group.
Design: A cluster randomized controlled trial was conducted in Thatta and Sujawal …

Non-Adherence To Who Recommendations Regarding Infant Feeding Practices Results In Dilemma Of Malnourishment: A Community-Based Prospective Cohort Study Conducted In Karachi, Pakistan, Muhammad Osama, Anosh Aslam Khan, Sohaib Hasan Syed, Osama Mohiuddin, Ammar Hassan, Syeda Ramsha Zaidi, Neelofar Sami

Community Health Sciences

Background: The prevalence of chronic malnutrition and its associated morbid outcomes has been a significant cause of health loss globally, affecting millions of children hampering their mental, physical, social, and immune system development. World Health Organization's (WHO) recommendations presenting infant feeding guidelines have largely controlled this burden. However, developing countries including Pakistan have failed to promote these guidelines and still succumb to a huge burden of morbidity and mortality secondary to malnourishment among infants.
Methodology: Our study is a prospective cohort including 300 infants without predisposing congenital anomaly, followed from 6 months to 18 months of age. The primary outcome …

How Nutrition Can Help To Fight Against Covid-19 Pandemic, Faseeha Aman, Sadia Masood

Section of Internal Medicine

Currently Covid-19 pandemic is a leading challenge across the globe. It is mandatory to attain and maintain good nutritional status to fight against virus. Nutritional status of individual is affected by several factors such as age, sex, health status, life style and medications. Nutritional status of individuals has been used as resilience towards destabilization during this COVID-19 pandemic. Optimal nutrition and dietary nutrient intake impact the immune system, therefore the only sustainable way to survive in current context is to strengthen the immune system. There is no evidence found that supplement can cure the immune system except Vit C, which …

Association Of Dairy Consumption With Metabolic Syndrome, Hypertension And Diabetes In 147 812 Individuals From 21 Countries, Balaji Bhavadharini, Mahshid Dehghan, Andrew Mente, Sumathy Rangarajan, Patrick Sheridan, Viswanathan Mohan, Romaina Iqbal, Rajeev Gupta, Scott Lear, Edelweiss Wentzel-Viljoen

Community Health Sciences

Objective: Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study.
Methods: The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the cross-sectional analyses, we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For the prospective analyses, we …

Determinants Of Linear Growth Faltering Among Children With Moderate-To-Severe Diarrhea In The Global Enteric Multicenter Study, Rebecca L. Brander, Patricia B. Pavlinac, Judd L. Walson, Grace C. John-Stewart, Marcia R. Weaver, Abu S. G Faruque, Anita K. M. Zaidi, Dipika Sur, Samba O. Sow, M Jahangir Hossain

Department of Paediatrics and Child Health

Background: Moderate-to-severe diarrhea (MSD) in the first 2 years of life can impair linear growth. We sought to determine risk factors for linear growth faltering and to build a clinical prediction tool to identify children most likely to experience growth faltering following an episode of MSD.
Methods: Using data from the Global Enteric Multicenter Study of children 0-23 months old presenting with MSD in Africa and Asia, we performed log-binomial regression to determine clinical and sociodemographic factors associated with severe linear growth faltering (loss of ≥ 0.5 length-for-age z-score [LAZ]). Linear regression was used to estimate associations with ΔLAZ. A …

Early Life Child Micronutrient Status, Maternal Reasoning, And A Nurturing Household Environment Have Persistent Influences On Child Cognitive Development At Age 5 Years: Results From Mal-Ed, Benjamin J J. Mccormick, Stephanie A. Richard, Laura E. Caulfield, Laura L. Pendergast, Jessica C. Seidman, Beena Koshy, Reeba Roshan, Rita Shrestha, Erling Svensen, Muneera Rasheed

Department of Paediatrics and Child Health

Background: Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown.
Objective: The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y.
Methods: Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured …

Challenges Of Implementing An Individual Randomized Controlled Trial (Women First: Preconception Maternal Nutrition Study) In A Rural Study Site: A Case Study From Pakistan, Sumera Aziz Ali, Umber S. Khan, Farina Abrejo, Sarah Saleem, Michael K. Hambidge, Nancy F. Krebs, Jamie E. Westcott, Robert L. Goldenberg, Elizabeth M. Mcclure, Omrana Pasha

Community Health Sciences

Persistent global disparities in maternal and neonatal outcomes associated with poor maternal nutrition provided the genesis of the Women First (WF) study, an individually randomized controlled trial on preconceptional maternal nutrition. This article describes the challenges that arose in implementing this trial related to nutrition or diet of the mother, in District Thatta-Pakistan. During different phases of the study, we encountered problems in identifying the eligible participants, taking consent from couples, randomizing participants in different arms, conducting biweekly follow-up visits on time, ensuring compliance to the intervention, and measuring the primary outcome within the 24 hours of birth. Each challenge …

The Incidence, Aetiology, And Adverse Clinical Consequences Of Less Severe Diarrhoeal Episodes Among Infants And Children Residing In Low-Income And Middle-Income Countries: A 12-Month Case-Control Study As A Follow-On To The Global Enteric Multicenter Study (Gems), Karen L. Kotloff, Dilruba Nasrin, William C. Blackwelder, Yukun Wu, Tamer Farag, Sandra Panchalingham, Samba O. Sow, Anita K. M. Zaidi, Shahida Qureshi, Farheen Quadri

Department of Paediatrics and Child Health

Background: Diarrheal diseases remain a leading cause of illness and death among children younger than 5 years in low-income and middle-income countries. The Global Enteric Multicenter Study (GEMS) has described the incidence, aetiology, and sequelae of medically attended moderate-to-severe diarrhoea (MSD) among children aged 0-59 months residing in censused populations in sub-Saharan Africa and south Asia, where most child deaths occur. To further characterise this disease burden and guide interventions, we extended this study to include children with episodes of less-severe diarrhoea (LSD) seeking care at health centres serving six GEMS sites.
Methods: We report a 1-year, multisite, age-stratified, matched …

Serum Tumour Necrosis Factor Alpha In Osteopenic And Osteoporotic Postmenopausal Females: A Cross-Sectional Study In Pakistan, Rafat Murad, Zahra Shezad, Saara Ahmed, Mussarat Ashraf, Murad Qadir, Rehana Rehman

Department of Biological & Biomedical Sciences

Objective: To compare biochemical parameters serum tumour necrosis factor alpha, calcium, magnesium, bone-specific alkaline phosphatase and vitamin D in postmenopausal women.
Methods: This cross-sectional study was carried out from June 2015 to July 2016 at Jinnah Medical and Dental College, Karachi, and comprised postmenopausal women. Bone mineral density done by dual energy X-ray absorptiometryscan categorised subjects by World Health Organisation classification into normal (T score > -1) osteopenic (T score between -1 and -2.5) and osteoporotic (T score < -2.5). Biochemical parameters like tumour necrosis alpha, calcium, magnesium, bone-specific alkaline phosphatase and vitamin D were measured by solid phase enzyme amplified sensitivity immunoassay method. SPSS 16 was used to analyse the data.
Results: Of the 146 women, 34(23%) were normal, 93(67%) were osteopenic and 19(13%) were osteoporotic. There was significant difference in mean body mass …

Setting Health Research Priorities Using The Chnri Method: Vii. A Review Of The First 50 Applications Of The Chnri Method, Igor Rudan, Sachiyo Yoshida, Kit Yee Chan, Devi Sridhar, Kerri Wazny, Harish Nair, Aziz Sheikh, Mark Tomlinson, Joy E. Lawn, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Several recent reviews of the methods used to set research priorities have identified the CHNRI method (acronym derived from the "Child Health and Nutrition Research Initiative") as an approach that clearly became popular and widely used over the past decade. In this paper we review the first 50 examples of application of the CHNRI method, published between 2007 and 2016, and summarize the most important messages that emerged from those experiences.
Methods: We conducted a literature review to identify the first 50 examples of application of the CHNRI method in chronological order. We searched Google Scholar, PubMed and so-called …

Causal Pathways From Enteropathogens To Environmental Enteropathy: Findings From The Mal-Ed Birth Cohort Study, Margaret N. Kosek, Zulfiqar Ahmed Bhutta, Anita K. M. Zaidi, Imran Ahmed, Syed Asad Ali, Muneera Rasheed, Sajid Bashir Soofi, Ali Turab, Didar Alam, Shahida Qureshi

Department of Paediatrics and Child Health

Background: Environmental enteropathy (EE), the adverse impact of frequent and numerous enteric infections on the gut resulting in a state of persistent immune activation and altered permeability, has been proposed as a key determinant of growth failure in children in low- and middle-income populations. A theory-driven systems model to critically evaluate pathways through which enteropathogens, gut permeability, and intestinal and systemic inflammation affect child growth was conducted within the framework of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) birth cohort study that included children from eight countries. …

Epidemiology And Impact Of Campylobacter Infection In Children In 8 Low-Resource Settings: Results From The Mal-Ed Study, Shahida Qureshi, Aneeta Hotwani, Sadia Shakoor, (Mal-Ed) Network Investigators, Imran Ahmed, Didar Alam, Syed Asad Ali, Zulfiqar Ahmed Bhutta, Muneera Rasheed, Sajid Bashir Soofi, Ali Turab, Anita K. M. Zaidi

Department of Paediatrics and Child Health

Background: Enteropathogen infections have been associated with enteric dysfunction and impaired growth in children in low-resource settings. In a multisite birth cohort study (MAL-ED), we describe the epidemiology and impact of Campylobacter infection in the first 2 years of life.
Methods: Children were actively followed up until 24 months of age. Diarrheal and nondiarrheal stool samples were collected and tested by enzyme immunoassay for Campylobacter Stool and blood samples were assayed for markers of intestinal permeability and inflammation.
Results: A total of 1892 children had 7601 diarrheal and 26 267 nondiarrheal stool samples tested for Campylobacter We describe a high …

Norovirus Infection And Acquired Immunity In 8 Countries: Results From The Mal-Ed Study, Furqan Kabir, Adil Kalam, Pascal Bessong Pascal Bessong, Zulfiqar Ahmed Bhutta, Anita K. M. Zaidi, (Mal-Ed) Network Investigators, Imran Ahmed, Didar Alam, Syed Asad Ali, Shahida Qureshi, Muneera Rasheed, Sajid Bashir Soofi, Ali Turab, Aisha Khizar Yousafzai

Department of Paediatrics and Child Health

Background: Norovirus is an important cause of childhood diarrhea. We present data from a longitudinal, multicountry study describing norovirus epidemiology during the first 2 years of life.
Methods: A birth cohort of 1457 children across 8 countries contributed 7077 diarrheal stools for norovirus testing. A subset of 199 children contributed additional asymptomatic samples (2307) and diarrheal stools (770), which were used to derive incidence rates and evaluate evidence for acquired immunity.
Results: Across sites, 89% of children experienced at least 1 norovirus infection before 24 months, and 22.7% of all diarrheal stools were norovirus positive. Severity of norovirus-positive diarrhea was …

Diagnosis, Treatment And Follow-Up In Four Children With Biotinidase Deficiency From Pakistan, Bushra Afroze, Mohammad Wasay

Department of Medicine

Biotinidase deficiency is an inherited disorder in which the vitamin biotin is not recycled. If untreated, affected individuals develop neurological and cutaneous symptoms. Untreated individuals with biotinidase deficiency either succumb to disease or are left with significant morbidity. We describe clinical course and follow-up of 4 children from Pakistan. All 4 presented with classical symptoms of biotinidase deficiency and responded dramatically to oral biotin within days to weeks. Biotinidase deficiency is reported in Pakistani children from different part of world, however; there is no such report from Pakistan. This highlights lack of awareness of biotinidase deficiency among physicians in Pakistan

Illuminating The Dark Side-Vitamin D Status In Different Localities Of Karachi, Romaina Iqbal, Lena Jafri, Ali Haroon, Aysha Habib Khan

Department of Pathology and Laboratory Medicine

This study was conducted to determine the association between place of residence (grouped into neighbourhoods), and 25-hydroxy D (25[OH]D) levels of individuals of Karachi. Addresses of 4788 individuals tested for 25[OH]D at the clinical laboratory of the Aga Khan University (AKU), Karachi, from January 2007 to June 2008 were reviewed. The neighbourhoods were categorized into ten, based on locality attributes. A high overall prevalence (74%) of vitamin D deficiency (VDD) was observed. There was a significant difference (p-value < 0.01) between mean log 25[OH]D levels amongst neighbourhoods grouped according to distinct housing structure attributes and localities. A high frequency of VDD in all the studied localities of an urban city warrant dietary vitamin D supplementation and food fortification.

Household Food Access And Child Malnutrition: Results From The Eight-Country Mal-Ed Study, Zulfiqar Ahmed Bhutta, Maled Network Investigators, Anita K. M. Zaidi, Sajid Bashir Soofi, Ali Turab, Didar Alam, Shahida Qureshi, Aisha Khizar Yousafzai, Syed Asad Ali, Imran Ahmed, Sajad Memon, Muneera Rasheed

Woman and Child Health

Background: Stunting results from decreased food intake, poor diet quality, and a high burden of early childhood infections, and contributes to significant morbidity and mortality worldwide. Although food insecurity is an important determinant of child nutrition, including stunting, development of universal measures has been challenging due to cumbersome nutritional questionnaires and concerns about lack of comparability across populations. We investigate the relationship between household food access, one component of food security, and indicators of nutritional status in early childhood across eight country sites.
Methods: We administered a socioeconomic survey to 800 households in research sites in eight countries, including a …

Biotinidase Deficiency In Pakistani Children; What Needs To Be Known And Done, Bushra Afroze, Mohammad Wasay

Department of Medicine

No abstract provided.

Acid Maltase Deficiency--Pompe's Disease, Sajjad Jamil, Shahid Ahmed, M. Tariq

Section of Internal Medicine

Mutation in genes encoding for proteins involved in glycogen synthesis, degradation or regulation results in various inborn errors of glycogen metabolism. The disorders that result in abnormal storage of glycogen are known as glycogen storage diseases (GSD). We report a rare and interesting case of a young boy who presented with generalized weakness and reduced muscle bulk since childhood. He was diagnosed to have acid maltase deficiency, also known as Pompe's disease, one of the rare types of glycogen storage disease. The case is presented here in the form of a case study, including a review of the pertinent literature …

Childhood Injuries In Pakistan: Results From Two Communities, Seema Zainulabdin Lasi, Ghazala Rafique, Habib Peermohammad

Human Development Programme

The study aimed at determining the incidence, nature, and extent of childhood injuries in two suburban and rural communities of Pakistan. The findings of the study are based on a cross-sectional survey of 2,292 children aged 1-8 years. Information was sought retrospectively from the primary caregiver on the occurrence of injury that required formal or informal medical consultation during the past three months. The incidence rate of non-fatal injuries that required care outside home for children aged 1-8 years was 19.7 injuries per 100 person (child)-years of exposure [95% confidence interval (CI) 16.41-23.51]: 26.5 injuries per 100 person (child)-years of …

Eight Key Household Practices Of Integrated Management Of Childhood Illnesses (Imci) Amongst Mothers Of Children Aged 6 To 59 Months In Gambat, Sindh, Pakistan, Ajmal Agha, Muhammad Younus, Muhammed Masood Kadir, Sajid Ali, Zafar Fatmi

Community Health Sciences

Objective:

To determine Knowledge, Attitudes and Practices (KAP) regarding eight key integrated management of childhood illness (IMCI) suggested practices and the association of these key practices with stunting as outcome.

Methods:

Sampling proportionate to sub-population sizes was employed to ensure representation from all the Union Councils of taluka Gambat-Sindh.

Results:

Low female education and mobility show the status of child's first care provider in a typical rural community. Few women knew about giving more food to a child suffering from diarrhoea. Moreover, very few exclusively breastfed their children for first 4-6 months, got their children completely immunized, washed hands before …

Helicobacter Pylori Infection And Micronutrient Deficiencies., Javed Yakoob, Wasim Jafri, Shahab Abid

Section of Gastroenterology

It is known that deficiencies of micronutrients due to infections increase morbidity and mortality. This phenomenon depicts itself conspicuously in developing countries. Deficiencies of iron, vitamins A, E, C, B12, etc are widely prevalent among populations living in the third world countries. Helicobacter pylori (H pylori) infection has a high prevalence throughout the world. Deficiencies of several micronutrients due to H pylori infection may be concomitantly present and vary from subtle sub-clinical states to severe clinical disorders. These essential trace elements/micronutrients are involved in host defense mechanisms, maintaining epithelial cell integrity, glycoprotein synthesis, transport mechanisms, myocardial contractility, brain development, cholesterol …

Association Of Iron Deficiency Anaemia In Children Of 1-2 Years Of Age With Low Birth Weight, Recurrent Diarrhoea Or Recurrent Respiratory Tract Infection - A Myth Or Fact?, Niloufer Sultan Ali, Rukhsana Wamiq Zuberi

Department for Educational Development

No abstract provided.