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Background: Eczema (atopic dermatitis) is a common inflammatory skin disease that is more prevalent in children and adolescents than adults. In Kuwait, there is a lack of empirical knowledge on eczema epidemiology among adolescents. Therefore, this study aimed to estimate the prevalence of eczema symptoms and severity, assess the frequency of eczema-related nocturnal sleep disturbance and its relation to antihistamine use, and determine factors that are associated with eczema prevalence and eczema-related nocturnal sleep disturbance. Methods: A school-based cross-sectional study enrolled adolescents (n = 3864) aged 11–14 years across Kuwait. Information on eczema symptoms and clinical history, use of antihistamines, parental history of eczema, mode of delivery, and childhood life-style factors and exposures were reported by parents. Current eczema was defined as chronic or chronically relapsing itchy dermatitis with characteristic morphology and distribution in the past 12 months. Among subjects reporting current itchy rash, frequency of nocturnal sleep disturbance due to itchy rash in the past 12 months was reported as: never, trend

Background Outcome studies of nonsurgical root canal treatment (NSRCT) in permanent teeth of children are scarce. This study investigated survival and assessed the variables associated with failure of endodontically treated teeth (ETT) in 6- to 18-year-olds. Methods Records of subjects who received NSRCT at age 6–18 years at Boston University between 2007 and 2015 were assessed for the occurrence of untoward events. Kaplan–Meier survival curves were used to investigate the survival of ETT in the total sample. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were estimated. Results The analysis included 341 patients (424 ETT). Kaplan–Meier survival curves differed according to age at treatment (log-rank P = 0.026), with survival being the lowest among the youngest age group. The estimated 5-year survival probability was 80% for 15- to 18-year-olds, 64.8% for 12- to 14-year-olds and 46.4% for 6- to 11-year-olds. Compared to age at treatment of 15–18 years, age at treatment of 6–11 years (aHR: 2.19, 95% CI 1.02–4.67) and 12–14 years (aHR: 2.02, 95% CI 1.15–3.55) was associated with an increased risk of ETT failure. In the total study sample, the estimated cumulative survival probability was 93.3% at 12 months, 88.0% at 24 months, 76.2% at 36 months, 71.0% at 48 months, and 69.1% at 60 months. Conclusions In children, ETT are more likely to survive when NSRCTs are performed at an older age.

Poor health literacy (HL) has received much attention recently as a risk factor for poor health outcomes especially among patients with chronic diseases. The degree to which HL affects health outcomes is unknown among patients with type 2 diabetes mellitus (T2DM) in Kuwait. This study aimed to investigate the association between HL and glycated hemoglobin (HbA1c) among patients with T2DM.356 patients with T2DM were selected from 27 primary care clinics covering the state of Kuwait. HL was measured by the Short Test of Functional Health Literacy in Adults (STOFHLA). Prevalence of uncontrolled HbA1c was estimated and its association with HL was modeled and tested using Poisson regression with log-link function and robust variance-covariance matrix, while adjusting for several confounders.The prevalence of uncontrolled HbA1c was 77.8%. Among those with inadequate or marginal HL, about 50.7% have uncontrolled HbA1c. The prevalence of uncontrolled HbA1c among those on diet alone was 36.3% lower compared to those on mixed treatment regimen (APR = 0.637, 95% CI: 0.455-0.891, PV = 0.008). The prevalence of uncontrolled HbA1c among patients on oral hypoglycemic (OH) drugs alone was 22.3% lower compared to those on mixed treatment (OH plus Insulin) regimen (APR = 0.777, 95% CI: 0.697-0.865, PV0.001). For every one-year increase in age, there is 1.4% reduction in the prevalence of uncontrolled HbA1c (APR = 0.986, 95% CI: 0.978-0.994, PV0.001). For one STOFHLA score increase, there is 0.3% reduction in the prevalence of uncontrolled HbA1c (APR = 0.997, 95% CI: 0.994-1.00, PV = 0.055). Finally, for every year increase since T2DM onset, there is 1.1% increase in the prevalence of uncontrolled HbA1c (APR = 1.011, 95% CI: 1.003-1.019, PV = 0.008).The prevalence of uncontrolled HbA1c among patients with T2DM in Kuwait is high. Half of T2DM with inadequate or marginal HL have uncontrolled HbA1c. Patients on diet alone or OH alone have lower prevalence of uncontrolled HbA1c compared to those on mixed treatment regimen. Older T2DM patients or those with higher STOFHLA score have lower prevalence of uncontrolled HbA1c, while those with longer T2DM onset have higher prevalence of uncontrolled HbA1c. Future interventions should focus on younger patients, improve HL, and establish better communications between physicians and patients with T2DM for better glycemic control.

Anwar Mohammad,1 Ali H Ziyab,2 Talal Mohammad3,4 1Department of Biochemistry and Molecular Biology, Dasman Diabetes Institute, Kuwait City, Kuwait; 2Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Safat, Kuwait; 3St. Antony’s College, University of Oxford, Oxford, UK; 4Department of Biological Anthropology, University of Cambridge, Cambridge, UKCorrespondence: Anwar MohammadDepartment of Biochemistry and Molecular Biology, Dasman Diabetes Institute, Al-Soor Street, Kuwait City, KuwaitEmail anwar.mohammad@dasmaninstitute.orgPurpose: This study aimed to estimate the prevalence of prediabetes and undiagnosed type 2 diabetes mellitus (T2DM) according to fasting plasma glucose (FPG), 2-h plasma glucose (PG) during oral glucose tolerance test (OGTT), and glycated hemoglobin (HbA1c) among a sample of Kuwaiti adults. In addition, associations of prediabetes and undiagnosed T2DM with sex, age, and body mass index (BMI) were assessed.Methods: A cross-sectional study enrolled 1238 subjects aged 18– 65 years who reported no prior history of DM. After overnight fasting, FPG and HbA1c were measured in the total study sample, and 2-h PG during a 75-g OGTT was measured in a subsample of 155 subjects. Prediabetes and undiagnosed T2DM were defined according to the American Diabetes Association criteria. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated.Results: We enrolled a total of 618 males and 620 females, with an average age of 43.0 years. The prevalence of prediabetes was estimated to be 47.9% (588/1228) by FPG, 36.8% (57/155) by 2-h PG OGTT, and 31.0% (355/1144) by HbA1c. The prevalence of undiagnosed T2DM was 6.9% (85/1228) by FPG, 11.0% (17/155) by 2-h PG OGTT, and 4.9% (56/1144) by HbA1c. Sex-related differences in the prevalence of prediabetes and undiagnosed T2DM were observed. Prediabetes and undiagnosed T2DM prevalence estimates showed increasing trends as age and BMI increased. For instance, obese subjects compared to under/normal weight subjects had an increased HbA1c-defined prediabetes prevalence (aPR = 1.62, 95% CI: 1.21– 2.16).Conclusion: Prediabetes and undiagnosed T2DM affect a considerable proportion of Kuwaiti adults, and variations across sex, age, and BMI exist. Hence, early identification and management of affected individuals may help reduce the public health burden.Keywords: prevalence, diabetes mellitus, prediabetes, undiagnosed, Kuwait

BackgroundFood allergy (FA) affects up to 10% of children globally, with clinical symptoms varying from mild to severe, and in rare instances, it is life-threatening. Approximately one in five children with FA experience a food-induced allergic reaction in school, leaving teachers as the first line of intervention. This study aimed to assess kindergarten teachers’ knowledge, attitudes and beliefs regarding FA.MethodsThis cross-sectional study enrolled kindergarten teachers in Kuwait using stratified cluster sampling. The Chicago Food Allergy Research Survey for the General Public was used to assess teachers’ knowledge, attitudes and beliefs regarding FA. The overall FA knowledge score was calculated for each participant. The χ2test was used to assess the differences in the distribution of categorical variables.ResultsResponses were obtained from 882 public kindergarten teachers from 63 kindergartens. Most teachers (81.9%) encountered students with FA in their classrooms. Only 13.5% of the teachers reported receiving training in FA. Overall, participants scored an average of 52.2% on the FA knowledge assessment, with participants receiving prior training in FA scoring on average higher than those with no prior training in FA (55.9% vs 51.6%, p=0.005). A few teachers (10.7%) were aware that lactose intolerance was not equivalent to milk allergy. In terms of attitudes regarding FA, only 14.9% of the participants acknowledged that children with FA are teased/stigmatised due to their condition, and 33.7% recognised that avoidance of allergenic food is difficult. Moreover, only 9.9% of the teachers self-reported their ability to use an epinephrine autoinjector.ConclusionsImproved knowledge and awareness of FA among public kindergarten teachers in Kuwait are needed to ensure the safety of children with FA in schools. Teachers should be trained to prevent, recognise and manage FA-related allergic reactions.

Objective: The objective of this study was to determine the acceptance of a coronavirus disease 2019 (COVID-19) vaccine among the general adult population in Kuwait and assess its determinants. Subjects and Methods: A web-based cross-sectional study was conducted by enrolling adults living in Kuwait (n = 2,368; aged ≥21 years). Acceptance of a COVID-19 vaccine was inferred if participants indicated that they “definitely or probably will accept vaccination against COVID-19 once a vaccine is available.” Associations were explored by applying a modified Poisson regression to estimate and infer adjusted prevalence ratios (aPR) and their 95% confidence intervals (CI). Results: In total, 53.1% (1,257/2,368) of the participants were willing to accept a COVID-19 vaccine once available. Male subjects were more willing to accept a COVID-19 vaccine than females (58.3 vs. 50.9%, p < 0.001). Subjects who viewed vaccines in general to have health-related risks were less willing to accept vaccination (aPR = 0.39, 95% CI: 0.35–0.44). Moreover, participants who previously received an influenza vaccine were more likely to accept a COVID-19 vaccine (aPR = 1.44, 95% CI: 1.31–1.58). Willingness to get vaccinated against COVID-19 increased as the self-perceived chances of contracting the infection increased (p < 0.001). Conclusion: Overall, 53.1% of the study participants demonstrated willingness to get vaccinated against COVID-19. We found several factors influencing the level of acceptance. Since vaccination appears to be an essential preventive measure that can halt the COVID-19 pandemic, factors relating to low vaccine acceptance need to be urgently addressed by public health strategies.

Background Globally, a surge in electronic cigarette (e-cigarette) use has been observed in recent years, with youth being the most susceptible group. Given their recent emergence, studies assessing the health consequences of using e-cigarettes and exposure to their secondhand aerosols (SHA) are limited. Hence, this study sought to assess associations between e-cigarette use and household exposure to SHA from e-cigarettes with asthma symptoms among adolescents. Methods A school-based cross-sectional study was conducted by enrolling high school students (n = 1565; aged 16–19 years) in Kuwait. Participants self-completed a questionnaire on tobacco products use (e-cigarettes and cigarettes) and asthma symptoms. Current e-cigarette use and cigarette smoking were defined as any use in the past 30 days. Household exposure to SHA from e-cigarettes in the past 7 days was reported as none (0 days), infrequent (1–2 days), and frequent (≥ 3 days). Asthma symptoms included current (past 12 months) wheeze, current asthma (history of clinical diagnosis and current wheeze and/or medication use), and current symptoms of uncontrolled asthma (≥ 4 attacks of wheeze, ≥ 1 night per week sleep disturbance from wheeze, and/or wheeze affecting speech). Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated. Results Among the analytical study sample (n = 1345), current e-cigarette use and cigarette smoking was reported by 369 (27.4%) and 358 (26.6%) participants, respectively. Compared to never e-cigarette users and never cigarette smokers, current e-cigarette users with no history of cigarette smoking had increased prevalence of current wheeze (aPR = 1.54, 95% CI 1.01–2.45) and current asthma (aPR = 1.85, 95% CI 1.03–3.41). Moreover, the frequency of exposure to household SHA from e-cigarettes was associated with asthma symptoms. For example, compared to those with no exposure to household SHA, frequent exposure to household SHA was associated with current wheeze (aPR = 1.30, 95% CI 1.04–1.59), current asthma (aPR = 1.56, 95% CI 1.13–2.16), and current uncontrolled asthma symptoms (aPR = 1.88, 95% CI 1.35–2.62). Conclusions E-cigarette use and their household SHA exposure were independently associated with asthma symptoms among adolescents. Hence, such observations indicate that e-cigarette use and passive exposure to their aerosols negatively impact respiratory health among adolescents.

Introduction Globally, the epidemiology of psoriasis is poorly understood, and most countries lack essential epidemiologic data regarding disease burden and its determinants. This study sought to estimate the prevalence of psoriasis among adolescents in Kuwait and assess its association with different risk factors, including obesity, sibship size, breastfeeding, and exposure to household secondhand smoke (SHS) and pets. Methods Schoolchildren aged 11–14 years (n = 3864) were enrolled in a cross-sectional study. Lifetime and current (past 12 months) prevalence of psoriasis were ascertained according to ever having a history of doctor-diagnosis plus current active lesion(s) and/or current use of treatment of psoriasis. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated. Results The lifetime and current prevalence of psoriasis were estimated to be 3.6% (136/3806) and 1.1% (42/3806), respectively. Commonly reported anatomical sites affected by psoriasis included scalp (47.6%) and the extensor surface of the knees (50%) and elbows (38.1%). Household SHS exposure was associated with increased lifetime psoriasis (aPR = 1.41, 95% CI 1.07–1.98), and showed a trend for association with current psoriasis (1.77, 0.89–3.53). Similarly, cat-keeping during infancy was associated with lifetime psoriasis (1.96, 1.14–3.37), and demonstrated a trend for association with current psoriasis (1.49, 0.52–1.98). In contrast, breastfeeding was associated with a decreased lifetime psoriasis (0.62, 0.44–0.89), but was not associated with current psoriasis. Trend analyses showed that the prevalence of lifetime and current psoriasis increased with increasing numbers of total, older, and younger siblings. Conclusions Psoriasis affects a considerable proportion of schoolchildren in Kuwait. Interestingly, psoriasis prevalence was related to risk factors also found in allergic diseases, such as exposure to SHS, cat-keeping in infancy, breastfeeding, and sibship size, possibly suggesting a role of immune dysregulation.

Background: Eczema is a common inflammatory skin disease with varying developmental trajectories/patterns that are influenced by different risk factors. The aim of this study was to investigate eczema development from infancy to early adulthood by identifying distinct developmental trajectories that describe disease patterns over time and evaluate the role of prenatal and early-life risk factors. Methods: The Isle of Wight Birth Cohort (n = 1456) was prospectively assessed at birth, 1, 2, 4, 10, 18 and 26 years. In all assessments, eczema was defined as chronic or chronically relapsing itchy dermatitis lasting >6 weeks with characteristic morphology and distribution in the past 12 months. Developmental trajectories of eczema between 1 or 2 and 26 years were identified separately for males and females by applying semiparametric mixture models. Associations were assessed by applying a modified Poisson regression to estimate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Results: In both males and females, the following eczema developmental trajectories were identified: unaffected/transient (males: 77.7% vs. females: 73.0%), mid-onset late-resolving (males: 7.8% vs. females: 4.4%), late-onset (males: 5.2% vs. females: 9.5%) and early-onset persistent (males: 9.3% vs. females: 5.4%). In females, an additional trajectory was identified as follows: early-onset early-resolving (7.7%). Among males, filaggrin gene (FLG) variants (aRR = 2.45, 95% CI: 1.34–4.46) and paternal eczema (2.66, 1.39–5.08) were associated with the early-onset persistent trajectory. Among females, maternal eczema (2.84, 1.42–5.70) and high birthweight (2.25, 1.08–4.69) were associated with the early-onset persistent trajectory. Conclusions: Four and five trajectories represented eczema development among males and females, respectively, with different predisposing risk factors. Our results indicate that males and females may experience a different course of eczema.

Objectives: The role of children in the transmission of coronavirus disease 2019 (COVID-19) remains unclear. We investigated whether having children is associated with self-reported COVID-19 among adults. Subjects and Methods: A web-based cross-sectional study enrolled adults living in Kuwait (n = 2,355; aged ≥21 years). Prior COVID-19 diagnosis and having children were self-reported. Associations were assessed using Poisson regression, and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated. Results: Of the 2,355 participants (1,595 female subjects), 744 (31.6%) and 605 (25.7%) were of age 21–29 and 30–39 years, respectively. Overall, 4.8% (114/2,355) of the participants reported having had COVID-19, with 4.8% of females and 5.1% of males reporting prior COVID-19 diagnosis. In the total study sample, having children showed a trend for association with having had COVID-19 (aPR: 1.46, 95% CI: 0.99–2.14, p = 0.056). Among participants aged 21–29 years, having children was associated with an increased prevalence of COVID-19 (aPR: 2.50, 95% CI: 1.21–5.20, p = 0.014). Such an association was not detected in adults aged ≥30 years. Conclusions: Our epidemiological findings highlight the possible role of children in spreading COVID-19. Hence, preventive measures should consider the role of children.

Background Eczema is a common inflammatory skin disease with varying developmental trajectories/patterns. This study sought to investigate eczema development from infancy to early adulthood by identifying distinct developmental trajectories that describe disease patterns over time and evaluate the role of early life risk factors. Methods The Isle of Wight Birth Cohort (n = 1456) was prospectively assessed at birth, 1, 2, 4, 10, 18, and 26 years. At each assessment, eczema was ascertained based on established clinical criteria. Developmental trajectories of eczema between 1-or-2 and 26 years were identified separately for males and females by applying semiparametric mixture models. Associations were assessed by applying a modified Poisson regression to estimate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Results In both males and females, the following eczema trajectories were identified: unaffected/transient (77.7% vs. 73.0%), mid-onset late-resolving (7.8% vs. 4.4%), late-onset (5.2% vs. 9.5%), and early-onset persistent (9.3% vs. 5.4%). In females, an additional trajectory was identified: early-onset early-resolving (7.7%). Among males, filaggrin gene (FLG) variants (aRR = 2.45, 95% CI: 1.34-4.46) and paternal eczema (2.66, 1.39-5.08) were associated with the early-onset persistent trajectory. Among females, maternal eczema (2.84, 1.42-5.70) and high birthweight (2.25, 1.08-4.69) were associated with the early-onset persistent trajectory. Conclusions Four and five trajectories represented eczema development among males and females, respectively, with different predisposing risk factors. Key messages Males and females may experience a different course of eczema and also sex-specific risk factors.

Objectives:This study aimed to examine age-specific trends in the prevalence of overweight and obesity in schoolchildren in Kuwait over a 13-year period (2007 to 2019) using the WHO, the Centers for Disease Control and Prevention (CDC) and the International Obesity Taskforce (IOTF) definitions.Design:Using cross-sectional approach, Kuwait Nutrition Surveillance System (KNSS) objectively measured weight and height of schoolchildren over a 13-year period. Log-binomial regression models were used to examine age-specific trends of obesity and overweight over the study period.Setting:Public primary, middle and high schools in all provinces of Kuwait.Participants:Schoolchildren aged 5–19 years (n 172 603).Results:According to the WHO definition, the prevalence of overweight and obesity in schoolchildren, respectively, increased from 17·73 % and 21·37 % in 2007 to 20·19 % and 28·39 % in 2019 (Pfor trend < 0·001). There is evidence that the obesity in females (but not males) has levelled off in the period 2014–2019 according to the three definitions of obesity, which is corroborated by a similar trend in the mean of BMI-for-age Z-score.Conclusion:The prevalence of obesity and overweight in schoolchildren in Kuwait has risen over the last 13 years and trends are similar across all definitions. Obesity is no longer increasing at the same pace and there is evidence that the prevalence of obesity in females has plateaued. The current level of childhood overweight and obesity is too high and requires community-based and school-based interventions.

Mohammad Almari,1,* Anwar Mohammad,2,* Jehad Abubaker,2 Ali H Ziyab3 1Department of Health Policy and Management, Faculty of Public Health, Kuwait University, Safat, Kuwait; 2Department of Biochemistry and Molecular Biology, Research Division, Dasman Diabetes Institute, Kuwait City, Kuwait; 3Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Safat, Kuwait*These authors contributed equally to this workCorrespondence: Ali H ZiyabDepartment of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait, P. O. Box 24923, Safat 13110, KuwaitTel +96524636545Fax +96525338948Email ali.ziyab@ku.edu.kwPurpose: Obesity and prediabetes are common among adolescents; however, it is unclear whether they jointly influence lipid levels. Hence, this study sought to assess whether obesity and prediabetes independently or jointly influence lipid levels among adolescents.Methods: A cross-sectional study enrolled school students aged 14– 19 years (n = 1584). Body mass index (BMI)-for-age z-scores were estimated, and glycated hemoglobin A1c (HbA1c) and lipid profile were measured in capillary blood. Prediabetes was defined as 5.7≤ HbA1c% ≤ 6.4. Geometric means of lipids were calculated, and linear regression was used to estimate the ratio of geometric means (RoGM) and their 95% confidence intervals (CI). All analyses were stratified by sex.Results: Of the total study participants, 52.1% (826/1584) were females and the majority were aged between 14.0 (5th percentile) and 18.0 (95th percentile) years. Based on BMI-for-age categories, 356 (22.5%) and 494 (31.2%) participants were classified as overweight and obese, respectively. Moreover, 34.3% (543/1584) of the study participants met the prediabetes definition. Compared to those with normal BMI and no prediabetes (reference category), participants classified as obese and having prediabetes had elevated levels of total cholesterol (TC; RoGM=1.09, 95% CI: 1.06– 1.13), low-density lipoprotein cholesterol (LDL-C; 1.21, 1.13– 1.29), non-high-density lipoprotein cholesterol (non-HDL-C; 1.20, 1.14– 1.26), and triglycerides (TG; 1.18, 1.09– 1.27) and reduced HDL-C (0.91, 0.88– 0.95) levels. Independent of prediabetes, obesity was associated with all the investigated lipids. Prediabetes alone was associated with reduced levels of LDL-C and increased levels of HDL-C only among females.Conclusion: Obesity independently and in combination with prediabetes demonstrated unfavorable effects on lipids among male and female adolescents, whereas prediabetes independently influenced LDL-C and HDL-C favorably only among females.Keywords: obesity, prediabetes, lipids, adolescents, Kuwait

Introduction Use of tobacco products among adolescents is a major global public health concern. Given the changing landscape of tobacco product use and the lack of epidemiologic data to inform tobacco prevention and control strategies in Kuwait, this study sought to estimate the prevalence and patterns of electronic cigarette (e-cigarette), conventional cigarette, and hookah use among adolescents in Kuwait. Moreover, exposure to secondhand smoke (SHS) and secondhand aerosol (SHA) from e-cigarettes was assessed. Methods This cross-sectional study enrolled high school students (n=1565; 16–19 years) across Kuwait. Current (past 30-day) use of e-cigarettes, conventional cigarettes, and hookah were assessed through self-reported data. Additionally, current (past 7-day) exposure to SHS and SHA in households and public places were ascertained. Associations were evaluated using Poisson regression, and adjusted prevalence ratios (APRs) and 95% confidence intervals (CIs) were estimated. Results Overall, 26.4% (402/1525), 25.1% (383/1525), and 20.9% (318/1525) of the study participants were current e-cigarette users, conventional cigarette smokers, and hookah smokers, respectively. Current use of any tobacco product was reported by 35.1% (535/1525) of the total study participants. The prevalence of concurrent triple use of ‘e-cigarettes, conventional cigarettes, and hookah’ was estimated to be 12.8% (195/1525). Also, among the study participants, 41.9% (619/1479) were exposed to household SHS, 32.0% (469/1465) were exposed to household SHA, and 62.2% (916/1472) were exposed to SHS and/or SHA in public places. Male adolescents were more likely than females to be current e-cigarette users (APR=5.19; 95% CI: 4.09–6.57), conventional cigarette smokers (APR=5.42; 95% CI: 4.26–6.90), and hookah smokers (APR=3.43; 95% CI: 2.72– 4.32). Conclusions A substantial proportion of adolescents in Kuwait are currently using tobacco products and being exposed to SHS/SHA. The findings emphasize the need to continue monitoring all forms of tobacco product use among adolescents and to strengthen tobacco prevention and control programs.

Background Prediabetes, a high-risk state for developing diabetes, has become more prevalent among children and adolescents in recent decades. This study sought to estimate the prevalence of prediabetes and assess its association with adiposity among adolescents in Kuwait. Also, to determine whether maternal and paternal history of diabetes associate with offspring prediabetes in a sex-specific manner. Methods A cross-sectional study was conducted by enrolling students (n = 1959; aged 14-19 years) attending high schools across Kuwait. Body mass index-for-age z-scores were estimated using the World Health Organization growth reference. Glycated hemoglobin A1c (HbA1c) was measured in capillary blood using point-of-care testing. Prediabetes was defined according to the diagnostic criteria of the American Diabetes Association (ADA; 5.7 ≤ HbA1c% ≤ 6.4) and the International Expert Committee (IEC; 6.0 ≤ HbA1c% ≤ 6.4). Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated using Poisson regression with robust variance estimation. Results According to the ADA criteria, 33.3% (620/1845) of participants had prediabetes; whereas, 8.5% (157/1845) met the IEC definition for prediabetes. Subjects classified as obese had higher prevalence of prediabetes compared to children in the thinness/normal group (aPR = 1.68, 95% CI: 1.44-1.95). Analysis stratified by offspring sex showed that maternal history of diabetes is associated with prediabetes among male offspring (aPR = 1.29, 95% CI: 1.02-1.63). In contrast, paternal history of diabetes showed an association with prediabetes among female offspring (aPR = 1.22, 95% CI: 1.01-1.48). Conclusions Prediabetes affects a substantial proportion of adolescents in Kuwait and adiposity and parental diabetes being the main associated factors with prediabetes.

Being etiologically positioned between the genome and the environment, epigenetic markers (e.g., DNA methylation) represent the cumulative memory of genetic susceptibility and environmental exposures. Hence, the premise of epigenetics is that it can serve as a biomarker of the interplay between genetic predisposition and current and past environmental exposures. Such biomarkers can identify at-risk subgroups and related past and current exposures, supportive in devising mitigating and preventive strategies. As explained in this chapter, exposures to environmental chemicals result in epigenetic modifications that, conditional on genetic susceptibilities, mediate exposure effects on disease development. However, to gain better insights on the link between environmental exposures, epigenetic modifications, and disease mechanisms, researchers need to develop and incorporate epidemiologic methods and strategies that can explain how epigenetics might mediate the influence of environmental exposures on disease development. Once causal and molecular pathways are elucidated, epigenetic markers will serve as diagnostic and therapeutic targets facilitating the vision of personalized precision medicine.

The goal of reconstruction of the alveolar cleft in patients with cleft lip and palate is to improve the quality of tissue, the structural stability, and increase the volume of bone. This study is a systematic review with meta-analysis of volumetric bony filling using autogenous bone and various tissue-engineered bone substitutes. We made an electronic search on MEDLINE, EMBASE, SCOPUS, WEB OF SCIENCE, "grey" publications (materials and research produced by organisations outside traditional channels for commercial or academic publishing and distribution), and relevant cross references according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported the outcomes of volumetric grafting were included in the meta-analysis. Of 1276 studies, 26 were included in the meta-analysis. Pooled analysis of 25 studies that used autogenous bone showed a significant reduction in the volume of the cleft equivalent to 62.0% bone fill (95% CI 54.3 to 69.6), in contrast to 10 studies that used a tissue-engineered material and reported bone filling of 68.7% (95% CI 54.5 to 82.8). The estimated sizes of pooled effects across studies showed that there was no significant difference between the two major intervention groups (p value 0.901). Our statistical analysis showed that autogenous bone grafts did not differ significantly from tissue-engineered materials in their ability to fill clefts. Systematic review registration: International Prospective Register of Systematic Reviews, PROSPERO (CRD42017065045).

Introduction Introduction: Detrimental effects of second-hand smoke (SHS) exposure are well established; however, data on SHS exposure among adolescents in Kuwait is lacking. Hence, this study sought to estimate the prevalence of household SHS exposure among two samples of adolescents in Kuwait and assess its variation by socioeconomic status and parental education level. Methods Methods: Data from two large school-based cross-sectional studies were analyzed. Adolescents attending public middle (n=3,864; aged 11–14 years) and high (n=1,959; aged 14–19 years) schools throughout Kuwait were enrolled in 2017-2018, and parental self-reported household SHS exposure was assessed. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated. Results Results: Overall, 45.8% (1755/3836; 95% CI: 44.2–47.3) of the enrolled middle school students and 51.6% (998/1936; 95% CI: 49.3–53.8) of the enrolled high school students were exposed to household SHS. Among middle and high school students, the prevalence of household SHS exposure increased as maternal/paternal education level and family income decreased. Among middle school students, paternal educational attainment of middle school or less compared to bachelor’s degree or higher associated with 1.60-fold (95% CI: 1.44-1.79) higher household SHS exposure. Similarly, in the sample of middle school students, the prevalence of household SHS exposure significantly increased from being 35.8% among children from families reporting highest household income to 50.5% among children from families with lowest reported household income (p-trend < 0.001). Conclusions Conclusions: Household SHS exposure is substantially high among adolescents in Kuwait. Enrolled adolescents from families with low socioeconomic status or with low parental education level have the highest household SHS exposure. These findings highlight the need for national comprehensive tobacco control policies and increasing parental awareness about the impact of SHS exposure on children.

Background Breastfeeding is protective against many long-term diseases, yet the mechanisms involved are unknown. Leptin gene (LEP) is reported to be associated with body mass index (BMI). On the other hand, breastfeeding duration has been found to be associated with DNA methylation (DNAm) of the LEP gene. Therefore, epigenetic regulation of LEP may represent the mechanism underlying the protective effect of breastfeeding duration against obesity. Methods In the Isle of Wight Birth Cohort, peripheral blood DNAm at 23 cytosine-phosphate-guanine sites (CpGs) in the LEP locus in 10-year-old (n = 297) samples and 16 CpGs in 18-year-old (n = 305) samples, were generated using the Illumina Infinium MethylationEPIC and HumanMethylation450 Beadchips respectively and tested for association with breastfeeding duration (total and exclusive) using linear regression. To explore the association between breastfeeding durations and genome-wide DNAm, epigenome-wide association studies (EWASs) and differential methylation region (DMR) analyses were performed. BMI trajectories spanning the first 18 years of life were used as the outcome to test the association with breastfeeding duration (exposure) using multi-nominal logistic regression. Mediation analysis was performed for significant CpG sites. Results Both total and exclusive breastfeeding duration were associated with DNAm at four LEP CpG sites at 10 years (P value < 0.05), and not at 18 years. Though no association was observed between breastfeeding duration and genome-wide DNAm, DMR analyses identified five significant differentially methylated regions (Sidak adjusted P value < 0.05). Breastfeeding duration was also associated with the early transient overweight trajectory. Furthermore, DNAm of LEP was associated with this trajectory at one CpG site and early persistent obesity at another, though mediation analysis was not significant. Conclusions Breastfeeding duration is associated with LEP methylation at age 10 years and BMI trajectory. LEP DNAm is also significantly associated with BMI trajectories throughout childhood, though sample sizes were small. However, mediation analysis did not demonstrate that DNAm of LEP explained the protective effect of breastfeeding against childhood obesity. Electronic supplementary material The online version of this article (10.1186/s13148-019-0727-9) contains supplementary material, which is available to authorized users.

Rhinoconjunctivitis is a public health problem that causes major illness and disability worldwide. Epidemiological studies intended to determine the burden of rhinoconjunctivitis in Kuwait are limited. Hence, this study sought to estimate the prevalence of rhinoconjunctivitis among adolescents in Kuwait and explore its association with different risk factors. Schoolchildren aged 11–14 years (n = 3,864) were enrolled in a cross-sectional study. Parents completed questionnaires regarding their children’s clinical history and symptoms of rhinoconjunctivitis and relevant exposures. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were estimated. The 12-month (current) prevalence estimates of rhinitis, rhinoconjunctivitis, and severe rhinoconjunctivitis were 28.6% (1,040/3,643), 13.5% (497/3,689), and 1.2% (44/3,689), respectively. The prevalence of current rhinoconjunctivitis symptoms was higher in boys compared to girls (aPR = 1.19, 95% CI: 1.01–1.41). Parental history of rhinitis and asthma showed positive associations with rhinoconjunctivitis in offspring. Trend analyses showed that rhinoconjunctivitis prevalence decreased with increasing numbers of total siblings (aPR = 0.92, Ptrend<0.001) and older siblings (aPR = 0.90, Ptrend<0.001). Rhinoconjunctivitis is common among adolescents in Kuwait and its epidemiology is similar to that found in western countries.

Immune-specific genes as well as genes responsible for the formation and integrity of the epidermal barrier have been implicated in the pathogeneses of allergic sensitization. This study sought to determine whether an epistatic effect (gene-gene interaction) between genetic variants within interleukin 4 receptor (IL4R) and filaggrin (FLG) genes predispose to the development of allergic sensitization. Data from two birth cohort studies were analyzed, namely the Isle of Wight (IOW; n = 1,456) and the Manchester Asthma and Allergy Study (MAAS; n = 1,058). In the IOW study, one interaction term (IL4R rs3024676 × FLG variants) showed statistical significance (interaction term: P = 0.003). To illustrate the observed epistasis, stratified analyses were performed, which showed that FLG variants were associated with allergic sensitization only among IL4R rs3024676 homozygotes (OR, 1.97; 95% CI, 1.27–3.05; P = 0.003). In contrast, FLG variants effect was masked among IL4R rs3024676 heterozygotes (OR, 0.53; 95% CI, 0.22–1.32; P = 0.175). Similar results were demonstrated in the MAAS study. Epistasis between immune (IL4R) and skin (FLG) regulatory genes exist in the pathogenesis of allergic sensitization. Hence, genetic susceptibility towards defective epidermal barrier and deviated immune responses could work together in the development of allergic sensitization.

Background: Mutations in NOD2/CARD15 gene have been linked to an increased risk of Crohn's disease (CD). The objective of this study is to determine NOD2/CARD15 gene mutations, and their association with the risk of CD in Arabs in Kuwait. Methods: Four NOD2 gene mutations, including Pro268Ser (SNP5), Arg702Trp (SNP8), Gly908Arg (SNP12), and Leu1007FsinsC (SNP13) were examined in Arab CD patients (n = 103) and control subjects (n = 100). The genomic DNA was isolated and used in polymerase chain reaction (PCR) with four sets of specific primers. The PCR-amplified DNA fragments were sequenced and analyzed for the NOD2 mutations. Logistic regression was used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI). Results: Of the four genotyped variants, the Arg702Trp (SNP8) and Leu1007FsinsC (SNP13) variants were not informative in our study sample due to minor allele frequency of

This cross-sectional study sought to estimate the prevalence of prediabetes and assess its association with obesity among young adults in Kuwait; a country with a high prevalence of obesity and diabetes. The estimated prevalence of prediabetes was 6.3% (95% CI: 4.8-8.1) and obesity was associated with elevated prediabetes prevalence.

Background Epidemiologic studies have demonstrated associations between acetaminophen use and asthma. This investigation sought to determine whether sex modifies the acetaminophen-asthma association and whether leptin (LEP) and leptin receptor (LEPR) gene polymorphisms modulate the sex-specific associations. Methods Data from the Isle of Wight birth cohort (IOW; n = 1456, aged 18 years) and Kuwait University Allergy (KUA; n = 1154, aged 18–26 years) studies were analyzed. Acetaminophen use and current asthma were self-reported. Genotype information for eighteen polymorphisms in LEP and LEPR genes were available in the IOW study. Associations between acetaminophen use and asthma were stratified by sex and genotype. Poisson regression models with robust variance estimation were evaluated to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Results Acetaminophen use was dose-dependently associated with an increased prevalence of current asthma in the IOW and KUA studies. In both studies, sex-stratified analysis showed that acetaminophen use was associated with asthma among males, but not in females (P interaction