Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate

Diala Abu Al-Halawa; Stephanny Vicuna Polo; Radwan Qasrawi

doi:10.12688/f1000research.132160.2

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Research Article

Revised

Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate 

[version 2; peer review: 1 approved, 1 approved with reservations]

Previously titled: Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian children in the Hebron governorate 

Diala Abu Al-Halawa¹, Stephanny Vicuna Polo², Radwan Qasrawi ^3,4

PUBLISHED 26 Sep 2023

Author details Author details

¹ Faculty of Medicine, Al-Quds University, Jerusalem, Palestinian Territory
² Center for Business Innovation and Entrepreneurship, Al-Quds University, Jerusalem, Palestinian Territory
³ Department of Computer Engineering, Istinye Universitesi, Istanbul, Ä°stanbul, Turkey
⁴ Department of Computer Science, Al-Quds University, Jerusalem, Palestinian Territory

Diala Abu Al-Halawa
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation

Stephanny Vicuna Polo
Roles: Writing – Review & Editing

Radwan Qasrawi
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: The prevalence of dysglycemia among adolescents and younger children has been rising, yet health professionals are still unaware of the significance of this problem. According to the Palestinian Ministry of Health (MOH) records, most diabetic children under the age of 20 in Palestine are classified as type 1; nonetheless, very limited data are available for policymakers to frame cost-effective screening programs. This study aims to determine the prevalence of dysglycemia in a sample of obese and overweight Palestinian adolescents, identify risk factors associated with dysglycemia, and examine risk factors variance by gender.
Methods: A cross-sectional sample of observed obese and overweight adolescents was selected from public schools in the Hebron governorate. Informed consent, physical examination, anthropometric, and laboratory tests (Random Blood Glucose Level (BGL) and fasting BGL ) were performed on a sample of 511 students (44.6% boys and 55.4% girls) aged 13–18-years (13-15 years =46.2% and 16-18 years =53.8%).
Results: The prevalence of confirmed overweight and obese cases was 73.2%, and dysglycemia prevalence among the confirmed cases was 3.7% (5.3% boys and 2.5% girls). The BMI classifications of the dysglycemic children indicated that 42.1% were overweight and 31.1% were obese. Furthermore, 64.6% reported high systolic and/or diastolic blood pressure readings.
Conclusions: The results of this study provide valuable information about the rising problem of dysglycemia among Palestinian adolescents and underlines the need for rapid screening programs and protocols for early detection and classification of the disease, leading to initiation of early prevention and treatment plans.

Keywords

Dysglycemia1, schoolchildren2, Diabetes3, nutrition4, risk factors5, obesity6

Corresponding author: Radwan Qasrawi

Competing interests: No competing interests were disclosed.

Grant information: The original study was funded by the Ministry of Higher Education under grant number HIE 20/Q2019.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2023 Abu Al-Halawa D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Abu Al-Halawa D, Vicuna Polo S and Qasrawi R. Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate  [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.2) First published: 06 Jul 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.1) Latest published: 26 Sep 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.2)

Revised Amendments from Version 1

The revised version of the manuscript entails further elaboration of the methodology section, particularly the methods for measuring weight and height of the study participants. Furthermore, the manuscript includes updated terminology and definitions, including the use of the term "adolescents" to describe the study sample, and updated definition of high blood pressure, which yielded an increase in the percentage of adolescents who had high systolic and/or diastolic blood pressure to around 64%. Moreover, we include an updated regression model that includes the updated variable. The results show minor changes in the model, which were addressed in the results and discussion sections.

See the authors' detailed response to the review by Huda Al Hourani

Introduction

Diabetes is a metabolic disease involving glucose dysregulation that can result in serious and life-threatening complications such as nephropathy, neuropathy, retinopathy, and heart disease. The underlying mechanism is a defect in insulin secretion, action, or both. This defect affects mainly carbohydrate metabolism, although the metabolism of proteins and lipids is also affected.¹^–³ Recent estimates by the International Diabetes Federation (IDF) show that globally, 424.9 million of adults have diabetes with 79% of cases in low and middle-income countries, 9.2% of which are present in the middle east and north Africa region (MENA), including Palestine.⁴ The prevalence of type 2 diabetes, however, is not only increasing among adults but also spreading into younger age groups, such as adolescents and children.

Originally thought of as a disease of adults, type 2 diabetes has recently been appearing at increasing rates among adolescents and even younger children around the world.⁵^–⁹ In the USA, the prevalence of prediabetes among adolescents was found to be 18%¹⁰; similarly, the prevalence of fully diagnosed type 2 diabetes in the US youth increased from 0.34/1000 in 2001 to 0.46/1000 in 2009.¹¹ Wide variations in the prevalence of type 2 diabetes have been observed in different countries and within various ethnicities.⁴^,¹² In the Middle East, a study in Kuwait found that 34.9 per 100,000 children between 6-18 years old suffered from type 2 diabetes.¹³ Moreover, a study in Saudi Arabia reported a 9.04% prevalence of type 2 diabetes among overweight and obese Saudi children.¹⁴ In the same manner, a case series study of medical records from the Al Ain hospital in the UAE revealed that of 96 newly diagnosed diabetics aged 0-18 years, 11.5% fulfilled the criteria for type 2 diabetes diagnosis, most of which were females and 82% were obese.¹⁵ This alarming trend could be a consequence of or a corollary to the rising epidemic of obesity worldwide. Obesity is associated with and is antecedent to a variety of health conditions that extend beyond aesthetics and increased fat deposition. Obese adolescents are at increased risk of developing metabolic syndromes, cardiovascular disease, and diabetes later in life.¹⁶^–¹⁸

Despite the wide variations in prevalence, risk factors appear to occur commonly across nationalities in a similar manner to the rates present for adults, such as genetic and demographic factors, lifestyle factors, and metabolic and biological measures. Demographic and genetic risk factors include age, sex, family history, exposure to diabetes in utero, and race. Impaired glucose regulation appears more commonly in females and the risk increases with age, pubertal onset, and certain ethnicities.¹^,³ Nonetheless, obesity remains the most predisposing risk factor to type 2 diabetes as it is generally agreed upon that obesity increases the risk of type 2 diabetes mainly by increasing insensitivity of peripheral tissues to insulin. Abdominal obesity and visceral fat appear to be particularly detrimental.¹⁹ The rates of obesity have rapidly risen around the world, in such a way that, recently, an epidemic of obesity has been observed in many Middle Eastern countries.²⁰^,²¹

Several studies have documented a strong association between physical activity and improved glucose regulation²²^,²³; growing evidence suggests that even low to moderate physical activity could improve insulin sensitivity and decrease hepatic steatosis.²⁴^,²⁵ Studies that were conducted on children show similar results to those in adults; thus, the Center for Disease Control and Prevention (CDC) recommend at least 60 minutes of physical activity for 6–17-year-old children and adolescents, including aerobic, muscle strengthening and bon strengthening activities to prevent type 2 diabetes.²⁶^,²⁷ Similarly, diet plays an important role in the prevention of dysglycemia,²⁸^,²⁹ nonetheless, relatively few studies have investigated the relationship between nutrition and dysglycemia in children. In a review of the diet strategies that could reduce the risk of type 2 diabetes among children, Gow et al. concluded that a diet low in carbohydrates, irrespective of the diet strategy, could decrease the risk factor for type 2 diabetes.³⁰

Dysglycemia and type 2 diabetes are escalating worldwide with modern sedentary lifestyles and unhealthy diet habits, such as fast-food consumption, on the rise. The prevalence of these diseases is rapidly increasing in the MENA region, and thus determining their prevalence among Palestinian schoolchildren would support policy screening and enhanced regulations to prevent diabetes type 2 in the country. Although population-wide screening is costly and time-consuming,³¹ screening of high-risk children in the country is possible and cost-effective.³² Some countries (e.g., India, Finland, and the USA) have developed risk scores for screening purposes.³²^,³³ Information on the prevalence and risk factors for diabetes in Palestine is needed to identify high-risk children in the country, as well as to raise awareness among health care professionals about the extent of the problem. Increased awareness will reduce cases of misdiagnoses, delayed diagnoses, or missed diagnoses. Therefore, this study aims be the first in the region to identify the prevalence of dysglycemia among a cohort of mainly overweight and obese adolescents in the Hebron governorate, Palestine.

Methods

Ethics

The study received ethical approval from the Ministry of Education and Al-Quds University Institutional Review Board (IRB).

Subjects were informed of the objectives, risks, and benefits of the study. The adolescents and their parents signed informed consent forms detailing their rights to decline to continue participating in the study at any moment. Informed consent forms were written at the readability levels of each age group.

Sampling methods

The Hebron Governorate is divided into four districts: the northern district, the southern district, Hebron city, and the Yatta district. Data from the Ministry of Education (MOE) shows that approximately 70000 students between the ages of 13-18 years attended public schools in the Hebron Governorate in the academic year 2018/2019. According to the online sample size calculator available from Creative Research Systems,³⁴ the sample size of students required to estimate the prevalence of dysglycemia within a 4% margin of error and 95% confidence interval in all districts is 595 students.

Multistage random sampling method was used to select the participants in this study. In the first stage, all public schools were enumerated in each of the four districts. Stratified random sampling was used to select two schools (one all-male and one all-female) in each district. In the second stage, a random sample of students from the selected schools was chosen, including those who were possibly overweight or obese. Therefore, a total number of 511 students between the ages 13 to 18 years constituted the final study sample. Obese patients with conditions known to cause diabetes such as steroid therapy, pancreatitis, pregnancy, and cystic fibrosis were excluded.

Study tools

Anthropometric and blood pressure measurements

Anthropometric measurements included weight and height collected by trained nurses registered in the Ministry of Health. The measurement took place in the schools’ health clinics. The nurses measured the weight in kilograms and height in meters once using a weight-height scale with a flat floor scale and a portable stadiometer. The Body Mass Index (BMI) was calculated as the weight divided by the square of the height in meter. BMI was expressed in standard deviations using the WHO standard curves for age and sex. The adolescents were grouped into five categories: underweight, normal BMI, 1-2 SDs above the average line (overweight), and more than 2 SDs above the average line (Obese). Blood pressure measurements were taken once for each student in a seating position after they rested for around 5 minutes. The measurements categorized as normal or high. High blood pressure is defined as systolic >120 and/or diastolic pressure >80.³⁵ This variable includes both elevated blood pressure and overt hypertension readings.

Study questionnaires

Structured, self-administered questionnaires were distributed to students. The questionnaire included questions to be answered by the parents (e.g., family history of diabetes), and questions to be answered by the students themselves (e.g., food preferences).

Parents’ questionnaire: Specific questions that should be filled by a parent included education (less than secondary school, secondary to high school and higher than high school), place of residence, and family history of diabetes, hypertension, heart diseases and hypercholesterolemia. Family history of diabetes was recorded based on self-reports of diabetes in first degree relatives (mother, father, or sibling).

Student questionnaires: Physical activity and dietary patterns were assessed using standard questionnaires which are validated for each age group. The questions concerning physical activity were based on the International Physical Activity Questionnaire (short form), which measures physical activity patterns during the last seven days,³⁶ and The Youth Risk Behavior Surveillance Survey (YRBS), a recall questionnaire for children 10-21 years old.³⁶ The questions concerning dietary habits were based on the Youth Risk Behavior Survey,³⁷ and the Adolescent Food Habits Checklist.³⁸ Healthy food intake included intake of fruits, vegetables, milk and derivatives, meat, and cereals. Unhealthy food intake included consumption of candies, cola and derivatives, sweetened fruit juices, energy drinks and fats. The variables were recoded according to 25^th, 50^th and 75^th percentiles into: Low, moderate and high, respectively.

Laboratory measures

Blood samples were collected by MOH registered nurses and analyzed centrally at a nearby health facility. Glucose regulation measures were examined using standard laboratory procedures for collection of blood samples. Normal glucose regulation is fasting blood glucose level (BGL) <100 mg/dl and random BGL <140 mg/dl. Diabetes mellitus was defined as having fasting BGL ≥126 mg/dl, random BGL ≥200 mg/dl and/or Hemoglobin A1C>6.4% as per ISPAD clinical consensus guidelines for diabetes diagnosis in children and adolescents.² Dysglycemia referred to in our study is the term that includes any abnormalities in glucose measures and therefore includes both prediabetes and diabetes.

Statistical methods

Variables were entered and analyzed using SPSS (version 21). Frequencies and percentages were used to describe the sociodemographic characteristics of the study participants. The risk factors associated with dysglycemia were explored by the three objectives. The first objective identified the most important risk factors, the second objective examined how these risk factors vary by BMI, and the third objective used the risk factors in a risk score based on (non-laboratory) clinical risk factors that identified high risk adolescents who need further investigation through laboratory tests to confirm the diagnosis of dysglycemia. These objectives were analyzed using various statistical approaches. Univariate and bivariate analysis were conducted as appropriate to show the relationship between each of the risk factors with dysglycemia without adjusting for potential confounders. To adjust for potential confounders, multivariate logistic regressions were used and included all the variables that show statistically significant relationship with the outcome variable. Chi² tests of comparisons were used for categorical variables. Multiple imputations were used to replace missing values.

Results

Demographic characteristics

Table 1 represents the distribution of the study participants between the ages of 13-15 and 16-18 by their sociodemographic characteristics. Females constituted 50% of the younger students and 60% of the older students groups. Most of the students of both age groups lived in the city of Hebron (98.7% of younger students, 83.3% of older students). In both age groups, over half of the students’ fathers and 45% of their mothers had an education level less than secondary school (52.1%, 53.1%; and 45.3%, 45.5%) respectively. Parental employment status, across all ages, demonstrated that most of the students’ fathers had a job, while mothers did not (father employment: 94.5% of 13–15-year-old students, 90.2% of 16–18-year-old students; and for mother employment: 14% of 13–15-year-old students, 12% of 16–18-year-old students) respectively.

Table 1. Sociodemographic characteristics of the sample.

N=511.

Variable	Category	Age group
		13-15	16-18
		n (column%)
Gender	Male	118(50)	110(40)
Gender	Female	118(50)	165(60)
Residence area	City	233(98.7)	229(83.3)
Residence area	Village	3(1.3)	46(16.7)
Father education	Less than secondary school	123(52.1)	146(53.1)
	Secondary to high school	65(27.5)	84(30.5)
	Higher than high school	48(20.3)	45(16.4)
Mother education	Less than secondary school	107(45.3)	125(45.5)
	Secondary to high school	81(34.3)	102(37.1)
	Higher than high school	48(20.3)	48(17.5)
Mother working status	No	203(86)	242(88)
Mother working status	Yes	33(14)	33(12)
Father working status	No	13(5.5)	27(9.8)
Father working status	Yes	223(94.5)	248(90.2)
BMI classes¹	Normal weight	36(15.3)	101(36.7)
	Overweight	109(46.2)	106(38.5)
	Obese	91(38.6)	68(24.7)

1 BMI: Body Mass Index.

The body mass index (BMI) classification shows that in a sample of observed overweight and obese students, around 46% of 13-18-year-old students were overweight while 38.6% were obese, whereas among older students, 38.5% were overweight and 24.7% were obese.

Lifestyle and health characteristics

The lifestyle characteristics including food consumption frequency and daily sports activity across students of different BMIs are displayed in Table 2. The food consumption frequency of students indicated that the consumption of most food groups didn’t differ significantly between normal, overweight, and obese students, except for candy, coke and derivatives, and sweetened fruit juices (p-value=0.000, p value=0.001, and p value=0.005 respectively). Interestingly, the results indicate that over one-third of students with a normal weight consume candy at least once daily, in comparison to 34.4% of overweight, and only 19.5% of obese students. In addition, 34.4% of overweight and 42.8% of obese students consume coke less than once a week, whereas 32.1% of normal-weight students consume coke 2-6 times a week. Moreover, over one-third of each group consumes fruit juices less than once a week (31.4% of normal weight, 33.5% of overweight, and 44% of obese students) respectively, however, around one-quarter of overweight and obese students consume fruit juices once a week. In contrast, around 30% of normal-weight students consume fruit juices two-six times a week.

Table 2. Lifestyle characteristics of students by their BMI classification.

Variables	Category	BMI classes
Variables	Category	Normal weight	Overweight	Obese
Food group		n(%)			F	P-value
Nutrition
Fruits	Less than once a week	19(13.9)	30(14)	17(10.7)	0.362	0.697
	Once a week	26(19)	38(17.7)	28(17.6)
	2-6 times a week	51(37.2)	68(31.6)	64(40.3)
	Once daily or more	41(29.9)	79(36.7)	50(31.4)
Vegetables	Less than once a week	30(21.9)	30(14)	32(20.1)	0.962	0.383
	Once a week	20(14.6)	51(23.7)	21(13.2)
	2-6 times a week	58(42.3)	69(32.1)	65(40.9)
	Once daily or more	29(21.2)	65(30.2)	41(25.8)
Milk and derivatives	Less than once a week	40(29.2)	54(25.1)	50(31.4)	0.908	0.404
	Once a week	21(15.3)	34(15.8)	26(16.4)
	2-6 times a week	38(27.7)	72(33.5)	47(29.6)
	Once daily or more	38(27.7)	55(25.6)	36(22.6)
Candies	Less than once a week	25(18.2)	30(14)	49(30.8)	9.01	0.000
	Once a week	23(16.8)	44(20.5)	27(17)
	2-6 times a week	39(28.5)	67(31.2)	52(32.7)
	Once daily or more	50(36.5)	74(34.4)	31(19.5)
Cola and derivatives	Less than once a week	34(24.8)	74(34.4)	68(42.8)	7.141	0.001
	Once a week	29(21.2)	45(20.9)	33(20.8)
	2-6 times a week	44(32.1)	53(24.7)	43(27)
	Once daily or more	30(21.9)	43(20)	15(9.4)
Sweetened fruit juices	Less than once a week	43(31.4)	72(33.5)	70(44)	5.437	0.005
	Once a week	28(20.4)	56(26)	43(27)
	2-6 times a week	41(29.9)	52(24.2)	29(18.2)
	Once daily or more	25(18.2)	35(16.3)	17(10.7)
Energy drinks	Less than once a week	97(70.8)	157(73)	119(74.8)	0.863	0.422
	Once a week	12(8.8)	20(9.3)	18(11.3)
	2-6 times a week	19(13.9)	22(10.2)	16(10.1)
	Once daily or more	9(6.6)	16(7.4)	6(3.8)
Dairy products	Less than once a week	23(16.8)	32(14.9)	29(18.2)	0.252	0.778
	Once a week	16(11.7)	29(13.5)	24(15.1)
	2-6 times a week	61(44.5)	86(40)	53(33.3)
	Once daily or more	37(27)	68(31.6)	53(33.3)
Meat	Less than once a week	24(17.5)	24(11.2)	30(18.9)	0.475	0.622
	Once a week	15(10.9)	56(26)	30(18.9)
	2-6 times a week	77(56.2)	106(49.3)	74(46.5)
	Once daily or more	21(15.3)	29(13.5)	25(15.7)
Cereals and other carbohydrates	Less than once a week	5(3.6)	14(6.5)	14(8.8)	1.851	0.158
	Once a week	6(4.4)	18(8.4)	14(8.8)
	2-6 times a week	42(30.7)	47(21.9)	41(25.8)
	Once daily or more	84(61.3)	136(63.3)	90(56.6)
Fats	Less than once a week	51(37.2)	84(39.1)	54(34)	0.504	0.604
	Once a week	23(16.8)	38(17.7)	30(18.9)
	2-6 times a week	42(30.7)	50(23.3)	40(25.2)
	Once daily or more	21(15.3)	43(20)	35(22)
Physical activity
Daily sports ≥ 60 min	None	28(20.4)	47(21.9)	33(20.8)	0.831	0.436
	1-3 days a week	55(40.1)	102(47.4)	75(47.2)
	>3 days a week	54(39.4)	66(30.7)	51(32.1)

The results show that most students consume fruits and vegetables two-six times a week (27.2%, 31.6% and 40% for fruits’ consumption; 42.3%, 32.1% and 40.9% for vegetables consumption), respectively. In terms of milk consumption, around one-quarter of students of each BMI group consume milk at least once daily (27.7% of normal weight, 25.6% of overweight, and 22.6% of obese students). Similarly, around one-third of students consume dairy products at least once daily (27%, 31.6%, and 33.3%). As for meat consumption, 56.2%, 49.3%, and 46.5% of normal, overweight, and obese students respectively consume meat two-six times a week. Additionally, 15.3% of normal-weight students consume fat daily, however there’s a higher percentage of daily consumption among overweight and obese students (20% and 22%), respectively.

The results for physical activity in the form of sports lasting over 60 minutes show that 40% of normal-weight students perform sports more than three times a week, however, most overweight, and obese students perform them one-three days a week (47.4% and 47.2% respectively). There is no statistically significant difference between in sports performance among students of different BMI groups.

Table 3 shows the students’ personal health status and their family history of non-communicable diseases. When asked if they experience any symptoms of diabetes (e.g., increased thirst), over half of the students experienced at least one symptom (57.7% of normal weight, 53.5% of overweight, and 55.3% of obese students). No statistically significant difference was found among the groups (p-value=0.745).

Table 3. Health characteristics of students by their BMI level.

Variable	Category	BMI classes
		Normal weight	Overweight	Obese
		n(%)			F	P-value
Personal health
Diabetes symptoms	No	58(42.3)	100(46.5)	71(44.7)	.295	0.745
Diabetes symptoms	Yes	79(57.7)	115(53.5)	88(55.3)	.295	0.745
Dysglycemia	No	133(97.1)	209(97.2)	150(94.3)	1.217	0.297
Dysglycemia	Yes	4(2.9)	6(2.8)	9(5.7)	1.217	0.297
Blood pressure	Normal	65(47.4)	81(37.7)	35(22)	21.990	0.000
Blood pressure	High blood pressure	72(52.6)	134(62.3)	124(78)	21.990	0.000
First degree relatives’ health
Obesity	No	120(87.6)	162(75.3)	100(62.9)	12.43	0.000
Obesity	Yes	17(12.4)	53(24.7)	59(37.1)	12.43	0.000
Diabetes	No	107(78.1)	161(74.9)	106(66.7)	2.737	0.066
Diabetes	Yes	30(21.9)	54(25.1)	53(33.3)	2.737	0.066
Hypertension	No	104(75.9)	164(76.3)	109(68.6)	1.631	0.197
Hypertension	Yes	33(24.1)	51(23.7)	50(31.4)	1.631	0.197
Hypercholesterolemia	No	128(93.4)	190(88.4)	136(85.5)	2.365	0.095
Hypercholesterolemia	Yes	9(6.6)	25(11.6)	23(14.5)	2.365	0.095
Heart disease	No	131(95.6)	189(87.9)	140(88.1)	3.29	0.038
Heart disease	Yes	6(4.4)	26(12.1)	19(11.9)	3.29	0.038

The students were examined for non-communicable diseases directly associated with obesity, such as dysglycemia, and high blood pressure. The diagnosis of dysglycemia was found in 19 students, 5.3% in males, and 2.5% in females. Furthermore, they constituted 2.9%, 2.8% and 5.7% of normal-weight, overweight, and obese students respectively; however, no statistically significant association was found (p-value=0.297). The blood pressure measurements indicated that over 56% of normal-weight students, 62% of overweight students, and 78% of obese students had high systolic and/or diastolic blood pressure. The differences in probable high blood pressure was found to be significantly different among BMI groups (p value=0.000).

In terms of non-communicable diseases in first-degree relatives, around 12%, 25%, and 37% of normal-weight, overweight, and obese students respectively had at least one obese first-degree relative, which was significantly associated with students’ obesity levels (p value=0.000). Moreover, family diabetes was reported in around 22%, 25%, and 33% of normal-weight, overweight, and obese students respectively, albeit these differences are not statistically significant (p value=0.066). On the other hand, hypercholesterolemia and heart diseases were less reported by normal-weight students (6.6% and 4.4% respectively), whereas they were reported by a higher percentage of overweight and obese students (11.6%,12.1%; 14.5% and 11.9% respectively). The differences in having relatives with heart disease among students with different BMI groups were found to be statistically significant (p value=0.038), however, no significance was found in having hypercholesterolemia in first-degree relatives (p value=0.095).

Dysglycemia-related risk factors

Table 4 demonstrates the results of binary logistic regression analysis of dysglycemia-related risk factors. In terms of sociodemographic characteristics, neither gender nor age were found to be significantly associated with dysglycemia (p value=0.07, p value=0.98), however, younger students presented a lower odd of dysglycemia (OR=0.98, 95%CI=0.34-2.85). In terms of parental education, the categories of parental education of secondary school education and above were summed for insertion to this model. Higher levels of paternal education were associated with an increased odds of dysglycemia, albeit not statistically significant (p value=0.40, OR=1.63, %CI=0.52-5.10). On the other hand, students with lower maternal education were less likely to have dysglycemia (p value=0.46, OR=0.65, %CI=0.21-2.03). In terms of parental working status, maternal and paternal working status didn’t exhibit significant difference in adolescents dysglycemia (OR=0.89, 95%CI=0.16-4.78, p value=0.89; OR=0.63, 95%CI=0.06-5.53, p value=0.63).

Table 4. Binary logistic regression analysis of dysglycemia-related risk factors.

Variable	Sig.	Exp(B)	95% CI for EXP(B)
Variable	Sig.	Exp(B)	Lower	Upper
Gender (boys)	0.07	2.80	0.93	8.47
Age (older students)	0.98	0.98	0.34	2.85
Lower maternal education	0.46	0.65	0.21	2.03
Lower paternal education	0.40	1.63	0.52	5.10
Mother working status	0.89	0.89	0.16	4.78
Father working status	0.63	0.57	0.06	5.53
Personal health
Healthy food intake	0.53
Moderate	0.61	1.79	0.19	16.80
Low	0.35	2.97	0.31	28.29
Unhealthy food intake	0.12
Moderate	0.05	0.20	0.04	1.03
High	0.73	0.80	0.23	2.79
Daily sports≥60 minutes	0.27
Four days a week	0.89	1.12	0.22	5.62
1-3 times a week	0.17	2.54	0.68	9.55
None	0.53	0.59	0.12	3.00
High blood pressure	0.20	2.50	0.61	10.25
Diabetes symptoms	0.01	8.03	1.61	40.04
First degree relatives’ health
Obesity	0.01	4.49	1.42	14.26
Diabetes	0.02	3.79	1.28	11.24
Hypertension	0.10	0.27	0.06	1.27
Hypercholesterolemia	0.18	2.85	0.61	13.26
Heart disease	0.97	1.03	0.22	4.90

Personal health-related risk factors, such as lower intake of healthy foods, were found to increase the risk of dysglycemia (OR=1.79, 95%CI=0.19-16.80, p value=0.61 for moderate intake; and OR=2.97, 95%CI=0.31-28.29, p value=0.35 for low intake), however, higher intake of unhealthy foods didn’t increase the risk of dysglycemia (OR=0.20, 95%CI=0.04-1.03, p value=0.05 for moderate intake; and OR=0.80, 95%CI=0.23-2.79, p value=0.73 for high intake respectively). Moreover, sports activity of over 60 minutes one to three days a week showed higher odds of dysglycemia prevalence as compared to sports activity over four days a week (OR=2.54, 95%CI=0.68-9.55, p value=0.17 for activity 1-3 days a week; OR=1.12, 95%CI=0.22-5.62, p value=0.89 for activity four days a week, respectively).

Blood pressure was examined among the study participants. High systolic and/or diastolic blood pressure readings non-significantly increased the risk of dysglycemia (OR=2.5, 95%CI=0.61-10.25, p value=0.20). First-degree relatives’ health showed that having an obese or diabetic relative was significantly associated with dysglycemia prevalence (OR=4.49, 95%CI=1.42-14.26, p value=0.01; OR=3.79, 95%CI=1.28-11.24, p value=0.02). Moreover, students who had a relative with hypercholesterolemia or heart disease were 2.85 and 1.03 times more likely to have dysglycemia (95%CI=0.61-13.26, p value=0.18; and 95%CI=0.22-4.90, p value=0.97). On the contrary, hypertension in first-degree relatives was not found to increase the odds or to be significantly associated with dysglycemia (OR=0.27, 95%CI=0.06-1.27, p value=0.10).

Discussion

Non-communicable diseases such as diabetes mellitus are increasing worldwide, particularly in the Middle East,⁹ however, there is a scarcity in the literature regarding children and adolescent dysglycemia and diabetes status in Palestine, including type 2 diabetes. The present study aimed to investigate the prevalence of dysglycemia and its associated risk factors among Palestinian schoolchildren. The results evidenced that among a cohort of seemingly overweight and obese adolescents, the average prevalence of dysglycemia was 3.7% overall, 5.3% in males, and 2.5% in females. Prevalence rates vary across the literature, depending on the region and selection criteria. For example, the ORANGE study in India found that 3.7% of 6–19-year-old children and adolescents had glucose intolerance.³⁹ On the other hand, Al-Rubeaan et al. found that 6.12% of Saudi children and adolescents had dysglyecmia.⁴⁰ Similarly, Nakiriba et al. reported the prevalence to be 6.4% among adolescent girls.³⁷

Obesity is known to be strongly associated with dysglycemia. In fact, a recent review article states that obesity was found to quadruple the risk of type 2 diabetes among children and adolescents.⁵ In this study, 73.2% of apparently obese adolescents were found to be overweight and obese by BMI classification. However, contrary to the literature, the prevalence of dysglycemia was not found significantly different across these groups,¹⁰^,¹⁸ which could be justified by the low number of dysglycemia cases in the BMI groups. Dysglycemia and obesity are also recognized to be associated with numerous non-communicable diseases, including hypertension, hyperlipidemia, cardiovascular diseases, and metabolic syndrome.¹⁷^,⁴¹ In our study population, around 64% of students had high blood pressure readings, which differed significantly between normal, overweight, and obese students, and increased the odds of developing dysglycemia. These findings are consistent with a pediatric hypertension literature review done in Africa, which concluded that the prevalence of hypertension differed significantly across the different BMI groups.⁴²

Dysglycemia and Type 2 diabetes are associated with increased morbidity, progression to adult diseases, and poor health in adulthood.⁴³^,⁴⁴ Lifestyle behaviors, non-exclusively including dietary habits and physical activity, play a significant role in the development of obesity and dysglycemia.⁷^,⁴⁵^,⁴⁶ In this study, we aimed to assess the association between nutrition and physical activity to obesity and dysglycemia. The results revealed that dietary habits among adolescents with distinct BMIs were somewhat similar with the exception of sweetened food items, such as coke, sweetened juices, and candy. However, the study found a discrepancy as normal-weight adolescents in our sample population showed higher consumption levels of unhealthy food items than overweight or obese adolescents. Similar results have been evidenced in other studies, such as in Ref. 47, where Viera et al. reported that normal-weight healthy Brazilian adolescents consumed more sugar and candy than obese adolescents. On the other hand, a study in Taiwan revealed that there was no association between sugar intake and obesity levels.⁴⁸ The discrepancy in our study may be a result of the wide availability of these food items in cafeterias in Palestinian schools, and the higher scrutiny of overweight and obese students on lowering the consumption of these items. Furthermore, our results evidence that lower intake of healthy foods did not significantly correlate to impaired glucose tolerance. On the other hand, a higher intake of unhealthy foods showed to be associated with a higher prevalence of impaired glucose tolerance.

In terms of physical activity, normal, overweight, and obese weight students reported similar frequencies of sports performance. Moreover, contrary to our expectations, physical activity was not found significantly associated with dysglycemia. Similar results were found in Ref. 44, where Nakiriba et al. expressed that the level of physical activity was not significantly associated with dysglycemia among Ugandan adolescent girls. Additionally, Al Amiri et al. reported a similar finding among 11–17-year-old Emirati students.⁴⁹ Nonetheless, several studies have demonstrated the impact of physical activity on blood glucose level management.²²^,²³^,⁵⁰ The results obtained in this study could be attributed to the fact that our study participants had abnormal glucose readings rather than full-blown diabetes.

Additionally, this study examined participants’ family history of non-communicable diseases, including obesity, hypertension, hyperlipidemia, and cardiovascular diseases. The results demonstrate that obesity in first-degree relatives was the main factor associated with childhood obesity and dysglycemia. We found that around 61% of overweight and obese students had at least one obese first-degree relative. The findings are consistent with several previous studies that associated parental obesity and obesity, dysglycemia, and diabetes among adolescents.⁴⁷^,⁵¹ Moreover, we found that diabetes in first-degree relatives is associated with dysglycemia among adolescents, however, it was not found significantly associated with childhood obesity. Various studies have demonstrated that offspring of diabetic parents are at increased risk for diabetes and obesity, independent of parental education.²^,⁴⁷^,⁴⁹

The results showed that other factors associated with dysglycemia prevalence among Palestinian adolescents included parental education and employment. Our results demonstrate paternal education higher than secondary school level was associated with decreased risk of dysglycemia. This finding is consistent with other studies that have found that parental education is positively associated with control of dysglycemia-related risk factors.⁵²^,⁵³ However, contrary to the stated studies, lower maternal educational levels were not associated with increased risk of dysglycemia. In the Palestinian context, this could be attributed to the fact that the less educated mothers are usually stay-at-home mothers, who could have more control on home cooked meals and children eating habits. Parental employment on the other hand was not found to be significantly associated with dysglycemia among adolescents.

Symptoms of diabetes, mainly increased thirst, excessive urination, increased food cravings, and fatigue, were found to be positively correlated to dysglycemia prevalence.⁷ The results demonstrate that over half of the students suffered from at least one symptom related to diabetes. This study’s findings illustrate the importance of early screening for impaired glucose tolerance among students, particularly adolescents presenting diabetes-related symptoms.

Potential limitations to this study include the small sample of dysglycemic patients, which we believe to be the reason for many of the non-significant associations in the regression model. Moreover, there were apparent cultural hindrances to the proper completion of blood testing. Many of the dysglycemic students’ parents refused to continue with a follow-up of blood glucose and lipids measurements, therefore we were unable to diagnose diabetes among adolescents, and classify them as type 1 or type 2. We believe this refusal could be attributed to the disease-related stigma present in the country. Parents believe that the diagnosis of diabetes could hinder their children’s progression in social and work life. Despite these limitations, this study highlights the presence of unrecognized dysglycemia among a cohort of Palestinian adolescents. Furthermore, it provides an insight on the importance of consideration of various factors associated with dysglycemia, including but not limited to family history of noncommunicable diseases. Additionally, the findings demonstrated the association of potential hypertension in adolescents who suffer from obesity, which emphasizes the need for proper screening programs among adolescents with obesity. In conclusion, we believe the study findings could offer a roadmap for further investigational studies on the status of dysglycemia and diabetes, particularly type 2 in the Palestinian pediatric population.

Data availability

Underlying data

Harvard Dataverse: Dysglycemia among Palestinian children. DOI: https://doi.org/10.7910/DVN/UPYHRR.⁵⁴

This project contains the following underlying data:

• Dysglycemia_data.tab

Zenodo Database: Dysglycemia_Palestinian_Children_questionnaires

10.5281/zenodo.7766216

This database contains the following underlying data:

• questionnaire-parent
• questionnaire-student

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Acknowledgements

We wish to thank Prof. Akram Kharounbi for his work on designing and supervising this study. We would like to thank the Ministry of Education, Palestine for its permission to perform the study. We also thank all study participants, and field workers.

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Version 2

VERSION 2 PUBLISHED 06 Jul 2023

Author details Author details

Diala Abu Al-Halawa
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation

Stephanny Vicuna Polo
Roles: Writing – Review & Editing

Radwan Qasrawi
Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation

Competing interests

No competing interests were disclosed.

Grant information

The original study was funded by the Ministry of Higher Education under grant number HIE 20/Q2019.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

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https://doi.org/10.12688/f1000research.132160.2

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Abu Al-Halawa D, Vicuna Polo S and Qasrawi R. Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate  [version 2; peer review: 1 approved, 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.2)

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Reviewer Report 29 Aug 2024

Ghadir Fakhri Al-Jayyousi, Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Doha, Qatar

Approved with Reservations

https://doi.org/10.5256/f1000research.155767.r311270

Thank you for giving me the opportunity to review this important work: “Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate”. This study aims to determine the prevalence of dysglycemia in a sample of Palestinian adolescents with overweight and obesity, identify risk factors associated with dysglycemia, and examine risk factors variance by gender. The results of this study will fill the gap in regards to the rising problem of dysglycemia among Palestinian adolescents and underlines the need for rapid screening programs and protocols for early detection and classification of the disease, leading to initiation of early prevention and treatment plans. I would recommend considering my comments to strengthen the article.

Title: kindly instead of overweight and obese Palestinian adolescents (through all the article wherever mentioned), please consider changing to Palestinian adolescents with overweight and obesity.

Abstract:
Methods- kindly mention: -The sampling strategy you followed- if the sample is convenient or random. -The statistical tests that have been applied to test the association, and the software you used.
Results- add P values and confidence intervals.
Conclusions- add research implications to the conclusions.

Introduction This is an important research study. The work is clearly and accurately presented and cite the current literature. Just please elaborate more on the significance of the study and back up from the literature available about diabetes type 2 in Palestine.

Methods The study design is appropriate and the work is technically sound. Sufficient details of methods and analysis are provided to allow replication by others. Just a few questions to address: In which language was the consent form (s)? and In which language was the students’ and parents’ questionnaire? Have you made any translation and back translation? Were you able to pilot the questionnaires? What about the validity of the questionnaires? The statistical analysis and its interpretation are appropriate. However, one of the objectives, as explicitly mentioned in the abstract, is to examine the variance of the risk factors by gender. This should also be singled out in the statistical methods section, also.

Results In table 1, please delete the word “column” just keep “%”, and it needs to be added for both age groups- N (%) Again, as in the methods section, one of the objectives, as explicitly mentioned in the abstract, is to examine the variance of the risk factors by gender. This should be more highlighted in the results section.

Discussion kindly change “obese weight” to obesity; there is no such obese weight. (end of page 10) Discuss the variance of the risk factors by gender. In the last paragraph, please mention the implications for future research. Finally, the conclusions drawn are adequately supported by the results.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health Education and promotion.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 29 Sep 2023

Huda Al Hourani, The Hashemite University, Az-Zarqa, Zarqa Governorate, Jordan

Approved

https://doi.org/10.5256/f1000research.155767.r209589

I am pleased with the author's ... Continue reading

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Reviewer Report 20 Jul 2023

Huda Al Hourani, The Hashemite University, Az-Zarqa, Zarqa Governorate, Jordan

Approved with Reservations

https://doi.org/10.5256/f1000research.145066.r186872

The most important suggestion for respected authors is to update some terms and definitions in the manuscript, such as using Arabic numerals for type 2 diabetes to avoid confusing the Roman numeral "II" with the Arabic number "11." Also, using the updated Clinical practice guideline for screening and managing high blood pressure in children and adolescents in 2017. Furthermore, the diagnostic cutoff point for HbA1c (All articles are attached).

The age ranges between 13-18 years, so it is better to call the participants adolescents, not children.

The authors' methodology for measuring weight, height, and blood pressure (how many times it is measured) and classifying it needs to be expanded.

The authors must provide more information about the dysglycemic subjects included in this study (it makes a difference as usually, T1DM do not have overweight or obesity).

The conclusion must be expanded, not as in the abstract.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

References

1. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.Diabetes Care. 1997; 20 (7): 1183-97 PubMed Abstract | Publisher Full Text
2. Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, et al.: Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.Pediatrics. 2017; 140 (3). PubMed Abstract | Publisher Full Text
3. Mayer-Davis EJ, Kahkoska AR, Jefferies C, Dabelea D, et al.: ISPAD Clinical Practice Consensus Guidelines 2018: Definition, epidemiology, and classification of diabetes in children and adolescents.Pediatr Diabetes. 2018; 19 Suppl 27 (Suppl 27): 7-19 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Overweight and obesity and its association with non-communicable diseases

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Author Response 26 Sep 2023

Diala Abu Al Halawa, Faculty of Medicine, Al-Quds University, Jerusalem, Palestinian Territory

26 Sep 2023

Author Response

Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to ... Continue reading Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to your comments:

The most important suggestion for respected authors is to update some terms and definitions in the manuscript, such as using Arabic numerals for type 2 diabetes to avoid confusing the Roman numeral "II" with the Arabic number "11." Also, using the updated Clinical practice guideline for screening and managing high blood pressure in children and adolescents in 2017. Furthermore, the diagnostic cutoff point for HbA1c (All articles are attached).
- Thank you for your valuable feedback. We have updated the terms as suggested.
As we updated the definition of high blood pressure, the percentage of adolescents who had high blood pressure readings increased to around 64%. Therefore, we have restudied the regression model. The were no major differences in the findings, and all changes are addressed in the results and discussion sections.

The age ranges between 13-18 years, so it is better to call the participants adolescents, not children.
- Thank you for your note. We have updated the term accordingly.

The authors' methodology for measuring weight, height, and blood pressure (how many times it is measured) and classifying it needs to be expanded.
We elaborated these specifics in the methodology section under (anthropometric and blood pressure measurements) section.
The authors must provide more information about the dysglycemic subjects included in this study (it makes a difference as usually, T1DM do not have overweight or obesity).
- In reference to the characteristics of the dysglycemic subjects, we added the total number of the cases and their distribution by gender, in addition to the distribution by the different BMI classes which was previously written in the article. However, due to the low number of cases, we believe that adding further information on the distribution of this group by the other sociodemographic variables won't contribute much value to the study.

The conclusion must be expanded, not as in the abstract.
- In reference to the conclusions, we extended the conclusions in the final paragraph of the discussion. However, we didn't further elaborate on the specifics of the conclusions supported by data since it's not a separate section but included in the discussion section.
Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to your comments:

The most important suggestion for respected authors is to update some terms and definitions in the manuscript, such as using Arabic numerals for type 2 diabetes to avoid confusing the Roman numeral "II" with the Arabic number "11." Also, using the updated Clinical practice guideline for screening and managing high blood pressure in children and adolescents in 2017. Furthermore, the diagnostic cutoff point for HbA1c (All articles are attached).
- Thank you for your valuable feedback. We have updated the terms as suggested.
As we updated the definition of high blood pressure, the percentage of adolescents who had high blood pressure readings increased to around 64%. Therefore, we have restudied the regression model. The were no major differences in the findings, and all changes are addressed in the results and discussion sections.

The age ranges between 13-18 years, so it is better to call the participants adolescents, not children.
- Thank you for your note. We have updated the term accordingly.

The authors' methodology for measuring weight, height, and blood pressure (how many times it is measured) and classifying it needs to be expanded.
We elaborated these specifics in the methodology section under (anthropometric and blood pressure measurements) section.
The authors must provide more information about the dysglycemic subjects included in this study (it makes a difference as usually, T1DM do not have overweight or obesity).
- In reference to the characteristics of the dysglycemic subjects, we added the total number of the cases and their distribution by gender, in addition to the distribution by the different BMI classes which was previously written in the article. However, due to the low number of cases, we believe that adding further information on the distribution of this group by the other sociodemographic variables won't contribute much value to the study.

The conclusion must be expanded, not as in the abstract.
- In reference to the conclusions, we extended the conclusions in the final paragraph of the discussion. However, we didn't further elaborate on the specifics of the conclusions supported by data since it's not a separate section but included in the discussion section.
Competing Interests: No competing interests were disclosed. Close
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Author Response 26 Sep 2023

Diala Abu Al Halawa, Faculty of Medicine, Al-Quds University, Jerusalem, Palestinian Territory

26 Sep 2023

Author Response

Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to ... Continue reading Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to your comments:

The most important suggestion for respected authors is to update some terms and definitions in the manuscript, such as using Arabic numerals for type 2 diabetes to avoid confusing the Roman numeral "II" with the Arabic number "11." Also, using the updated Clinical practice guideline for screening and managing high blood pressure in children and adolescents in 2017. Furthermore, the diagnostic cutoff point for HbA1c (All articles are attached).
- Thank you for your valuable feedback. We have updated the terms as suggested.
As we updated the definition of high blood pressure, the percentage of adolescents who had high blood pressure readings increased to around 64%. Therefore, we have restudied the regression model. The were no major differences in the findings, and all changes are addressed in the results and discussion sections.

The age ranges between 13-18 years, so it is better to call the participants adolescents, not children.
- Thank you for your note. We have updated the term accordingly.

The authors' methodology for measuring weight, height, and blood pressure (how many times it is measured) and classifying it needs to be expanded.
We elaborated these specifics in the methodology section under (anthropometric and blood pressure measurements) section.
The authors must provide more information about the dysglycemic subjects included in this study (it makes a difference as usually, T1DM do not have overweight or obesity).
- In reference to the characteristics of the dysglycemic subjects, we added the total number of the cases and their distribution by gender, in addition to the distribution by the different BMI classes which was previously written in the article. However, due to the low number of cases, we believe that adding further information on the distribution of this group by the other sociodemographic variables won't contribute much value to the study.

The conclusion must be expanded, not as in the abstract.
- In reference to the conclusions, we extended the conclusions in the final paragraph of the discussion. However, we didn't further elaborate on the specifics of the conclusions supported by data since it's not a separate section but included in the discussion section.
Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to your comments:

The most important suggestion for respected authors is to update some terms and definitions in the manuscript, such as using Arabic numerals for type 2 diabetes to avoid confusing the Roman numeral "II" with the Arabic number "11." Also, using the updated Clinical practice guideline for screening and managing high blood pressure in children and adolescents in 2017. Furthermore, the diagnostic cutoff point for HbA1c (All articles are attached).
- Thank you for your valuable feedback. We have updated the terms as suggested.
As we updated the definition of high blood pressure, the percentage of adolescents who had high blood pressure readings increased to around 64%. Therefore, we have restudied the regression model. The were no major differences in the findings, and all changes are addressed in the results and discussion sections.

The age ranges between 13-18 years, so it is better to call the participants adolescents, not children.
- Thank you for your note. We have updated the term accordingly.

The authors' methodology for measuring weight, height, and blood pressure (how many times it is measured) and classifying it needs to be expanded.
We elaborated these specifics in the methodology section under (anthropometric and blood pressure measurements) section.
The authors must provide more information about the dysglycemic subjects included in this study (it makes a difference as usually, T1DM do not have overweight or obesity).
- In reference to the characteristics of the dysglycemic subjects, we added the total number of the cases and their distribution by gender, in addition to the distribution by the different BMI classes which was previously written in the article. However, due to the low number of cases, we believe that adding further information on the distribution of this group by the other sociodemographic variables won't contribute much value to the study.

The conclusion must be expanded, not as in the abstract.
- In reference to the conclusions, we extended the conclusions in the final paragraph of the discussion. However, we didn't further elaborate on the specifics of the conclusions supported by data since it's not a separate section but included in the discussion section.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 06 Jul 2023

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Version 2 (revision) 26 Sep 23	read	read
Version 1 06 Jul 23	read

Huda Al Hourani, The Hashemite University, Az-Zarqa, Jordan
Ghadir Fakhri Al-Jayyousi, Qatar University, Doha, Qatar

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29 Aug 2024 | for Version 2

Ghadir Fakhri Al-Jayyousi, Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Doha, Qatar

1 Views Cite this report Responses(0)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health Education and promotion.

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3 Views

29 Sep 2023 | for Version 2

Huda Al Hourani, The Hashemite University, Az-Zarqa, Zarqa Governorate, Jordan

3 Views Cite this report Responses(0)

Approved

I am pleased with the author's responses to my previous version's comments.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Overweight and obesity and its association with non-communicable diseases

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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19 Views

20 Jul 2023 | for Version 1

Huda Al Hourani, The Hashemite University, Az-Zarqa, Zarqa Governorate, Jordan

19 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Overweight and obesity and its association with non-communicable diseases

Respond to this report

Responses (1)

Author Response

26 Sep 2023

Diala Abu Al Halawa, Faculty of Medicine, Al-Quds University, Jerusalem, Palestinian Territory

Dear reviewer,

Thank you greatly for your response. We made the suggested changes to the manuscript an updated the submission accordingly.
Here is a point by point response to your comments:

The most important suggestion for respected authors is to update some terms and definitions in the manuscript, such as using Arabic numerals for type 2 diabetes to avoid confusing the Roman numeral "II" with the Arabic number "11." Also, using the updated Clinical practice guideline for screening and managing high blood pressure in children and adolescents in 2017. Furthermore, the diagnostic cutoff point for HbA1c (All articles are attached).
- Thank you for your valuable feedback. We have updated the terms as suggested.
As we updated the definition of high blood pressure, the percentage of adolescents who had high blood pressure readings increased to around 64%. Therefore, we have restudied the regression model. The were no major differences in the findings, and all changes are addressed in the results and discussion sections.

The age ranges between 13-18 years, so it is better to call the participants adolescents, not children.
- Thank you for your note. We have updated the term accordingly.

The authors' methodology for measuring weight, height, and blood pressure (how many times it is measured) and classifying it needs to be expanded.
We elaborated these specifics in the methodology section under (anthropometric and blood pressure measurements) section.
The authors must provide more information about the dysglycemic subjects included in this study (it makes a difference as usually, T1DM do not have overweight or obesity).
- In reference to the characteristics of the dysglycemic subjects, we added the total number of the cases and their distribution by gender, in addition to the distribution by the different BMI classes which was previously written in the article. However, due to the low number of cases, we believe that adding further information on the distribution of this group by the other sociodemographic variables won't contribute much value to the study.

The conclusion must be expanded, not as in the abstract.
- In reference to the conclusions, we extended the conclusions in the final paragraph of the discussion. However, we didn't further elaborate on the specifics of the conclusions supported by data since it's not a separate section but included in the discussion section.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Ethics

Sampling methods

Study tools

Statistical methods

Results

Demographic characteristics

Table 1. Sociodemographic characteristics of the sample.

Lifestyle and health characteristics

Table 2. Lifestyle characteristics of students by their BMI classification.

Table 3. Health characteristics of students by their BMI level.

Dysglycemia-related risk factors

Table 4. Binary logistic regression analysis of dysglycemia-related risk factors.

Discussion

Data availability

Underlying data

Acknowledgements

References

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Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian adolescents in the Hebron governorate 