Keywords
Dysglycemia1, schoolchildren2, Diabetes3, nutrition4, risk factors5, obesity6
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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 children in the Hebron governorate [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.1)
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Research Article
Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian children in the Hebron governorate
[version 1; peer review: 1 approved with reservations]
PUBLISHED 06 Jul 2023
OPEN PEER REVIEW
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Abstract
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 children in the Hebron governorate [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.1)
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)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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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 II 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 II 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 II 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 II 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 II diabetes.13 Moreover, a study in Saudi Arabia reported a 9.04% prevalence of type II 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 II 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 II diabetes as it is generally agreed upon that obesity increases the risk of type II 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 II 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 II 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 II diabetes.30
Dysglycemia and type II 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 II 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 children 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 children 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 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. Children 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 for each student and categorized as normal or high. High blood pressure is defined as systolic or diastolic pressure more than 95th percentile for age, sex, or height based on standard tables.35
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 no family history 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 and appropriate 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 25th, 50th and 75th 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 glucose <100 mg/dl and random plasma glucose (RPG) <140 mg/dl. Diabetes mellitus was defined as having fasting glucose ≥126 mg/dl, RPG≥200 mg/dl or Hemoglobin A1C>6.4% as per ISPAD clinical consensus guidelines for diabetes diagnosis in children and adolescents.39 Dysglycemia 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 children 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) |
| Female | 118(50) | 165(60) | |
| Residence area | City | 233(98.7) | 229(83.3) |
| 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) |
| Yes | 33(14) | 33(12) | |
| Father working status | No | 13(5.5) | 27(9.8) |
| 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) | |
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 46.7% 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.
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 |
| Yes | 79(57.7) | 115(53.5) | 88(55.3) | |||
| Dysglycemia | No | 133(97.1) | 209(97.2) | 150(94.3) | 1.217 | 0.297 |
| Yes | 4(2.9) | 6(2.8) | 9(5.7) | |||
| Hypertension | No | 108(78.8) | 154(71.6) | 87(55.1) | 20.39 | 0.000 |
| Hyper (S or D)1 | 22(16.1) | 48(22.3) | 57(36.1) | |||
| Hyper (S & D) | 7(5.1) | 13(6) | 14(8.9) | |||
| First degree relatives’ health | ||||||
| Obesity | No | 120(87.6) | 162(75.3) | 100(62.9) | 12.43 | 0.000 |
| Yes | 17(12.4) | 53(24.7) | 59(37.1) | |||
| Diabetes | No | 107(78.1) | 161(74.9) | 106(66.7) | 2.737 | 0.066 |
| Yes | 30(21.9) | 54(25.1) | 53(33.3) | |||
| Hypertension | No | 104(75.9) | 164(76.3) | 109(68.6) | 1.631 | 0.197 |
| Yes | 33(24.1) | 51(23.7) | 50(31.4) | |||
| Hypercholesterolemia | No | 128(93.4) | 190(88.4) | 136(85.5) | 2.365 | 0.095 |
| Yes | 9(6.6) | 25(11.6) | 23(14.5) | |||
| Heart disease | No | 131(95.6) | 189(87.9) | 140(88.1) | 3.29 | 0.038 |
| Yes | 6(4.4) | 26(12.1) | 19(11.9) | |||
The students were examined for non-communicable diseases directly associated with obesity, such dysglycemia, and high blood pressure. The diagnosis of dysglycemia was found among 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 20% of normal-weight students, 28% of overweight students, and 45% of obese students had high systolic and/or diastolic blood pressure. The differences in probable hypertension were 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=0.08, p value=0.94), however, younger students presented a lower odd of dysglycemia (OR=0.96, 95%CI=0.33-2.79). 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=0.56, OR=1.41, %CI=0.44-4.49). On the other hand, students with lower maternal education were less likely to have dysglycemia (p value= 0.29, OR=0.55, %CI=0/18-1.67). In terms of parental working status, paternal and maternal working status didn’t exhibit significant difference in children dysglycemia (OR=0.58, 95%CI=0.06-5.79, p value=0.65; OR=0.85, 95%CI=0.16-4.54, p value=0.85).
Table 4. Binary logistic regression analysis of dysglycemia-related risk factors.
Personal health-related risk factors, such as lower intake of healthy foods, were found to increase the risk of dysglycemia (OR=1.61, 95%CI=0.17-15.33, p value=0.68 for moderate intake; and OR=2.81, 95%CI=0.29-27.33, p value=0.37 for low intake), however, higher intake of unhealthy foods didn’t increase the risk of dysglycemia (OR=0.021, 95%CI=0.04-1.06, p value=0.06 for moderate intake; and OR=0.89, 95%CI=0.25-3.1, p value=0.85 for high intake respectively). Moreover, sports activity of over 60 minutes one to three times a week showed higher dysglycemia prevalence as compared to sports activity over four days a week (OR=3.34, 95%CI=0.85-13.17, p value=0.09).
Hypertension was studied among schoolchildren. Systolic and diastolic hypertension significantly increased the risk of dysglycemia (OR=7.1, 95%CI=1.45-34.71, p value=0.02). First-degree relatives’ health showed that having an obese or diabetic relative was significantly associated with dysglycemia prevalence (OR=5.65, 95%CI=1.7-18.78, p value=0.01; OR=3.47, 95%CI=1.38-13.84, p value=0.01). Moreover, students who had a relative with hypercholesterolemia or heart disease were 2.97 and 1.05 times more likely to have dysglycemia (95%CI=0.65-13.51, p value=0.16; and 95%CI=0.21-5.15, p value=0.96). On the contrary, hypertension in first-degree relatives was not found to be significantly associated with dysglycemia prevalence (OR=0.23, 95%CI=0.05-1.11, p value=0.07).
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 II 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 children and 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.40 On the other hand, Al-Rubeaan et al. found that 6.12% of Saudi children and adolescents had dysglyecmia.41 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 II diabetes among children and adolescents.5 In this study, 73.2% of apparently obese children 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 this can be justified due to 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.17,42 In our study population, around 33% of students had probable hypertension, 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.43
Dysglycemia and Type II diabetes are associated with increased morbidity, progression to adult diseases, and poor health in adulthood.44,45 Lifestyle behaviors, non-exclusively including dietary habits and physical activity, play a significant role in the development of obesity and dysglycemia.7,46,47 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 children 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 children in our sample population showed higher consumption levels of unhealthy food items than overweight or obese children. Similar results have been evidenced in other studies, such as in Ref. 48, 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.49 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. 45, 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.50 Nonetheless, several studies have demonstrated the impact of physical activity on blood glucose level management.22,23,51 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 children.48,52 Moreover, we found that diabetes in first-degree relatives is associated with dysglycemia among children and adolescents, however, it was not found significantly associated with childhood obesity. Various studies have demonstrated that children of diabetic parents are at increased risk for diabetes and obesity, independent of parental education.39,48,50
The results showed that other factors associated with dysglycemia prevalence among Palestinian children and 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.53,54 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 children.
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 children and 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 children, and classify them as type I or type II. 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 children and adolescents and offers a roadmap for further investigational studies on the status of dysglycemia and diabetes, particularly type II in the Palestinian pediatric population.
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how to cite this article
Abu Al-Halawa D, Vicuna Polo S and Qasrawi R. Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian children in the Hebron governorate [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.12688/f1000research.132160.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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How to cite this report:
Al Hourani H. Reviewer Report For: Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian children in the Hebron governorate [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.5256/f1000research.145066.r186872)
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NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 20 Jul 2023
Approved with Reservations
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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
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Al Hourani H. Reviewer Report For: Prevalence and risk factors associated with dysglycemia among overweight and obese Palestinian children in the Hebron governorate [version 1; peer review: 1 approved with reservations]. F1000Research 2023, 12:792 (https://doi.org/10.5256/f1000research.145066.r186872)
The direct URL for this report is:
https://f1000research.com/articles/12-792/v1#referee-response-186872
https://f1000research.com/articles/12-792/v1#referee-response-186872
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Author Response 26 Sep 2023Diala Abu Al Halawa, Faculty of Medicine, Al-Quds University, Jerusalem, Palestinian Territory26 Sep 2023Author ResponseDear 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
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Author Response 26 Sep 2023Diala Abu Al Halawa, Faculty of Medicine, Al-Quds University, Jerusalem, Palestinian Territory26 Sep 2023Author ResponseDear 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
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