RATIONALE, AIMS, AND OBJECTIVESThe accreditation of healthcare organizations has been applied as a quality assurance mechanism of healthcare services. Kuwait health authorities implemented a national healthcare accreditation program at the governmental healthcare system. This study aimed to explore the perceptions of healthcare professionals (HCPs) about healthcare accreditation, perceived challenges to implementing accreditation, and views on how to overcome these challenges.METHODSA phenomenological qualitative framework was adopted to conduct focus group interviews to explore perceptions of HCPs about accreditation in governmental healthcare system. Data were collected from 30 HCPs using seven focus group interviews. The verbatim transcripts of the interviews were analysed using the framework approach.RESULTSThe HCPs indicated that accreditation enhanced patient safety culture at their organizations through staff adherence to good practices, improved documentation and patient handover practices, and incident reporting. The facilitators to the implementation of accreditation that emerged from interviews included administrative support, staff training about accreditation, and expansion in application of electronic systems. Participants reported several challenges to implementing accreditation including challenges related to staff (eg, high workload, burdens imposed by accreditation requirements), challenges related to organizational system and resources (eg, poor teamwork among HCPs, inadequate infrastructure in some facilities), and challenges related to patients (eg, poor understanding about accreditation). However, most participants expressed positive attitudes towards accreditation and appreciated its impact on quality of healthcare. Participants suggested ways to support accreditation such as increasing staff numbers to reduce workload, enhancing staff motivation and education about accreditation, developing proactive leadership and staff teamwork, and improving patients' awareness about accreditation.CONCLUSIONSHCPs in Kuwait expressed positive attitudes towards accreditation while also recognizing the challenges that may hinder its implementation. The collaboration between different stakeholders in this process is essential to overcome these challenges and support HCPs to meet accreditation standards and improve quality of healthcare services.

Background: Little is known about the nutritional knowledge of children in Kuwait and school-based nutrition interventions are scarce. No validated tool to assess the nutrition knowledge of schoolchildren in Kuwait is available. Aims: This study determined the validity and reliability of a nutrition knowledge questionnaire in Kuwaiti primary-school children, and measured children's nutrition knowledge before and after a nutrition awareness intervention. Methods: The questionnaire included five questions to measure nutritional knowledge. The face and content validity were assessed by nutrition and paediatric experts. To assess questionnaire reliability and nutrition knowledge, 642 schoolchildren (8-12 years) were assigned to an intervention, control or reliability group. Each group completed the questionnaire twice, one or two weeks apart. Students in the intervention group attended a nutrition knowledge presentation before completing the questionnaire the second time. Independent and paired samples t-tests were used to assess score differences between and within the intervention and control groups for changes in nutrition knowledge. Pearson correlation coefficients were used to measure score consistency in the reliability group. Results: Overall, the questionnaire had good content validity and moderate to strong reliability (r = 0.44, P < 0.001). Students in the intervention group had significantly higher mean nutritional knowledge scores after the intervention (from 3.65 (SD 1.03) to 4.20 (SD 1.02); P = 0.17). Control group scores were mostly unchanged. Conclusions: The Kuwait child nutrition knowledge questionnaire is a valid and reliable tool to assess nutritional knowledge in schoolchildren in Kuwait. Nutrition knowledge of Kuwaiti schoolchildren should be improved using age-appropriate interventions in school.

OBJECTIVE:To assess the validity and reliability of the Kuwait Adult Nutrition Knowledge Questionnaire (KANKQ) in adult students as an initial step to validation in the general adult population. METHODS:Participants (n = 253; aged ≥21 years) were categorized based on academic background and designated into groups known to differ in nutrition knowledge. Participants completed the questionnaire twice. Independent-samples t test, Pearson correlation coefficients, and Cronbach α were used to assess reliability and validity (P < .05). RESULTS:Participants with health-related (n = 144) and nutrition-training backgrounds (n = 58) scored significantly higher than did those without them (n = 109 and 178, respectively; P < .001), indicating good construct validity of the KANKQ. Test-retest reliability (r = .67; P < .001) and internal consistency (α = .81) of the questionnaire were moderate to high. CONCLUSIONS AND IMPLICATIONS:Further testing of the KANKQ in workplaces and public areas is required for validation in the general adult population. Applicability to neighboring countries of similar background is warranted.

BACKGROUND:Type II diabetes (T2D) has been associated with changes in oral bacterial diversity and frequency. It is not known whether these changes are part of the etiology of T2D, or one of its effects. METHODS:We measured the glucose concentration, bacterial counts, and relative frequencies of 42 bacterial species in whole saliva samples from 8,173 Kuwaiti adolescents (mean age 10.00 ± 0.67 years) using DNA probe analysis. In addition, clinical data related to obesity, dental caries, and gingivitis were collected. Data were compared between adolescents with high salivary glucose (HSG; glucose concentration ≥ 1.0 mg/d, n = 175) and those with low salivary glucose (LSG, glucose concentration < 0.1 mg/dL n = 2,537). RESULTS:HSG was associated with dental caries and gingivitis in the study population. The overall salivary bacterial load in saliva decreased with increasing salivary glucose concentration. Under HSG conditions, the bacterial count for 35 (83%) of 42 species was significantly reduced, and relative bacterial frequencies in 27 species (64%) were altered, as compared with LSG conditions. These alterations were stronger predictors of high salivary glucose than measures of oral disease, obesity, sleep or fitness. CONCLUSIONS:HSG was associated with a reduction in overall bacterial load and alterations to many relative bacterial frequencies in saliva when compared with LSG in samples from adolescents. We propose that hyperglycemia due to obesity and/or T2D results in HSG and subsequent acidification of the oral environment, leading to a generalized perturbation in the oral microbiome. This suggests a basis for the observation that hyperglycemia is associated with an increased risk of dental erosion, dental caries, and gingivitis. We conclude that HSG in adolescents may be predicted from salivary microbial diversity or frequency, and that the changes in the oral microbial composition seen in adolescents with developing metabolic disease may the consequence of hyperglycemia.

Functional foods contain biologically active ingredients associated with physiological health benefits for preventing and managing chronic diseases, such as type 2 diabetes mellitus (T2DM). A regular consumption of functional foods may be associated with enhanced anti-oxidant, anti-inflammatory, insulin sensitivity, and anti-cholesterol functions, which are considered integral to prevent and manage T2DM. Components of the Mediterranean diet (MD)—such as fruits, vegetables, oily fish, olive oil, and tree nuts—serve as a model for functional foods based on their natural contents of nutraceuticals, including polyphenols, terpenoids, flavonoids, alkaloids, sterols, pigments, and unsaturated fatty acids. Polyphenols within MD and polyphenol-rich herbs—such as coffee, green tea, black tea, and yerba maté—have shown clinically-meaningful benefits on metabolic and microvascular activities, cholesterol and fasting glucose lowering, and anti-inflammation and anti-oxidation in high-risk and T2DM patients. However, combining exercise with functional food consumption can trigger and augment several metabolic and cardiovascular protective benefits, but it is under-investigated in people with T2DM and bariatric surgery patients. Detecting functional food benefits can now rely on an “omics” biological profiling of individuals’ molecular, genetics, transcriptomics, proteomics, and metabolomics, but is under-investigated in multi-component interventions. A personalized approach for preventing and managing T2DM should consider biological and behavioral models, and embed nutrition education as part of lifestyle diabetes prevention studies. Functional foods may provide additional benefits in such an approach.

The increasing prevalence of childhood obesity and obesity-related metabolic disorders is now considered a global pandemic. The main goal of the pediatric obesity research community is to identify children who are at risk of becoming obese before their body mass index rises above age norms. To do so, we must identify biomarkers of metabolic health and immunometabolism that can be used for large-scale screening and diagnosis initiatives among at-risk children. Because blood sampling is often unacceptable to both parents and children when there is no direct benefit to the child, as in a community-based research study, there is a clear need for a low-risk, non-invasive sampling strategy. Salivary analysis is now well recognized as a likely candidate for this purpose. In this review, we discuss the physiologic role of saliva and its strengths and limitations as a fluid for biomarker discovery, obesity screening, metabolic disease diagnosis, and response monitoring after interventions. We also describe the current state of the salivary biomarker field as it pertains to metabolic research, with a special emphasis on studies conducted in children and adolescents. Finally, we look forward to technological developments, such as salivary "omics" and point of service diagnostic devices, which have the potential to accelerate the pace of research and discovery in this vitally important field.

OBJECTIVE:Here, we investigated the relationships between obesity and the salivary concentrations of insulin, glucose, and 20 metabolic biomarkers in Kuwaiti adolescents. Previously, we have shown that certain salivary metabolic markers can act as surrogates for blood concentrations.METHODS:Salivary samples of whole saliva were collected from 8,317 adolescents. Salivary glucose concentration was measured by a high-sensitivity glucose oxidase method implemented on a robotic chemical analyzer. The concentration of salivary insulin and 20 other metabolic biomarkers was assayed in 744 randomly selected saliva samples by multiplexed bead-based immunoassay.RESULTS:Obesity was seen in 26.5% of the adolescents. Salivary insulin predicting hyperinsulinemia occurred in 4.3% of normal-weight adolescents, 8.3% of overweight adolescents, and 25.7% of obese adolescents (p < 0.0001). Salivary glucose predicting hyperglycemia was found in only 3% of obese children and was not predictive (p = 0.89). Elevated salivary glucose and insulin occurring together was associated with elevated vascular endothelial growth factor and reduced salivary interleukin-12.CONCLUSION:Considering the surrogate nature of salivary insulin and glucose, this study suggests that elevated insulin may be a dominant sign of metabolic disease in adolescent populations. It also appears that a proangiogenic environment may accompany elevated glucose in obese adolescents.

BACKGROUND:Binary definitions of the metabolic syndrome based on the presence of a particular number of individual risk factors are limited, particularly in the pediatric population. To address this limitation, we aimed at constructing composite and continuous metabolic syndrome scores (cmetS) to represent an overall measure of metabolic syndrome (MetS) in a large cohort of metabolically at-risk children, focusing on the use of the usual clinical parameters (waist circumference (WC) and systolic blood pressure (SBP), supplemented with two salivary surrogate variables (glucose and high density lipoprotein cholesterol (HDLC). Two different approaches used to create the scores were evaluated in comparison.METHODS:Data from 8,112 Kuwaiti children (10.00 ± 0.67 years) were used to construct two cmetS for each subject. The first cmetS (cmetS-Z) was created by summing standardized residuals of each variable regressed on age and gender; and the second cmetS (cmetS-PCA) was defined as the first principal component from gender-specific principal component analysis based on the four variables.RESULTS:There was a graded relationship between both scores and the number of adverse risk factors. The areas under the curve using cmetS-Z and cmetS-PCA as predictors for severe metabolic syndrome (defined as the presence of ≥3 metabolic risk factors) were 0.935 and 0.912, respectively. cmetS-Z was positively associated with WC, SBP, and glucose, but inversely associated with HDLC. Except for the lack of association with glucose, cmetS-PCA was similar to cmetS-Z in boys, but had minimum loading on HDLC in girls. Analysis using quantile regression showed an inverse association of fitness level with cmetS-PCA (p = 0.001 for boys; p = 0.002 for girls), and comparison of cmetS-Z and cmetS-PCA suggested that WC and SBP were main contributory components. Significant alterations in the relationship between cmetS and salivary adipocytokines were demonstrated in overweight and obese children as compared to underweight and normal-weight children.CONCLUSION:We have derived continuous summary scores for MetS from a large-scale pediatric study using two different approaches, incorporating salivary measures as surrogate for plasma measures. The derived scores were viable expressions of metabolic risk, and can be utilized to study the relationships of MetS with various aspects of the metabolic disease process.

BACKGROUND:The rising prevalence of obesity and diabetes in Kuwait represents a significant challenge for the country's healthcare system. Diabetes care in Scotland has improved by adopting a system of managed clinical networks supported by a national informatics platform. In 2010, a Kuwait-Dundee collaboration was established with a view to transforming diabetes care in Kuwait. This paper describes the significant progress that has been made to date.METHODS:The Kuwait-Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, industry and government. KSeHIN aims to deliver a package of clinical service development, education (including a formal postgraduate programme and continuing professional development) and research underpinned by a comprehensive informatics system.RESULTS:The informatics system includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational data. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The adult registry (KHN), implemented in four primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-bearing postgraduate educational programme provides module-based teaching and workplace-based projects. In addition, a new clinical skills centre provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date.CONCLUSION:KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, system performance and professional development to provide a sustainable transformation in the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

Background Metabolic syndrome in childhood predicts the development of cardiovascular disease and type 2 diabetes (T2D) in adulthood. Testing for features of metabolic syndrome, such as fasting plasma glucose concentration, requires blood sampling which can be difficult in children. Here we evaluated salivary glucose concentration as a surrogate measurement for plasma glucose concentration in 11-year-old US children. Methods Children from Portland, Maine, and Cambridge, Massachusetts, with a mean age of 10.6±0.2 years provided 6-hour fasting samples of both blood and whole saliva. Salivary glucose levels were measured with a high-sensitivity assay (sensitivity =0.002 mg/dL). Plasma glucose levels were determined by a commercial clinical laboratory. Blood pressure, salivary flow rate, height, and weight were also measured. Results Of the 65 children enrolled, there were two underweight children (3.1%), 30 normal-weight children (46.2%), 12 overweight children (18.4%), and 21 obese children (32.3%). The mean overall glucose concentrations were 0.11±0.02 mg/dL in saliva and 86.3±0.8 mg/dL in plasma, and these did not differ significantly by body–weight groups. By regression analysis, the plasma concentration equaled 13.5 times the saliva concentration, with a threshold level of 84.8 mg/dL. Salivary glucose values less than threshold plasma concentration were essentially zero. Diagnostic analysis indicated a positive predictive value of 50%, a negative predictive value of 90%, and a sensitivity and specificity both of approximately 75%. The salivary glucose concentration did not vary with saliva flow rate. Conclusion Taking into account the threshold response characteristics of the salivary glucose concentration response, these results suggest that testing salivary glucose levels may be useful as a screening assay for high fasting plasma glucose levels. The low false positive value is important to assure a low fraction of missed diagnoses.

Background The rising prevalence of obesity and diabetes in Kuwait represents a significant challenge for the country’s healthcare system. Diabetes care in Scotland has improved by adopting a system of managed clinical networks supported by a nationalinformatics platform. In 2010, a Kuwait–Dundee collaboration was established with a view to transforming diabetes care in Kuwait. This paper describes the significant progress that has been made to date. Methods The Kuwait–Scotland eHealth Innovation Network (KSeHIN) is a partnership among health, education, industry and government. KSeHIN aims to deliver a package of clinical service development, education (including a formal postgraduate programme and continuing professional development) and research underpinned by a comprehensivem informatics system. Results The informatics system includes a disease registry for children and adults with diabetes. At the patient level, the system provides an overview of clinical and operational data. At the population level, users view key performance indicators based on national standards of diabetes care established by KSeHIN. The national childhood registry (CODeR) accumulates approximately 300 children a year. The adult registry (KHN), implemented in four primary healthcare centres in 2013, has approximately 4000 registered patients, most of whom are not yet meeting national clinical targets. A credit-bearing postgraduate educational programme provides module-based teaching and workplace-based projects. In addition, a new clinical skills centre provides simulator-based training. Over 150 masters students from throughout Kuwait are enrolled and over 400 work-based projects have been completed to date. Conclusion KSeHIN represents a successful collaboration between multiple stakeholders working across traditional boundaries. It is targeting patient outcomes, system performance and professional development to provide a sustainable transformationin the quality of diabetes healthcare for the growing population of Kuwaitis with diabetes in Kuwait.

Objective: The study of obesity-related metabolic syndrome or Type 2 diabetes (T2D) in children is particularly difficult because of fear of needles. We tested a non-invasive approach to study inflammatory parameters in an at-risk population of children to provide proof-of-principle for future investigations of vulnerable subjects.Design and Methods: We evaluated metabolic differences in 744, 11-year old children selected from underweight, normal healthy weight, overweight and obese categories by analyzing fasting saliva samples for 20 biomarkers. Saliva supernatants were obtained following centrifugation and used for analyses.Results: Salivary C-reactive protein (CRP) was 6 times higher, salivary insulin and leptin were 3 times higher, and adiponectin was 30% lower in obese children compared to healthy normal weight children (all P<0.0001). Categorical analysis suggested that there might be three types of obesity in children. Distinctly inflammatory characteristics appeared in 76% of obese children while in 13%, salivary insulin was high but not associated with inflammatory mediators. The remaining 11% of obese children had high insulin and reduced adiponectin. Forty percent of the non-obese children were found in groups which, based on biomarker characteristics, may be at risk for becoming obese.Conclusions: Significantly altered levels of salivary biomarkers in obese children from a high-risk population, suggest the potential for developing non-invasive screening procedures to identify T2D-vulnerable individuals and a means to test preventative strategies.

Objective: To evaluate the relationship of children's obesity and dental decay.Methods: We measured parameters related to obesity and dental decay in 8,275 4th and 5th grade Kuwaiti children (average age=11.36 years) in a cross-sectional study. First to determine body weight, height, age for computation of BMI. Second, to determine numbers of teeth, numbers of fillings and numbers of untreated decayed teeth to determine extent and severity of dental disease. From these measurements, we computed measures of dental decay in children from four body weight categories; obese, overweight, normal healthy weight and underweight children.Results: The percentage of children with decayed or filled teeth varied inversely with the body weight category. The percentage of decayed or filled teeth decreased from 15.61% (n=193) in underweight children, to 13.03% (n=4,094) in normal healthy weight children, to 9.73% (n=1,786) in overweight children to 7.87% (n=2,202) in obese children. Differences between all groups were statistically significant. Male children in this population had more dental decay than female children but the reduction of tooth decay as a function of BMI was greater in male children.Conclusions: The finding of an inverse obesity-dental decay relationship contradicts the obesity-sugar and the obesity-dental decay relationship hypotheses. Sugar is well recognized as necessary and sufficient for dental decay. Sugar is also hypothesized to be a leading co-factor in obesity. If the later hypothesis is true, one would expect dental decay to increase with obesity. This was not found. The reasons for this inverse relationship are not currently clear.

Population level data on how older individuals living at high latitudes achieve optimal vitamin D status are not fully explored. Our objective was to examine the intake of vitamin D among healthy older individuals with 25-hydroxyvitamin D [25(OH)D] concentrations ≥75 nmol/L and to describe current sources of dietary vitamin D. We conducted a population-based, cross-sectional study of 404 healthy men and women aged 69 to 83 y randomly selected from the NuAge longitudinal study in Québec, Canada. Dietary intakes were assessed by 6 24-h recalls. We examined the contribution of foods and vitamin/mineral supplements to vitamin D intake. Serum 25(OH)D was assessed by RIA. We assessed smoking status, season of 25(OH)D measurement, physical activity, and anthropometric and sociodemographic variables. Vitamin D status was distributed as follows: 7% (<37.5 nmol/L), 48% (37.5–74.9 nmol/L), and 45% (≥75 nmol/L). Vitamin D intake from supplements varied across the 3 vitamin D status groups: 0.5, 4.1, and 8.9 μg/d, respectively (P < 0.0001). Adding food sources, these total intakes were 4.6, 8.7, and 14.1 μg/d, respectively. In multivariate analysis, vitamin D from foods and supplements and by season was associated with vitamin D status. These healthy, community-dwelling older men and women with 25(OH)D concentrations >75 nmol/L had mean intakes of 14.1 μg/d from food and supplements. Supplement use is an important contributor to achieve a minimal target of 25(OH)D concentration ≥75 nmol/L.