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Herman K, Brough HA, Pier J, Venter C, Järvinen KM. Prevention of IgE-Mediated Food Allergy: Emerging Strategies Through Maternal and Neonatal Interventions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1686-1694. [PMID: 38677585 DOI: 10.1016/j.jaip.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024]
Abstract
Whereas the early introduction of highly allergenic foods has been shown to be effective at preventing the onset of food allergy (FA) in high-risk infants, sensitization to food antigens can occur prior to complementary food introduction, and thus, additional earlier FA prevention strategies are urgently needed. Currently, aside from early introduction of peanut and egg, no therapies are strongly recommended by international professional allergy societies for the primary prevention of FA. This review focuses on maternal- and neonatal-directed interventions that are being actively investigated and developed, including maternal dietary factors and supplementation, specific elimination diets, breastfeeding, cow's milk formula supplementation, microbiome manipulations, bacterial lysate therapy, and skin barrier therapies. Evaluating how these factors and various prenatal/early life environmental exposures may impact the development of FA is crucial for accurately counseling caregivers in the prevention of FA.
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Affiliation(s)
- Katherine Herman
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Center for Food Allergy, University of Rochester Medical Center, Rochester, NY
| | - Helen A Brough
- Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, Children's Allergy Service. King's College London, Pediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, London, UK
| | - Jennifer Pier
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Center for Food Allergy, University of Rochester Medical Center, Rochester, NY
| | - Carina Venter
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado/University of Colorado, Denver, Colo
| | - Kirsi M Järvinen
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Center for Food Allergy, University of Rochester Medical Center, Rochester, NY.
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2
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Landau T, Gamrasni K, Levin A, Barlev Y, Sanders O, Benor S, Brandwein M. Development of a predictive model for pediatric atopic dermatitis: A retrospective cross-sectional nationwide database study. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00361-2. [PMID: 38901543 DOI: 10.1016/j.anai.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/09/2024] [Accepted: 06/06/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The rise in prevalence of atopic dermatitis (AD) has been correlated with numerous elements of the exposome, modern-day lifestyle, and familial history. The combined analysis of familial history and other risk elements may allow us to understand the driving factors behind the development of AD. OBJECTIVE To develop prediction models to assess the risk of developing AD using a large and diverse cohort (N = 77,525) and easily assessed risk factors. METHODS We analyzed electronic medical record data from Leumit Health System. Documented predictive factors include sex, season of birth, environment (urban/rural), socioeconomic status, household smoking, diagnosed skin conditions, number of siblings, a paternal, maternal, or sibling history of an atopic condition, and antibiotic prescriptions during pregnancy or after birth. Predictive models were trained and validated on the data set. RESULTS Medium (odds ratio [OR] 2.04, CI 1.92-2.17, P < .001) and high (OR 2.13, CI 1.95-2.34, P < .001) socioeconomic status, a previous diagnosis of contact dermatitis (OR 2.57, CI 2.37-2.78, P < .001), presence of siblings with an AD diagnosis (OR 2.21, CI 2.04-2.40, P < .001), and the percentage of siblings with any atopic condition (OR 2.58, CI 2.09-3.17, P < .001) drove risk for AD in a logistic regression model. A random forest prediction model with a sensitivity of 61% and a specificity of 84% was developed. Generalized mixed models accounting for the random effect of familial relationships boasted an area under the curve of 0.98. CONCLUSION Predictive modeling using noninvasive and accessible inputs is a powerful tool to stratify risk for developing AD.
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Affiliation(s)
| | | | - Alex Levin
- MYOR Diagnostics Ltd, Zichron Yaakov, Israel
| | - Yotam Barlev
- MYOR Diagnostics Ltd, Zichron Yaakov, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oliver Sanders
- Department of Pediatrics, Hadassah University Medical Center, Jerusalem, Israel
| | - Shira Benor
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Leumit Health Services, Tel Aviv, Israel; Allergy and Clinical Immunology Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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3
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Tham EH, Chia M, Riggioni C, Nagarajan N, Common JE, Kong HH. The skin microbiome in pediatric atopic dermatitis and food allergy. Allergy 2024; 79:1470-1484. [PMID: 38308490 PMCID: PMC11142881 DOI: 10.1111/all.16044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/03/2024] [Accepted: 01/23/2024] [Indexed: 02/04/2024]
Abstract
The skin microbiome is an extensive community of bacteria, fungi, mites, viruses and archaea colonizing the skin. Fluctuations in the composition of the skin microbiome have been observed in atopic dermatitis (AD) and food allergy (FA), particularly in early life, established disease, and associated with therapeutics. However, AD is a multifactorial disease characterized by skin barrier aberrations modulated by genetics, immunology, and environmental influences, thus the skin microbiome is not the sole feature of this disease. Future research should focus on mechanistic understanding of how early-life skin microbial shifts may influence AD and FA onset, to guide potential early intervention strategies or as microbial biomarkers to identify high-risk infants who may benefit from possible microbiome-based biotherapeutic strategies. Harnessing skin microbes as AD biotherapeutics is an emerging field, but more work is needed to investigate whether this approach can lead to sustained clinical responses.
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Affiliation(s)
- Elizabeth Huiwen Tham
- Khoo Teck Puat-National University Children’s Medical Institute, National University Health System (NUHS), Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Minghao Chia
- Genome Institute of Singapore (GIS), Agency for Science, Technology and Research (A*STAR), Singapore
| | - Carmen Riggioni
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore
| | - Niranjan Nagarajan
- Genome Institute of Singapore (GIS), Agency for Science, Technology and Research (A*STAR), Singapore
| | - John E.A. Common
- A*STAR Skin Research Labs (A*SRL), Agency for Science, Technology and Research (A*STAR), Singapore
| | - Heidi H. Kong
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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4
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Chaudhary PP, O'Laughlin B, Kumar PS, Dabdoub SM, Levy S, Myles IA, Hourigan SK. Vaginal delivery provides skin colonization resistance from environmental microbes in the NICU. Clin Transl Med 2023; 13:e1506. [PMID: 38058267 PMCID: PMC10701179 DOI: 10.1002/ctm2.1506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 12/08/2023] Open
Affiliation(s)
- Prem Prashant Chaudhary
- Epithelial Therapeutics UnitNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Brynn O'Laughlin
- Clinical Microbiome UnitNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Purnima S. Kumar
- Department of Periodontics and Oral MedicineUniversity of Michigan School of DentistryAnn ArborMichiganUSA
| | - Shareef M. Dabdoub
- Division of Biostatistics and Computational BiologyCollege of DentistryUniversity of IowaIowa CityIowaUSA
| | - Shira Levy
- Clinical Microbiome UnitNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Ian A. Myles
- Epithelial Therapeutics UnitNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
| | - Suchitra K. Hourigan
- Clinical Microbiome UnitNational Institute of Allergy and Infectious DiseasesNational Institutes of HealthBethesdaMarylandUSA
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Cheung MK, Leung TF, Tam WH, Leung ASY, Chan OM, Ng RWY, Yau JWK, Yuen LY, Tong SLY, Ho WCS, Yeung ACM, Chen Z, Chan PKS. Development of the early-life gut microbiome and associations with eczema in a prospective Chinese cohort. mSystems 2023; 8:e0052123. [PMID: 37646516 PMCID: PMC10654104 DOI: 10.1128/msystems.00521-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/20/2023] [Indexed: 09/01/2023] Open
Abstract
IMPORTANCE Eczema is a major allergic disease in children, which is particularly prevalent in Chinese children during their first year of life. In this study, we showed that alterations in the infant gut microbiota precede the development of eczema in a prospective Chinese cohort. In particular, we discovered enrichments of the genera Clostridium sensu stricto 1 and Finegoldia in the cases at 3 and 1 month of age, respectively, which may represent potential targets for intervention to prevent eczema. Besides, we identified a depletion of Bacteroides from 1 to 6 months of age and an enrichment of Clostridium sensu stricto 1 at 3 months in the eczema cases, patterns also observed in C-section-born infants within the same time frames, providing first evidence to support a role of the gut microbiota in previously reported associations between C-section and increased risk of eczema in infancy.
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Affiliation(s)
- Man Kit Cheung
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Ting Fan Leung
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Wing Hung Tam
- Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Agnes S. Y. Leung
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Oi Man Chan
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Rita W. Y. Ng
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Jennifer W. K. Yau
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Lai-yuk Yuen
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Sylvia L. Y. Tong
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Wendy C. S. Ho
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Apple C. M. Yeung
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Zigui Chen
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
| | - Paul K. S. Chan
- Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
- Centre for Gut Microbiota Research, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China
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Chaudhary A, Nadeem M, Townsend J, Miller VJ, Hajrasouliha AR. Perinatal events and development of juvenile idiopathic arthritis-associated uveitis. Sci Rep 2023; 13:17576. [PMID: 37845273 PMCID: PMC10579364 DOI: 10.1038/s41598-023-44208-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/05/2023] [Indexed: 10/18/2023] Open
Abstract
Uveitis is one of the most common manifestations of juvenile idiopathic arthritis (JIA). Currently, JIA is associated with decreased gut microbiota diversity. Studies confirm that perinatal events can cause aberrant microbial colonization. The objective of this study is to determine if JIA is associated with perinatal events with a secondary focus on these variables to the development of JIA-uveitis. 369 patients with strabismus (n = 200) or JIA (n = 196) were included in the study. Completed surveys (JIA 37; strabismus 18) collected data about birth route, pregnancy and labor complications, JIA medications, and the presence of eye disorders. Analysis indicates that there is no relationship between JIA development and the perinatal events investigated. Similarly, no significance was found between JIA-uveitis and birth route or labor complications. Pregnancy complications, namely gestational diabetes (GD), were statistically higher in the JIA group with uveitis compared to JIA without uveitis. The data from this survey study showed that JIA-uveitis was highly associated with pregnancy complications, particularly with GD. However, no statistically significant association was found between JIA and route of delivery, labor complications, or pregnancy complications. Further studies are needed to understand the ways that GD interrelates with the development of uveitis in JIA patients.
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Affiliation(s)
- Aysha Chaudhary
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN, 46202, USA
| | - Manahil Nadeem
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN, 46202, USA
| | - Jack Townsend
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN, 46202, USA
| | - Victoria J Miller
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN, 46202, USA
| | - Amir R Hajrasouliha
- Eugene and Marilyn Glick Eye Institute and Department of Ophthalmology, Indiana University School of Medicine, 1160 W Michigan St, Indianapolis, IN, 46202, USA.
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Rennie GH, Zhao J, Camus-Ela M, Shi J, Jiang L, Zhang L, Wang J, Raghavan V. Influence of Lifestyle and Dietary Habits on the Prevalence of Food Allergies: A Scoping Review. Foods 2023; 12:3290. [PMID: 37685223 PMCID: PMC10486777 DOI: 10.3390/foods12173290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/10/2023] [Accepted: 08/11/2023] [Indexed: 09/10/2023] Open
Abstract
Changes in behavior, lifestyle, and nutritional patterns have influenced many potential risk variables globally. In recent decades, food allergies (FAs) have been elevated to a severe public health issue both in developed countries and developing countries (third-world countries). This study aims to evaluate the effects caused by certain factors such as lifestyle and dietary habits on food allergies, review the association of lifestyle and dietary habit status with FAs, and outline why more people are allergic to food sources as a result of lifestyle changes and dietary habits. We searched electronic international databases including Scopus, PubMed, Google Scholar, and Web of Science using combinations of keywords. Utilizing Excel, the relevant studies were included and the irrelevant studies were excluded, and Mendeley was used for referencing and also to remove duplicates. The framework proposed by Arksey and O'Malley was used for this scoping review. The papers published in the databases from 2016 to 2020 were extracted. A total of eight studies were extracted, and this scoping review was carried out according to the risk factors. In our review, we found that some lifestyle choices (Caesarean section and antibiotics) and dietary habits (n-3 PUFA, fast food, duration of dietary intervention, and vitamin D), were important contributing factors for FA.
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Affiliation(s)
- Gardiner Henric Rennie
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Jinlong Zhao
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Mukeshimana Camus-Ela
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Jialu Shi
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Lan Jiang
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Lili Zhang
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Jin Wang
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing 210009, China; (G.H.R.); (J.Z.); (L.J.)
| | - Vijaya Raghavan
- Department of Bioresource Engineering, Faculty of Agricultural and Environmental Sciences, McGill University, 21111 Lakeshore Rd, Sainte-Anne-de-Bellevue, QC H9X 3V9, Canada
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Soriano VX, Eigenmann P, Peters RL. Editorial comments on: "The mode of delivery and offspring atopic dermatitis in a Swedish nationwide study". Pediatr Allergy Immunol 2023; 34:e13906. [PMID: 36705038 DOI: 10.1111/pai.13906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 01/09/2023]
Affiliation(s)
| | - Philippe Eigenmann
- Department of Pediatrics, Gynecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
| | - Rachel L Peters
- Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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Ziyab AH, Holloway JW, Ali YM, Zhang H, Karmaus W. Eczema among adolescents in Kuwait: Prevalence, severity, sleep disturbance, antihistamine use, and risk factors. World Allergy Organ J 2022; 16:100731. [PMID: 36601260 PMCID: PMC9791032 DOI: 10.1016/j.waojou.2022.100731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/15/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background Eczema (atopic dermatitis) is a common inflammatory skin disease that is more prevalent in children and adolescents than adults. In Kuwait, there is a lack of empirical knowledge on eczema epidemiology among adolescents. Therefore, this study aimed to estimate the prevalence of eczema symptoms and severity, assess the frequency of eczema-related nocturnal sleep disturbance and its relation to antihistamine use, and determine factors that are associated with eczema prevalence and eczema-related nocturnal sleep disturbance. Methods A school-based cross-sectional study enrolled adolescents (n = 3864) aged 11-14 years across Kuwait. Information on eczema symptoms and clinical history, use of antihistamines, parental history of eczema, mode of delivery, and childhood life-style factors and exposures were reported by parents. Current eczema was defined as chronic or chronically relapsing itchy dermatitis with characteristic morphology and distribution in the past 12 months. Among subjects reporting current itchy rash, frequency of nocturnal sleep disturbance due to itchy rash in the past 12 months was reported as: never, <1 night per week, and ≥1 nights per week. Associations were assessed by applying a modified Poisson regression to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Results The prevalence estimate of current (past 12 months) itchy rash was 20.5% (735/3593) and current eczema was 10.2% (388/3791), with 19.5% (736/3775) reporting history of ever doctor-diagnosed eczema. Among subjects with current itchy rash, nocturnal sleep disturbance due to itchy rash affected 21.7% (157/724) of participants for <1 night per week and affected 12.7% (92/724) of participants for ≥1 nights per week. Antihistamine use at least once per month increased as the frequency of nocturnal sleep disturbance due to itchy rash increased (Ptrend <0.001). Factors that demonstrated association with current eczema prevalence included underweight body mass index (aPR = 1.71, 95% CI: 1.16-2.53), Cesarean section delivery (1.29, 1.01-1.65), and maternal (1.72, 1.35-2.19) and paternal (1.83, 1.44-2.32) history of eczema. Frequent (≥1 nights per week) nocturnal sleep disturbance was associated with Cesarean section delivery (1.98, 1.37-2.85), exposure to household tobacco smoke (1.70, 1.18-2.47), and dog-keeping (1.93, 1.06-3.52). Conclusions Eczema symptoms are common among adolescents in Kuwait, with similar epidemiological patterns as those observed in western countries. A large proportion of affected adolescents reported nocturnal sleep disturbance due to itchy rash. Modifiable risk factors were associated increased prevalence of eczema and night awakenings.
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Affiliation(s)
- Ali H. Ziyab
- Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait,Corresponding author. Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, P. O. Box 24923, Safat 13110, Kuwait
| | - John W. Holloway
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Yaser M. Ali
- Department of Internal Medicine, Mubarak Al-Kabeer Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Hongmei Zhang
- Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Wilfried Karmaus
- Division of Epidemiology, Biostatistics and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA
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