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Chan CMJ, Müller-Riemenschneider F, Chia MYH, Hildon ZJL, Chong MFF. Promoting hEalthy Diet and Active Lifestyle (PEDAL): a protocol for the development and feasibility study of a multicomponent intervention among primary school children in Singapore. Pilot Feasibility Stud 2024; 10:52. [PMID: 38521958 PMCID: PMC10960416 DOI: 10.1186/s40814-024-01479-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/12/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Setting healthy lifestyle habits during the formative years of childhood is critical as habits can track to adulthood and help prevent obesity and chronic disease risks in later life. While multicomponent interventions have been shown to be effective in changing the lifestyle behaviours of children, there is a limited understanding of the feasibility of such interventions in primary schools in Singapore. A multiphase mixed method study was conducted to develop and examine the feasibility of a theory-based multicomponent school-based intervention-Promoting hEatlthy Eating and Active Lifestyle (PEDAL). METHODS Underpinned by Kincaid's ideation model, the PEDAL intervention was developed to increase fruit and vegetable consumption and decrease sedentary behaviours among children. This study consists of three phases. Phase 1 details the development of PEDAL, which consists of four components: (A) a series of interactive health education lessons, (B) actionable home activities to support habit formation, (C) parental/guardian engagement, and (D) optimising the school environment. In Phase 2, components A and B of PEDAL were implemented in two public, co-educational primary schools among Primary 5 students (aged 10-12 years) in Singapore. Data was collected quantitatively using questionnaires and qualitatively using focus group discussions (FGDs) with students and teachers. The feasibility dimensions of components A and B, including recruitment capability, data collection, social validity, and practicality were examined, and ideation on healthy eating and physical activity was explored. In Phase 3, the full PEDAL intervention was pilot-tested in two other public, co-education primary schools with the same target population, using a concurrent mixed method quasi-experimental study design. Feasibility dimensions and potential effectiveness of the intervention will be assessed. DISCUSSION This study will provide insights into the feasibility of PEDAL and inform its refinement. Findings from the pilot test will guide the planning of a larger-scale definitive trial. TRIAL REGISTRATION Registered with ISRCTN registry (ISRCTN16114046) on 16 October 2022.
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Affiliation(s)
- Cindy Mei Jun Chan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Tahir Foundation Building (MD1), 12 Science Drive 2, #09-01Q, Singapore, 117549, Singapore
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Tahir Foundation Building (MD1), 12 Science Drive 2, #09-01Q, Singapore, 117549, Singapore
- Center for Digital Health, Berlin Institute of Health (BIH), Charité-Universitatsmedizin Berlin, Berlin, Germany
| | - Michael Yong Hwa Chia
- Physical Education & Sports Science Academic Group, National Institute of Education, Nanyang Technological University, Singapore, Singapore
| | - Zoe Jane-Lara Hildon
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Tahir Foundation Building (MD1), 12 Science Drive 2, #09-01Q, Singapore, 117549, Singapore
| | - Mary Foong-Fong Chong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Tahir Foundation Building (MD1), 12 Science Drive 2, #09-01Q, Singapore, 117549, Singapore.
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore, Singapore.
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Sritart H, Taertulakarn S, Miyazaki H. Disparities in Childhood Obesity Prevalence and Spatial Clustering Related to Socioeconomic Factors in Isaan, Thailand. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:626. [PMID: 36612948 PMCID: PMC9819306 DOI: 10.3390/ijerph20010626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
Globally, rapid economic growth has contributed to an overall increase in the incidence of childhood obesity. Although the prevalence of obesity has been well recognized, the disparities related to a region's socioeconomic environment in terms of the incidence of obesity are still less understood. Therefore, the purpose of this study was to examine the spatial pattern of childhood obesity and identify the potential associations between childhood obesity and socioeconomic environment in the northeastern region of Thailand, Isaan. Using nationally collected obesity data from children aged 0-5 years in 2019, we employed a geographic information system (GIS) to perform obesity cluster analysis at the smaller regional level, investigating a total of 322 districts in study area. Global and local statistical approaches were applied to calculate spatial associations between the socioeconomic status of neighborhoods and childhood obesity. The study revealed that 12.42% of the total area showed significant clusters at the district level, with high values observed in the western and northeastern areas. The results of the spatial statistical model revealed that childhood obesity was significantly positively associated with areas exhibiting high levels of socioeconomic environment factors. Identifying the associated factors and highlighting geographic regions with significant spatial clusters is a powerful approach towards understanding the role of location and expanding the knowledge on the factors contributing to childhood obesity. Our findings, as a first step, offer valuable references that could support policy-makers and local authorities in enhancing policy development with the aim of reducing childhood obesity and improving public health.
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Affiliation(s)
- Hiranya Sritart
- Faculty of Allied Health Sciences, Thammasat University, Pathum Thani 12120, Thailand
| | - Somchat Taertulakarn
- Faculty of Allied Health Sciences, Thammasat University, Pathum Thani 12120, Thailand
| | - Hiroyuki Miyazaki
- Center for Spatial Information Science, University of Tokyo, Chiba 277-8568, Japan
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3
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Zhang Y, Lou H, Huang Y, Wang R, Wen X, Wu C, Hao C, Li R, Gao G, Lou X, Wang X. Trends of overweight and obesity prevalence in school-aged children among Henan Province from 2000 to 2019. Front Public Health 2022; 10:1046026. [PMID: 36544796 PMCID: PMC9760942 DOI: 10.3389/fpubh.2022.1046026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives Overweight and obesity are harmful to human health. However, the latest trends of Chinese childhood overweight and obesity prevalence are not available. The aim of this study was to examine the trends from 2000 to 2019 among students in China. Methods We analyzed data of 66,072 students in the Chinese National Survey on Students' Constitution and Health from 2000 to 2019. Overweight and obesity were defined based on the standard formulated by the International Obesity Task Force (IOTF standard), the World Health Organization (WHO standard), and the Working Group on Obesity in China (WGOC standard), respectively. The χ2-test was used to test the trends of overweight and obesity prevalence and logistic regression was conducted to evaluate the prevalence odds ratios of boys vs. girls and urban vs. rural areas. Results The prevalence of obesity/overweight and obesity combined was 6.03/23.58% (IOTF standard), 10.56/25.88% (WGOC standard) and 10.75/29.69% (WHO standard) in 2019. From 2000 to 2019, according to the WGOC standard, the prevalence increased from 2.51 to 10.56% for obesity and increased from 9.81 to 25.88% for overweight and obesity combined (P for trend < 0.001). Obesity/overweight and obesity were greater problems in boys than girls and urban than rural areas, but urban-rural differences decreased over time. Conclusion Overweight and obesity prevalence increased significantly in children and adolescents in China from 2000 to 2019. The prevalence of overweight and obesity in rural areas may contribute to a large percentage of children with overweight and obesity.
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Affiliation(s)
- Yuhao Zhang
- College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Hao Lou
- Department of Nosocomial Infection Management, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ye Huang
- College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Ruijuan Wang
- Zhengzhou Hospital of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Xiao Wen
- Zhengzhou Hospital of Traditional Chinese Medicine, Zhengzhou, Henan, China
| | - Cuiping Wu
- College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Changfu Hao
- College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Ran Li
- Zhengzhou Station for Students' Health, Zhengzhou, Henan, China
| | - Genli Gao
- The Education Department of Henan Province, Zhengzhou, Henan, China
| | - Xiaomin Lou
- College of Public Health, Zhengzhou University, Zhengzhou, Henan, China
| | - Xian Wang
- College of Public Health, Zhengzhou University, Zhengzhou, Henan, China,*Correspondence: Xian Wang
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4
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Chen B, Kui KY, Padmapriya N, Müller AM, Müller-Riemenschneider F. Correlates of sedentary behavior in Asian preschool-aged children: A systematic review. Obes Rev 2022; 23:e13485. [PMID: 35698280 DOI: 10.1111/obr.13485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/11/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
This systematic review aims to identify the multilevel correlates of sedentary behavior (SB) and its sub-domains among preschool-aged children aged 0-7 years in Asia. We systematically searched for studies published from 2000 onwards using terms related to SB correlates and Asia in six databases. Eligible studies were observational and used quantitative methods to examine correlates of total, and domain-specific SB (screen viewing [SV] and non-screen-based SB) in Asian children living in Asia. Two reviewers independently screened identified references. Following quality assessment of included studies, we performed narrative synthesis to summarize the evidence on the intrapersonal, interpersonal, environmental correlates of total and domain-specific SB (PROSPERO: CRD42018095268). Twenty-two studies from 4 regions and 12 countries/territories were included. Out of the 94 correlates explored, the following associations were consistent: older age, being a boy, non-Chinese ethnicity (Southeast Asia), younger maternal age, higher maternal and paternal television-viewing time with higher SV; higher SV at earlier age with higher SV and total SB; and presence of TV/computer in the bedroom with higher leisure-time SB. We encourage more studies from low- and middle-income Asian countries with an increased focus on different SB domains, further exploration of environmental correlates, and the use of objective measurements to capture SB.
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Affiliation(s)
- Bozhi Chen
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Kiran Yan Kui
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Natarajan Padmapriya
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.,Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andre Matthias Müller
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.,Centre for Sport and Exercise Sciences, University of Malaya, Kuala Lumpur, Malaysia
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.,Institute for Social Medicine, Epidemiology and Health Economics, Charite University Medical Centre Berlin, Berlin, Germany
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Xu K, Zhang Y, Dong W, Tuerxun P, Li C, Chang R, Qi H, Zhang Y, Zhang J. The Mediation Role of Health Behaviors in the Association between Self-Regulation and Weight Status among Preschool Children: A Sex-Specific Analysis. Nutrients 2022; 14:1692. [PMID: 35565663 PMCID: PMC9104780 DOI: 10.3390/nu14091692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023] Open
Abstract
Previous studies have supported the link between children’s self-regulation (CSR) and weight status, but the potential pathways have not been elucidated yet. We aimed to investigate whether and to what extent health behaviors mediate this association, as well as to explore the sex effect. For this study, we recruited 3740 preschoolers in Wuhan, China. The height and weight of children were measured, and a body mass index of the ≥85th percentile was defined as overweight/obesity (OWO). We used the Children’s Behavior Questionnaire, with measured domains including inhibitory control, impulsivity, anger, and attentional focusing, to assess CSR. The primary caregivers’ SR (PSR) was assessed with the Self-Control Scale. Information on lifestyles collected from questionnaires was utilized to construct the health behavior index (HBI). We found that Children’s HBI was associated with both CSR and PSR, inhibitory control (OR = 0.81, p < 0.001), anger (OR = 1.23, p < 0.001), attentional focusing (OR = 0.70, p < 0.001), impulsivity (OR = 1.23, p < 0.001), and PSR (OR = 0.73, p < 0.001). Children’s impulsivity was associated with their OWO (OR = 1.11, p = 0.013) which was partly mediated by the HBI (direct effect: β = 0.092, p = 0.026; indirect effect: β = 0.011, p = 0.007). The sex-specific analysis indicated that this mediation effect was only significant in boys. These results indicated that impulsivity is associated with childhood weight status, which is partially mediated by health behaviors, especially in boys.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jianduan Zhang
- Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Rd., Wuhan 430030, China; (K.X.); (Y.Z.); (W.D.); (P.T.); (C.L.); (R.C.); (H.Q.); (Y.Z.)
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6
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Liu Z, Gao P, Gao AY, Lin Y, Feng XX, Zhang F, Xu LQ, Niu WY, Fang H, Zhou S, Li WH, Yuan JH, Xu CX, Wu N, Li HJ, Wen LM, Patton GC, Wang HJ, Wu YF. Effectiveness of a Multifaceted Intervention for Prevention of Obesity in Primary School Children in China: A Cluster Randomized Clinical Trial. JAMA Pediatr 2022; 176:e214375. [PMID: 34747972 PMCID: PMC8576631 DOI: 10.1001/jamapediatrics.2021.4375] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE A rapid nutritional transition has caused greater childhood obesity prevalence in many countries, but the repertoire of effective preventive interventions remains limited. OBJECTIVE To determine the effectiveness of a novel multifaceted intervention for obesity prevention in primary school children. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial was conducted during a single school year (from September 11, 2018, to June 30, 2019) across 3 socioeconomically distinct regions in China according to a prespecified trial protocol. Twenty-four schools were randomly allocated (1:1) to the intervention or the control group, with 1392 eligible children aged 8 to 10 years participating. Data from the intent-to-treat population were analyzed from October 1 to December 31, 2019. INTERVENTIONS A multifaceted intervention targeted both children (promoting healthy diet and physical activity) and their environment (engaging schools and families to support children's behavioral changes). The intervention was novel in its strengthening of family involvement with the assistance of a smartphone app. The control schools engaged in their usual practices. MAIN OUTCOMES AND MEASURES The primary outcome was the change in body mass index (BMI; calculated as weight in kilograms divided by height in square meters) from baseline to the end of the trial. Secondary outcomes included changes in adiposity outcomes (eg, BMI z score, prevalence of obesity), blood pressure, physical activity and dietary behaviors, obesity-related knowledge, and physical fitness. Generalized linear mixed models were used in the analyses. RESULTS Among the 1392 participants (mean [SD] age, 9.6 [0.4] years; 717 boys [51.5%]; mean [SD] BMI, 18.6 [3.7]), 1362 (97.8%) with follow-up data were included in the analyses. From baseline to the end of the trial, the mean BMI decreased in the intervention group, whereas it increased in the control group; the mean between-group difference in BMI change was -0.46 (95% CI, -0.67 to -0.25; P < .001), which showed no evidence of difference across different regions, sexes, maternal education levels, and primary caregivers (parents vs nonparents). The prevalence of obesity decreased by 27.0% of the baseline figure (a relative decrease) in the intervention group, compared with 5.6% in the control group. The intervention also improved other adiposity outcomes, dietary, sedentary, and physical activity behaviors, and obesity-related knowledge, but it did not change moderate- to vigorous-intensity physical activity, physical fitness, or blood pressure. No adverse events were observed during the intervention. CONCLUSIONS AND RELEVANCE The multifaceted intervention effectively reduced the mean BMI and obesity prevalence in primary school children across socioeconomically distinct regions in China, suggesting its potential for national scaling. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03665857.
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Affiliation(s)
- Zheng Liu
- Department of Maternal and Child Health, School of Public Health, Peking University, National Health Commission Key Laboratory of Reproductive Health, Beijing, China
| | - Pei Gao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Ai-Yu Gao
- Dongcheng Primary and Secondary School Health Care Center, Beijing, China
| | - Yi Lin
- Urumqi Primary and Secondary School Health Care Center, Xinjiang, China
| | | | - Fang Zhang
- Mentougou Primary and Secondary School Health Care Center, Beijing, China
| | - Li-Qun Xu
- Center of Excellence for mHealth and Smart Healthcare, China Mobile Research Institute, China Mobile Communications Corporation, Beijing, China
| | - Wen-Yi Niu
- Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing, China
| | - Hai Fang
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Shuang Zhou
- Department of Maternal and Child Health, School of Public Health, Peking University, National Health Commission Key Laboratory of Reproductive Health, Beijing, China
| | - Wen-Hao Li
- Department of Maternal and Child Health, School of Public Health, Peking University, National Health Commission Key Laboratory of Reproductive Health, Beijing, China
| | | | - Chun-Xia Xu
- Urumqi Primary and Secondary School Health Care Center, Xinjiang, China
| | - Na Wu
- Center of Excellence for mHealth and Smart Healthcare, China Mobile Research Institute, China Mobile Communications Corporation, Beijing, China
| | - Hui-Juan Li
- Peking University Clinical Research Institute, Beijing, China
| | - Li-Ming Wen
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - George C. Patton
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Hai-Jun Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, National Health Commission Key Laboratory of Reproductive Health, Beijing, China
| | - Yang-Feng Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China,Peking University Clinical Research Institute, Beijing, China
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Zanganeh M, Adab P, Li B, Pallan M, Liu WJ, Hemming K, Lin R, Liu W, Martin J, Cheng KK, Frew E. Cost-Effectiveness of a School-and Family-Based Childhood Obesity Prevention Programme in China: The "CHIRPY DRAGON" Cluster-Randomised Controlled Trial. Int J Public Health 2021; 66:1604025. [PMID: 34531712 PMCID: PMC8439195 DOI: 10.3389/ijph.2021.1604025] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/04/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives: Rapid socioeconomic and nutrition transitions in Chinese populations have contributed to the growth in childhood obesity. This study presents a cost-effectiveness analysis of a school- and family-based childhood obesity prevention programme in China. Methods: A trial-based economic evaluation assessed cost-effectiveness at 12 months. Forty schools with 1,641 children were randomised to either receive the multi-component (diet and physical activity) intervention or to continue with usual activities. Both public sector and societal perspectives were adopted. Costs and benefits in the form of quality-adjusted life years (QALYs) were compared and uncertainty was assessed using established UK and US thresholds. Results: The intervention cost was 35.53 Yuan (£7.04/US$10.01) per child from a public sector perspective and 536.95 Yuan (£106/US$151) from a societal perspective. The incremental cost-effectiveness ratio (ICER) was 272.7 Yuan (£54/US$77)/BMI z-score change. The ICER was 8,888 Yuan (£1,760/US$2,502) and 73,831 Yuan (£14,620/US$20,796) per QALY from a public sector and societal perspective, respectively and was cost-effective using UK (£20,000) and US (US$50,000) per QALY thresholds. Conclusion: A multi-component school-based prevention programme is a cost-effective means of preventing childhood obesity in China.
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Affiliation(s)
- Mandana Zanganeh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Peymane Adab
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Bai Li
- School for Public Studies, University of Bristol, Bristol, United Kingdom
| | - Miranda Pallan
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Wei Jia Liu
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - Karla Hemming
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rong Lin
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - Wei Liu
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - James Martin
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Kar Keung Cheng
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Emma Frew
- Institute for Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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8
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Chen B, Waters CN, Compier T, Uijtdewilligen L, Petrunoff NA, Lim YW, van Dam R, Müller-Riemenschneider F. Understanding physical activity and sedentary behaviour among preschool-aged children in Singapore: a mixed-methods approach. BMJ Open 2020; 10:e030606. [PMID: 32265237 PMCID: PMC7245386 DOI: 10.1136/bmjopen-2019-030606] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES This study investigated physical activity (PA) and sedentary behaviour (SB) among preschool-aged children in Singapore and potential correlates at multiple levels of the socioecological model from in-school and out-of-school settings. DESIGN A cross-sectional study using a mixed-methods approach. PARTICIPANTS Parent-child dyads from six preschools in Singapore. METHODS PA and SB of children (n=72) were quantified using wrist-worn accelerometers for seven consecutive days. Three focus group discussions (FGDs) among 12 teachers explored diverse influences on children's activities, and System for Observing Play and Leisure Activity in Youth (SOPLAY) assessed PA environment and children's activity levels at preschools. Seventy-three parents completed questionnaires on home and neighbourhood factors influencing children's PA and SB. Descriptive analyses of quantitative data and thematic analysis of FGDs were performed. RESULTS Based on accelerometry, children (4.4±1.1 years) spent a median of 7.8 (IQR 6.4-9.0) hours/day in SB, and 0.5 (0.3-0.8) hours/day in moderate-to-vigorous physical activity (MVPA). MVPA was similar throughout the week, and SB was slightly higher on non-school days. In preschools, SOPLAY showed more children engaging in MVPA outdoors (34.0%) than indoors (7.7%), and absence of portable active play equipment. FGDs revealed issues that could restrict active time at preschool, including academic requirements of the central curriculum and its local implementation. The teachers had varying knowledge about PA guidelines and perceived that the children were sufficiently active. In out-of-school settings, parents reported that their children rarely used outdoor facilities for active play and spent little time in active travel. Few children (23.5%) participated in extracurricular sports, but most (94.5%) reported watching screens for 1.5 (0.5-3.0) hours/day. CONCLUSION MVPA was low and SB was high in preschool-aged children in an urban Asian setting. We identified diverse in-school and out-of-school correlates of PA and SB that should be taken into account in health promotion strategies.
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Affiliation(s)
- Bozhi Chen
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | | | - Thomas Compier
- VUmc School of Medical Sciences, VU University Medical Center, Amsterdam, The Netherlands
| | - Leonie Uijtdewilligen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | - Yee Wei Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Rob van Dam
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
- T H Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
- Institute of Social Medicine Epidemiology and Health Economics, Charite University Hospital Berlin, Berlin, Germany
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9
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Cao Z, Hua J, Zhang D, Thapa JR, Wang S. A cohort study assessing the sustainable long-term effectiveness of a childhood-obesity intervention in China. Int J Epidemiol 2020; 48:108-115. [PMID: 30357404 DOI: 10.1093/ije/dyy145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Obesity has become a global epidemic, with substantial impacts on children's health. Numerous intervention studies for the prevention of obesity in children have been conducted during the most recent decade, but very few have evaluated the long-term and sustainable effectiveness of such prevention efforts. METHODS We conducted a follow-up study during September 2015 and September 2017, based upon a previous 3-year cluster randomized-controlled study (RCT) for a comprehensive childhood-obesity intervention in 14 primary schools in Shanghai, China. A total of 929 students were enrolled in the study. Generalized estimating equation approaches were applied to analyse student's body mass index (BMI), BMI z-score at baseline and three annual long-term follow-ups. RESULTS Three years after the end of the RCT study, the odds of developing obesity and the odds of developing obesity or overweight in the intervention group were both lower than in the control group among girls [OR(obesity) = 0.299, p = 0.010 and OR (overweight/obesity) = 0.493, p = 0.013]; the odds of developing obesity or overweight in the intervention group was lower than in the control group among boys (OR = 0.369, p = 0.017). Compared with the baseline, the BMI z-scores in the intervention group were lower than those in the control group for both normal-weight students (-0.027) and overweight or obese students (-0.074). CONCLUSIONS The 3-year RCT showed significant and reliable long-term effects on preventing childhood obesity, particularly among girls.
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Affiliation(s)
- Zhijuan Cao
- Department of Women and Children's Health Care, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jing Hua
- Department of Women and Children's Health Care, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China.,Shanghai Key Laboratory of Meteorology and Health, Shanghai Meteorological Service, Shanghai, China
| | - Donglan Zhang
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Janani R Thapa
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Shumei Wang
- Department of Child and Adolescent Health, School of Public Health, Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, China
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10
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Bozbulut R, Ertaş-Öztürk Y, Döğer E, Bideci A, Köksal E. Increased Obesity Awareness and Adherence to Healthy Lifestyle-Diet Reduce Metabolic Syndrome Risk in Overweight Children. J Am Coll Nutr 2019; 39:432-437. [PMID: 31755852 DOI: 10.1080/07315724.2019.1691951] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Obesity is a common epidemic issue in all over the world. In order to prevent obesity it is essential to know about obesity and its detrimental consequences. This study aimed to evaluate children's awareness about obesity and to determine the associations between level of awareness, healthy lifestyle, dietary habits and risk factors for metabolic syndrome.Methods: Two hundred and thirty-six overweight children (119 boys and 117 girls) aged 10-14 years were enrolled to the study. Anthropometric and biochemical measurements were taken and metabolic syndrome (MetS) definition were done according to the International Diabetes Federation (IDF) consensus and divided into two groups as MetS (+) and MetS (-). Obesity awareness scale (OBA) and Adapted Healthy Lifestyle-Diet Index for Turkey (HLD-TR) were performed.Results: Among children, the prevalence of having MetS was found as 26.3%. Obesity awareness and HLD-TR index sores were lower in MetS (+) group than MetS (-) group. Metabolic syndrome related biochemical parameters and anthropometric measurements were associated with obesity awareness level of the children. The binary logistic regression model shows that a one-unit increase in the OBA index score increases the odd of not having MetS for 1.12 times after adjustments for age, gender, body mass index, and HLD-TR index score.Conclusions: Increased awareness about obesity among children will help to reduce the risk of metabolic syndrome, type 2 diabetes and atherosclerotic cardiovascular diseases in the future.
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Affiliation(s)
- Rukiye Bozbulut
- Faculty of Medicine, Department of Pediatric Endocrinology, Gazi University, Ankara, Turkey
| | - Yasemin Ertaş-Öztürk
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Gazi University, Ankara, Turkey
| | - Esra Döğer
- Faculty of Medicine, Department of Pediatric Endocrinology, Gazi University, Ankara, Turkey
| | - Aysun Bideci
- Faculty of Medicine, Department of Pediatric Endocrinology, Gazi University, Ankara, Turkey
| | - Eda Köksal
- Faculty of Health Sciences, Department of Nutrition and Dietetics, Gazi University, Ankara, Turkey
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The CHIRPY DRAGON intervention in preventing obesity in Chinese primary-school--aged children: A cluster-randomised controlled trial. PLoS Med 2019; 16:e1002971. [PMID: 31770371 PMCID: PMC6879117 DOI: 10.1371/journal.pmed.1002971] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/18/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In countries undergoing rapid economic transition such as China, rates of increase in childhood obesity exceed that in the West. However, prevention trials in these countries are inadequate in both quantity and methodological quality. In high-income countries, recent reviews have demonstrated that school-based prevention interventions are moderately effective but have some methodological limitations. To address these issues, this study evaluated clinical- and cost- effectiveness of the Chinese Primary School Children Physical Activity and Dietary Behaviour Changes Intervention (CHIRPY DRAGON) developed using the United Kingdom Medical Research Council complex intervention framework to prevent obesity in Chinese primary-school-aged children. METHODS AND FINDINGS In this cluster-randomised controlled trial, we recruited 40 state-funded primary schools from urban districts of Guangzhou, China. A total of 1,641 year-one children with parent/guardian consent took part in baseline assessments prior to stratified randomisation of schools (intervention arm, 20 schools, n = 832, mean age = 6.15 years, 55.6% boys; control arm n = 809, mean age = 6.14 years, 53.3% boys). The 12-month intervention programme included 4 school- and family-based components delivered by 5 dedicated project staff. We promoted physical activity and healthy eating behaviours through educational and practical workshops, family activities, and supporting the school to improve physical activity and food provision. The primary outcome, assessed blind to allocation, was between-arm difference in body mass index (BMI) z score at completion of the intervention. A range of prespecified, secondary anthropometric, behavioural, and psychosocial outcomes were also measured. We estimated cost effectiveness based on quality-adjusted life years (QALYs), taking a public sector perspective. Attrition was low with 55 children lost to follow up (3.4%) and no school dropout. Implementation adherence was high. Using intention to treat analysis, the mean difference (MD) in BMI z scores (intervention - control) was -0.13 (-0.26 to 0.00, p = 0.048), with the effect being greater in girls (MD = -0.18, -0.32 to -0.05, p = 0.007, p for interaction = 0.015) and in children with overweight or obesity at baseline (MD = -0.49, -0.73 to -0.25, p < 0.001, p for interaction < 0.001). Significant beneficial intervention effects were also observed on consumption of fruit and vegetables, sugar-sweetened beverages and unhealthy snacks, screen-based sedentary behaviour, and physical activity in the intervention group. Cost effectiveness was estimated at £1,760 per QALY, with the probability of the intervention being cost effective compared with usual care being at least 95% at a willingness to pay threshold of £20,000 to 30,000 per QALY. There was no evidence of adverse effects or harms. The main limitations of this study were the use of dietary assessment tools not yet validated for Chinese children and the use of the UK value set to estimate QALYS. CONCLUSIONS This school- and family-based obesity prevention programme was effective and highly cost effective in reducing BMI z scores in primary-school-aged children in China. Future research should identify strategies to enhance beneficial effects among boys and investigate the transferability of the intervention to other provinces in China and countries that share the same language and cultures. TRIAL REGISTRATION ISRCTN Identifier ISRCTN11867516.
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Chen B, Bernard JY, Padmapriya N, Yao J, Goh C, Tan KH, Yap F, Chong YS, Shek L, Godfrey KM, Chan SY, Eriksson JG, Müller-Riemenschneider F. Socio-demographic and maternal predictors of adherence to 24-hour movement guidelines in Singaporean children. Int J Behav Nutr Phys Act 2019; 16:70. [PMID: 31438965 PMCID: PMC6704617 DOI: 10.1186/s12966-019-0834-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/13/2019] [Indexed: 03/09/2023] Open
Abstract
PURPOSE Integrated 24-Hour Movement Guidelines provide specific recommendations on screen viewing (SV), moderate-to-vigorous physical activity (MVPA) and sleep to improve health of children and youth. However, few studies have examined whether these guidelines are met in young children, particularly in Asia. We evaluated adherence to integrated and individual guidelines and its predictors in 5.5-year-old Singaporean children. METHODS Growing Up in Singapore towards Healthy Outcomes (GUSTO) is a mother-offspring birth cohort study. At age 5.5 years, child SV was reported by parents. Movement behaviours (MBs) were measured continuously using wrist-worn accelerometers over 7 consecutive days and nights. For accelerometer data including ≥3 days with ≥16 h/day we estimated mean (±SD) daily MVPA, SV and nighttime sleep duration across the week. Adherence to integrated (Canadian/Australian) guidelines was defined as meeting all individual guidelines: ≥60 min of MVPA/day, ≤2 h of screen time/day, and 9-11 h of sleep/night. Socio-demographic and maternal predictors collected at pregnancy enrolment and at 26-28 weeks' gestation were examined by multivariable logistic regression. RESULTS Of 864 children followed up age 5.5 years, 547 (63.3%) had both valid ActiGraph and questionnaire data (51.7% boys and 58.3% Chinese ethnicity). Children averaged 101.9 (± 88.7) min/day SV, 67.3 (± 23.7) min/day MVPA and 480.6 (± 57.2) min/night sleep. Few children met integrated guidelines. Specifically, the proportions of children who met none, SV, MVPA, sleep and integrated guidelines were 11.2, 70.2, 59.6, 13.7 and 5.5%, respectively. Multivariable analysis showed that maternal activity and television (TV) viewing were associated with meeting integrated guidelines (insufficiently vs. highly active (OR [95% CI]): 0.11 [0.01, 0.95]; 2-3 vs. ≥ 3 h TV: 3.52 [1.02, 12.22]). Examining higher adherence to individual guidelines, Chinese ethnicity, younger maternal age and lower maternal TV and sleep time were associated with greater SV; male sex, Malay ethnicity, higher birth order and higher maternal activity level were associated with greater MVPA; and older maternal age was associated with adherence to sleep guideline. CONCLUSIONS Beyond individual behaviours, consideration of the full spectrum of MBs may be important to improve children's health. However, few Singaporean children adhere to integrated 24-h movement guidelines. Maternal behaviours as early as during pregnancy could be important targets for future interventions aiming to promote these MBs in children.
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Affiliation(s)
- Bozhi Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building (Block MD1), 12 Science Drive 2, #09-01v, Singapore, 117549 Singapore
| | - Jonathan Y. Bernard
- Inserm, Centre for Research in Epidemiology and StatisticS (CRESS), Research team on Early life Origins of Health (EAROH), Villejuif, France
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
| | - Natarajan Padmapriya
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Jiali Yao
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building (Block MD1), 12 Science Drive 2, #09-01v, Singapore, 117549 Singapore
| | - Claire Goh
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
| | - Kok Hian Tan
- Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Fabian Yap
- Duke-NUS Medical School, Singapore, Singapore
- Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Yap-Seng Chong
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Lynette Shek
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Paediatric Allergy, Immunology & Rheumatology, Khoo Teck Puat - National University Children’s Medical Institute, National University Health System, Singapore, Singapore
| | - Keith M. Godfrey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Shiao-Yng Chan
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Johan G. Eriksson
- Agency for Science Technology and Research (A*STAR), Singapore Institute for Clinical Sciences (SICS), Singapore, Singapore
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Falk Müller-Riemenschneider
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building (Block MD1), 12 Science Drive 2, #09-01v, Singapore, 117549 Singapore
- Institute for Social Medicine, Epidemiology and Health Economics, Charite University Medical Centre, Berlin, Germany
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Zhang J, Wang H, Wang Z, Du W, Su C, Zhang J, Jiang H, Jia X, Huang F, Ouyang Y, Wang Y, Zhang B. Prevalence and stabilizing trends in overweight and obesity among children and adolescents in China, 2011-2015. BMC Public Health 2018; 18:571. [PMID: 29716560 PMCID: PMC5930802 DOI: 10.1186/s12889-018-5483-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 04/19/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The prevalence of childhood overweight and obesity in developed countries appears to be plateauing. The purpose of this study was to provide the most recent data on the prevalence and trends in overweight and obesity among Chinese children and adolescents from 2011 to 2015. METHODS We used data collected in the China Health and Nutrition Survey (CHNS) and China Nutritional Transition Cohort Study (CNTCS). We used two waves of the survey in 12 provinces conducted in 2011 (aged 7-18 years; n = 1458) and 2015 (aged 7-18 years; n = 1084) to perform a trend analysis. We used data collected in 15 provinces (aged 7-18 years; n = 1617) to estimate the prevalence of overweight and obesity among Chinese children and adolescents in 2015. RESULTS In 2015, based on the Working Group for Obesity in China (WGOC) criteria, the prevalence of overweight and obesity were 14.0% (95% CI, 11.6-16.3) and 10.5% (95% CI, 8.4-12.6) in boys, and 9.7% (95% CI, 7.7-11.8) and 7.1% (95% CI, 5.2-8.9) in girls, respectively. The increase in BMI z-scores from 2011 to 2015 was statistically significant among adolescents (p = 0.0083), but not among children. No significant changes were observed in prevalence of overweight and obesity between 2011 and 2015, excepting adolescents aged 12-18 years (p = 0.0086). CONCLUSIONS Since 2011, overweight has remained stable, and obesity has stabilized in children, though not in adolescents. Although levels of childhood overweight and obesity in China are not high compared to other developed countries, they remain concerning enough that effective policies and interventions need to be sustained and intensified for lowering rates of childhood overweight and obesity.
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Affiliation(s)
- Jiguo Zhang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Huijun Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Zhihong Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Wenwen Du
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Chang Su
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Ji Zhang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Hongru Jiang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Xiaofang Jia
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Feifei Huang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Yifei Ouyang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Yun Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China
| | - Bing Zhang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, No.29 Nanwei Road, Beijing, 100050, China.
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Shao X, Ding X, Wang B, Li L, An X, Yao Q, Song R, Zhang JA. Antibiotic Exposure in Early Life Increases Risk of Childhood Obesity: A Systematic Review and Meta-Analysis. Front Endocrinol (Lausanne) 2017; 8:170. [PMID: 28775712 PMCID: PMC5517403 DOI: 10.3389/fendo.2017.00170] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 07/03/2017] [Indexed: 12/21/2022] Open
Abstract
A number of studies have previously assessed the impact of antibiotic exposure in early life on the risk of childhood obesity, but no systematic assessment is currently available. A systematic review and meta-analysis was performed to comprehensively and quantitatively elucidate the risk of childhood obesity caused by antibiotic exposure in early life. Literature search was performed in PubMed, Embase, and Web of Science. Random-effect meta-analysis was used to pool the statistical estimates. Fifteen cohort studies involving 445,880 participants were finally included, and all those studies were performed in developed countries. Antibiotic exposure in early life significantly increased risk of childhood overweight [relative risk (RR) = 1.23, 95% confidence interval (CI) 1.13-1.35, P < 0.001] and childhood obesity (RR = 1.21, 95% CI 1.13-1.30, P < 0.001). Antibiotic exposure in early life also significantly increased the z-score of childhood body mass index (mean difference: 0.07, 95% CI 0.05-0.09, P < 0.00001). Importantly, there was an obvious dose-response relationship between antibiotic exposure in early life and childhood adiposity, with a 7% increment in the risk of overweight (RR = 1.07, 95% CI 1.01-1.15, P = 0.03) and a 6% increment in the risk of obesity (RR = 1.06, 95% CI 1.02-1.09, P < 0.001) for each additional course of antibiotic exposure. In conclusion, antibiotic exposure in early life significantly increases risk of childhood obesity. Moreover, current analyses are mainly taken from developed countries, and therefore the impact of antibiotic exposure on risk of childhood obesity in vulnerable populations or developing countries still needs to be evaluated in future studies.
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Affiliation(s)
- Xiaoqing Shao
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Xiaolian Ding
- Department of Nephrology and Endocrinology, Weinan Central Hospital, Weinan, China
| | - Bin Wang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Ling Li
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Xiaofei An
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Qiuming Yao
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Ronghua Song
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
| | - Jin-an Zhang
- Department of Endocrinology, Jinshan Hospital of Fudan University, Shanghai, China
- *Correspondence: Jin-an Zhang,
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