Effectiveness of a Multifaceted Intervention for Prevention of Obesity in Primary School Children in China: A Cluster Randomized Clinical Trial

The effectiveness of physical activity interventions on blood pressure in children and adolescents: A systematic review and network meta-analysis

BACKGROUND

High blood pressure (BP) is a major contributor to mortality and cardiovascular diseases. Despite the known benefits of exercise for reducing BP, it is crucial to identify the most effective physical activity (PA) intervention. This systematic review and network meta-analysis (NMA) aimed to evaluate the available evidence on the effectiveness of various PA interventions for reducing BP and to determine their hierarchy based on their impact on BP.

METHODS

A search of PubMed, SPORTDiscus, PsycINFO, Web of Science, CINAHL, Cochrane, and Eric databases was conducted up to December 2022 for this systematic review and NMA. Randomized controlled trials and quasi-experimental studies targeting healthy children and adolescents aged 6-12 years old were included in this study. Only studies that compared controlled and intervention groups using PA or exercise as the major influence were included. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent investigators performed the literature screening, data extraction, and risk of bias assessment. We used Bayesian arm-based NMA to synthesize the data. The primary outcomes were systolic BP and diastolic BP. We calculated the mean differences (MDs) in systolic BP and diastolic BP before and after treatment. Mean treatment differences were estimated using NMA and random-effect models.

RESULTS

We synthesized 27 studies involving 15,220 children and adolescents. PA combined with nutrition and behavior change was the most effective intervention for reducing both systolic BP and diastolic BP (MD = -8.64, 95% credible interval (95%CI):-11.44 to -5.84; MD = -6.75, 95%CI: -10.44 to -3.11), followed by interventions with multiple components (MD = -1.39, 95%CI: -1.94 to -0.84; MD = -2.54, 95%CI: -4.89 to -0.29).

CONCLUSION

Our findings suggest that PA interventions incorporating nutrition and behavior change, followed by interventions with multiple components, are most effective for reducing both systolic BP and diastolic BP in children and adolescents.

Isotemporal Substitution Effects of Daily Time Use on Cardiorespiratory Fitness of Children in the OptiChild Study: A Mediation Analysis with Diet Quality

(1) Background: Although daily time-use is associated with diet quality and cardiorespiratory fitness (CRF) in children, their interdependence remains unexplored. This study first examined the associations between reallocating daily movement time and diet quality and CRF, and second the mediating role of diet quality in the relationship between daily time-use and CRF. (2) Methods: This study included 1131 Chinese children (aged 8 to 10 years; median [interquartile range]: 8.5 [8.3, 8.8]) at baseline (September 2022) and 1268 children at the 9-month follow-up (June 2023) from the OptiChild study. Daily durations of moderate-to-vigorous physical activity (MVPA), sleep, and sedentary behavior (e.g., screen time) were self-reported or proxy-reported by parents. Diet quality was assessed via the Diet Quality Questionnaire (DQQ), which uses a 24 h dietary recall and is categorized according to the Global Dietary Recommendations (GDR) score and Food Group Diversity Score (FGDS). The CRF was measured using VO2max after the 20 m shuttle run test. Longitudinal associations between daily time-use, diet quality, and CRF were calculated using isotemporal substitution models. Mediation analyses were used to determine whether diet quality mediated the associations between daily time-use and CRF. (3) Results: Reallocation of 30 min from screen time to MVPA resulted in significant improvements in the GDR score (β baseline = 0.11, p = 0.024; β follow-up = 0.26, p < 0.001), FGDS (β baseline = 0.11, p = 0.006; β follow-up = 0.19, p < 0.001), and CRF (β baseline = 0.40, p < 0.001; β follow-up = 0.26, p = 0.001). Diet quality partially mediated the associations between MVPA, screen time, and CRF. Substituting 30 min of screen time for MVPA led to diet quality mediating a proportion of the association with CRF (GDR score: 11.4%, FGDS: 6.6%). (4) Conclusions: These findings underscore the importance of optimizing daily time-use of MVPA and screen time and improving diet quality to promote physical fitness in school-aged children.

A Latent Class Analysis of Family Eating Behaviors and Home Environment Habits on Preschool-Aged Children's Body Mass Index

Background: The etiology of obesity is multifaceted, with multiple risk factors occurring during early childhood (e.g., fast food frequency, eating dinner as a family, TV in the bedroom). Many past studies have largely considered obesity risk factors in isolation, when in reality, the risk factors likely cluster together. A latent class analysis can be used to identify patterns in child eating behaviors, parent feeding behaviors, and household habits among preschool-aged children and their families to identify distinct, heterogenous classes and to determine if classes are associated with overweight and obesity. Methods: We used data from a community-based study of 624 three- to five-year-old children and a parent in New Hampshire, from March 2014 to October 2015. Parent-reported data were used to determine frequency of eating behaviors and household habits. Height and weight were objectively measured. Results: Four classes were identified; Class 1: "Healthy/Mildly accommodating," Class 2: "Healthy/Accommodating," Class 3: "Moderately healthy/Moderately accommodating," and Class 4: "Least healthy/Least accommodating." Compared with Class 1, children in Class 4 had increased odds of being overweight or obese [adjusted odds ratio (aOR): 1.64, 95% confidence interval (CI): 1.13-2.15], whereas Classes 2 and 3 were not associated with BMI (Class 2: aOR: 1.24, 95% CI: 0.62-1.86; Class 3: aOR: 1.31, 95% CI: 0.81-1.81). Conclusion: Study findings highlight that child-parent interactions around meals differentially relate to children's weight status given the context of children's eating habits. Most important, our study findings confirm the importance of adapting multiple healthy habits within the home social and physical environment to offset obesity risk in young children.

Personality traits and co-occurrence of depressive symptoms and high BMI: a prospective cohort study

We assess the associations between personality traits and co-occurrence of depressive symptoms and high BMI from adolescence to early adulthood. We employed a nationally representative cohort in China from 2010 to 2020 year. We included adolescents aged 10-19 years without depressive symptoms and unhealthy weight status (obesity, overweight, or thinness) at baseline and excluded those without any measurement of depressive symptoms or BMI at follow-ups. We assessed baseline personality traits in 7 dimensions of conscientiousness, openness, neuroticism, agreeableness, extraversion, self-esteem, and responsibility. We also assessed the combined effects of these 7 dimensions of personality traits by generating individual-level personality trait risk scores based on the weighted sum of all these 7 dimensions of personality traits. We measured the co-occurrence of depressive symptoms and high BMI using both a single measurement of depressive symptoms and BMI at the last follow-up and repeated measurements of them over 10 years. We used the multinomial logistic regression models to examine the exposure-outcome associations. At baseline, we included 1778 individuals (mean age: 14.4 year; female: 853 (48.0%)). At follow-ups, we observed increased risk of co-occurrence of depressive symptoms and high BMI per 1-SD increase in neuroticism score (1.95-2.38 odds ratio) or 1-SD decrease in self-esteem and conscientiousness (0.63-0.80 odds ratio; all P values < 0.05); we observed no evidence of associations between openness, agreeableness, extraversion, or responsibility and the risk of co-occurrence of depressive symptoms and high BMI (all P values > 0.05). For the combined effects of the 7 dimensions of personality traits, we found an elevated risk of co-occurrence of depressive symptoms and high BMI per 1-SD increase in the personality trait risk scores (OR (95% CI), single measurement at the last follow-up: 2.01, 1.66 to 2.43; trajectory classification using the repeated measurements 2.30, 1.55 to 3.42; average level using the repeated measurements: 2.27, 1.93 to 2.67). In this national cohort in China, personality traits were found to be associated with the co-occurrence of depressive symptoms and high BMI from adolescence to early adulthood. These findings highlight the importance of stratifying individuals based on their personality traits and providing targeted interventions for those at risk of comorbid depression and obesity.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Effectiveness of mHealth App-Based Interventions for Increasing Physical Activity and Improving Physical Fitness in Children and Adolescents: Systematic Review and Meta-Analysis

BACKGROUND

The COVID-19 pandemic has significantly reduced physical activity (PA) levels and increased sedentary behavior (SB), which can lead to worsening physical fitness (PF). Children and adolescents may benefit from mobile health (mHealth) apps to increase PA and improve PF. However, the effectiveness of mHealth app-based interventions and potential moderators in this population are not yet fully understood.

OBJECTIVE

This study aims to review and analyze the effectiveness of mHealth app-based interventions in promoting PA and improving PF and identify potential moderators of the efficacy of mHealth app-based interventions in children and adolescents.

METHODS

We searched for randomized controlled trials (RCTs) published in the PubMed, Web of Science, EBSCO, and Cochrane Library databases until December 25, 2023, to conduct this meta-analysis. We included articles with intervention groups that investigated the effects of mHealth-based apps on PA and PF among children and adolescents. Due to high heterogeneity, a meta-analysis was conducted using a random effects model. The Cochrane Risk of Bias Assessment Tool was used to evaluate the risk of bias. Subgroup analysis and meta-regression analyses were performed to identify potential influences impacting effect sizes.

RESULTS

We included 28 RCTs with a total of 5643 participants. In general, the risk of bias of included studies was low. Our findings showed that mHealth app-based interventions significantly increased total PA (TPA; standardized mean difference [SMD] 0.29, 95% CI 0.13-0.45; P<.001), reduced SB (SMD -0.97, 95% CI -1.67 to -0.28; P=.006) and BMI (weighted mean difference -0.31 kg/m2, 95% CI -0.60 to -0.01 kg/m2; P=.12), and improved muscle strength (SMD 1.97, 95% CI 0.09-3.86; P=.04) and agility (SMD -0.35, 95% CI -0.61 to -0.10; P=.006). However, mHealth app-based interventions insignificantly affected moderate to vigorous PA (MVPA; SMD 0.11, 95% CI -0.04 to 0.25; P<.001), waist circumference (weighted mean difference 0.38 cm, 95% CI -1.28 to 2.04 cm; P=.65), muscular power (SMD 0.01, 95% CI -0.08 to 0.10; P=.81), cardiorespiratory fitness (SMD -0.20, 95% CI -0.45 to 0.05; P=.11), muscular endurance (SMD 0.47, 95% CI -0.08 to 1.02; P=.10), and flexibility (SMD 0.09, 95% CI -0.23 to 0.41; P=.58). Subgroup analyses and meta-regression showed that intervention duration was associated with TPA and MVPA, and age and types of intervention was associated with BMI.

CONCLUSIONS

Our meta-analysis suggests that mHealth app-based interventions may yield small-to-large beneficial effects on TPA, SB, BMI, agility, and muscle strength in children and adolescents. Furthermore, age and intervention duration may correlate with the higher effectiveness of mHealth app-based interventions. However, due to the limited number and quality of included studies, the aforementioned conclusions require validation through additional high-quality research.

TRIAL REGISTRATION

PROSPERO CRD42023426532; https://tinyurl.com/25jm4kmf.

Time to act on childhood obesity: the use of technology

Childhood obesity is rapidly increasing worldwide and there is an urgent need to implement treatment and prevention programs. Over the last decade, in addition to increasing rates of childhood obesity, we have also observed rapid technological and digital development. The Covid-19 pandemic has largely contributed to both expansions but has also allowed an opening towards a broader vision of medicine, through new therapeutic opportunities such as mobile healthcare. The digital and technological delivery of obesity prevention and treatment programs can represent an innovative tool to support children and families to overcome some limitations and barriers such as the accessibility of programs that prevent them from adopting healthy lifestyle changes. This review aimed to summarize the impact of different digital interventions for children and adolescent affected by obesity.

A Systematic Review of School-Based Nutrition Interventions for Promoting Healthy Dietary Practices and Lifestyle Among School Children and Adolescents

Childhood malnutrition is one of the foremost community health problems in the world, particularly in developing countries like India. This current review was conducted to evaluate the effectiveness of various school-centered nutrition interventions/intervention programs developed in recent years, and their impact on the nutritional status, dietary habits, food preferences, lifestyle, and dietary behaviors in relation to diet, as well as physical activities for school children, especially adolescents. This review included studies found in the PubMed/Medline, SCOPUS, and Web of Science (WOS) databases, published from July 2017 to 2023. They were analyzed for eligibility criteria defined for this study, including school children and adolescents, school-based nutrition interventions/strategies/policies/initiatives, nutritional status, physical activity, dietary habits, and lifestyle. The Risk of Bias assessment was conducted using Review Manager version 5.4. Among 1776 potentially related studies, 108 met the eligibility criteria. Following this review, 62 studies were identified as eligible for this study, in which 38 intervention programs were discussed. A total of 13 studies were considered comprehensive and multi-component, 15 were nutrition education interventions, six were identified as physical activity interventions, and four focused on lifestyle and dietary behavior-related interventions. Another 24 of the 62 studies reviewed (approximately 39%) were either original articles, review articles, or articles pertaining to nutritional program guidelines, protocols, and/or reports. These studies uncovered a possible relationship between a decrease in BMI and school children's engagement in diet and/or physical activity. Results also suggest that these programs can be effective, although evidence for the long-term sustainability of changes in BMI was less evident and not fully substantiated/supported. Most of these findings are based on self-reported program data and may consist of biases linked to recall, selection of participants, and the desire to report favorable final measures (physical activity, lifestyle, and dietary habits). This study has the potential for use in public health programs devoted to healthy nutrition behavior and lifestyle practices. This research was primarily conducted by clinical researchers and did not receive any standardized institutional or organization-derived grant funding and support.

PM2.5 constituents associated with childhood obesity and larger BMI growth trajectory: A 14-year longitudinal study

BACKGROUND

The association of specific PM2.5 chemical constituents with childhood overweight or obesity (OWOB) remain unclear. Furthermore, the long-term impacts of PM2.5 exposure on the trajectory of children's body mass index (BMI) have not been explored.

METHODS

We conducted a longitudinal study among 1,450,830 Chinese children aged 6-19 years from Beijing and Zhongshan in China during 2005-2018 to examine the associations of PM2.5 and its chemical constituents with incident OWOB risk. We extracted PM2.5 mass and five main component exposure from Tracking Air Pollution in China (TAP) dataset. Cox proportional hazards models were applied to quantify exposure-response associations. We further performed principal component analysis (PCA) to handle the multi-collinearity and used quantile g-computation (QGC) approach to analyze the impacts of exposure mixtures. Additionally, we selected 125,863 children with at least 8 physical examination measurements and combined group-based trajectory models (GBTM) with multinomial logistic regression models to explore the impacts of exposure to PM2.5 mass and five constituents on BMI and BMI Z-score trajectories during 6-19 years.

RESULTS

We observed each interquartile range increment in PM2.5 exposure was significantly associated with a 5.1 % increase in the risk of incident OWOB (95 % confidence Interval [CI]: 1.036-1.066). We also found black carbon, sulfate, organic matter, often linked to fossil combustion, had comparable or larger estimates of the effect (HR = 1.139-1.153) than PM2.5. Furthermore, Exposure to PM2.5 mass, sulfate, nitrate, ammonium, organic matter and black carbon was significantly associated with an increased odds of being in a larger BMI trajectory and being assigned to persistent OWOB trajectory.

CONCLUSIONS

Our findings provide evidence that the constituents mainly from fossil fuel combustion may have a perceptible influence on increased OWOB risk associated with PM2.5 exposure in China. Moreover, long-term exposure to PM2.5 contributes to an increased odds of being in a lager BMI and a persistent OWOB trajectories.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.

Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.

Long-term trends and urban-rural disparities in the physical growth of children and adolescents in China: an analysis of five national school surveys over three decades

BACKGROUND

China's rapid economic growth has brought opportunities for improved health and growth of children and adolescents. We sought to explore the long-term trends and urban-rural inequalities in physical growth (specifically height and BMI) among school-aged children and adolescents in China to identify policy priorities for a healthier generation.

METHODS

We used the 1985, 1995, 2005, 2014, and 2019 cycles of the Chinese National Survey on Students' Constitution and Health from primary and secondary schools in 30 mainland provinces, autonomous regions, and municipalities. We analysed height and BMI data for 7, 12, and 18 year old children and adolescents of Han ethnicity. Children and adolescents who had complete data on age, sex, location, weight, and height were included. All surveys used a multi-stage stratified random cluster sampling method and were nationally representative. A univariate kernel density estimation was used to plot the distribution of height and BMI. Quantile regression was used to examine associations between urban and rural locations and the primary outcomes of height and BMI at specific quantiles of distribution (5th, 25th, 50th, 75th, and 95th).

FINDINGS

Across the five surveys (in 1985, 1995, 2005, 2014, and 2019), 313 973 children and adolescents were included. From 1985 to 2019, the height and BMI distribution curves shifted to the right for each age group and sex, with the BMI curve becoming more dispersed. Median height in adolescents aged 18 years increased by 3·8 cm (95% CI 3·4-4·1) in boys in urban areas and 5·7 cm (5·3-6·1) in boys in rural areas, and 2·7 cm (2·4-3·0) in girls in urban areas and 3·7 cm (3·4-4·0) in girls in rural areas. Children in urban areas were taller than those in rural areas at every quantile, but the magnitude of this disparity narrowed by 2019. In 2019, the median height of boys in urban areas were 1·4 cm (1·0-1·8) greater in those aged 7 years, 2·5 cm (1·9-3·1) greater in those aged 12 years, and 1·1 cm (0·6-1·5) greater in those aged 18 years than their rural counterparts, whereas the median height of girls in urban areas were 1·1 cm (0·7-1·4) greater in those aged 7 years, 1·6 cm (1·1-2·1) greater in those aged 12 years, and 1·1 cm (0·7-1·5) greater in those aged 18 years than rural girls. Over this period, urban-rural differences in BMI disappeared at the lowest quantile, but persisted at higher quantiles. In 2019, the urban-rural differences in BMI for boys aged 12 years were 0·6 kg/m2 (95% CI 0·3-0·8) at the median, 1·0 kg/m2 (0·6-1·4) at the 75th quantile, and 0·7 kg/m2 (0·1-1·3) at the 95th quantile; for girls aged 12 years, 0·3 kg/m2 (0·1-0·5) at the median, 0·5 kg/m2 (0·2-0·8) at the 75th quantile, and 0·9 kg/m2 (0·3-1·5) at the 95th quantile; for boys aged 18 years, 0·6 kg/m2 (0·4-0·8) at the median, 0·8 kg/m2 (0·5-1·2) at the 75th quantile, and 0.7 kg/m2 (0·0-1·5) at the 95th quantile; and for girls aged 18 years, 0·2 kg/m2 (0·1-0·4) at the median, 0·5 kg/m2 (0·3-0·8) at the 75th quantile, and 1·0 kg/m2 (0·5-1·5) at the 95th quantile.

INTERPRETATION

Across three decades, school-aged children and adolescents in China have increased in height and BMI, with less disparity between urban and rural locations. Investments are needed to improve the affordability of healthy foods to help children and adolescents in rural areas reach their potential maximum height. Meanwhile, these changes in BMI necessitate tailored strategies according to urban-rural settings to contain the increase in overweight and obesity and promote optimal growth for children and adolescents.

FUNDING

Capital's Funds for Health Improvement and Research, and National Natural Science Foundation of China.

Longitudinal association of serum 25-hydroxyvitamin D levels with metabolically healthy body size transition in children and adolescents: A prospective cohort study with 2 years of follow-up

BACKGROUND AND AIMS

Although the associations of vitamin D with obesity and metabolic abnormalities have been reported, the role of vitamin D in the transition of obesity phenotype remains unclear but is highly desired since it is crucial to identify potential methods for obesity management. Therefore, we aimed to investigate the relationship between vitamin D and the risk for metabolically unhealthy obesity (MUO) or metabolically healthy obesity (MHO) in metabolically healthy children with 2 years of follow-up.

METHODS

Data were collected from a population-based cohort consisting of 6424 metabolically healthy children aged 6-16 years at baseline. Metabolic abnormalities including hypertension, high triglycerides (TG), low high-density lipoprotein cholesterol (HDL-C), hyperglycemia, and hyperuricemia were assessed both at baseline and follow-up. Baseline serum 25-hydroxyvitamin D (25[OH]D) concentrations were measured as exposure. The obesity phenotype transition was evaluated by weight status with the combination of metabolic health status from baseline to follow-up.

RESULTS

During a 2-year follow-up, 889 (13.8 %) incident MUO cases occurred. For participants with obesity, each 10 nmol/L increment in 25(OH)D concentrations was associated with a 21 % (95%CI: 13 %∼43 %) and a 7 % (95%CI: 1 %∼14 %) decreased risk in high TG and hyperuricemia, respectively. A 51 % (95%CI: 22 %∼69 %) lower risk of MUO was observed in participants with sufficient vitamin D levels (≥50 nmol/L) compared to those with vitamin D deficiency (<30 nmol/L). Besides, among children who were MHO at baseline, those with sufficient vitamin D levels (≥50 nmol/L) were more likely to transition to metabolically healthy normal weight (MHNW) than vitamin D deficient individuals (<30 nmol/L).

CONCLUSIONS

Vitamin D may prevent the development of MUO and help increase the transition from MHO to MHNW. The findings highlight that vitamin D might be an effective nutrient for obesity management.

Association of Sugar-Sweetened Beverage Consumption and Moderate-to-Vigorous Physical Activity with Childhood and Adolescent Overweight/Obesity: Findings from a Surveillance Project in Jiangsu Province of China

Sugar-sweetened beverage (SSB) consumption and inadequate moderate-to-vigorous physical activity (MVPA) have been suggested as potential contributors to overweight/obesity during childhood or adolescence; however, the results of previous studies are inconsistent. It was crucial to estimate the independent and joint association of SSB consumption and inadequate MVPA for childhood and adolescent overweight/obesity. The "Surveillance for Common Disease and Health Risk Factors Among Students in Jiangsu Province 2021-2022" initiative provided us with representative population-based data that we studied. SSB consumption and inadequate MVPA were determined by self-reported SSB habit and MVPA frequency (days/week). The body mass index for each gender and age subgroup was used to identify those who were overweight or obese. With stratified analyses to ascertain differences in age or gender, we employed the logistic regression model to assess the association of SSB and MVPA with overweight/obesity and applied the likelihood ratio test to explore the interactions. Approximately 38.2% of the study population (119,467 students aged 8-17) were overweight/obese. After adjusting covariates, SSB consumption or inadequate MVPA was associated with overweight/obesity (OR = 1.05, 95% CI = 1.02-1.07; and OR = 1.07, 95% CI = 1.03-1.10). In comparison to students with "no SSB consumption and adequate MVPA", those with "SSB consumption and inadequate MVPA" had a higher risk of being overweight/obese (OR = 1.13, 95% CI = 1.08-1.18). Regardless of age and gender subgroups, the correlation of SSB and MVPA alone and together with being overweight/obese was generally similar, with the adolescent group aged 13-17 years (OR = 1.15, 95% CI = 1.09-1.22) and females (OR = 1.09, 95% CI = 1.02-1.17) being more susceptible. Moreover, there was a significant interaction between SSB consumption and gender (p < 0.001), as well as between SSB consumption and inadequate MVPA (p = 0.008). Hence, SSB consumption in students is significantly associated with overweight/obesity, especially when MVPA is inadequate. In light of the rapidly expanding childhood and adolescent obesity epidemic, proper attention should be given to these modifiable behaviors, particularly SSB and MVPA.

The status and childcare management of overweight and obesity among preschool children in Hangzhou

OBJECTIVES

This study aims to investigate the prevalence of overweight and obesity in preschool children in Hangzhou and assess the impact of childcare management. By examining the characteristics and predicting the trends of overweight and obesity, we hope to emphasize the significance of childcare management in primary community health service centers and the use of Electronic Health-care System in kindergartens. This study also seeks to provide evidence for intervention measures and effective prevention and control management of childhood obesity.

METHODS

From 2020 to 2022, kindergarten children aged 3-6 years old were selected as the research objects in kindergartens in Hangzhou. The Electronic Health-care System will be utilized to facilitate the management of childhood obesity and provide guidance and training to pediatricians and Primary Care Physicians.

RESULTS

The overall detection rates of overweight and obesity were 7.27 % and 3.55 %, respectively, among children aged 3-6 years in Hangzhou. The rates of simple obesity in Hangzhou preschool children aged 3-6 years were 4.25 , 3.42, and 3.04 % from 2020 to 2022, respectively; the overweight detection rates of children were 8.27 , 7.28, and 6.34 %, respectively, and the difference was statistically significant (p<0.05). The detection rates of overweight and obesity in 2022 were significantly lower than those in 2020 (p<0.05). The prevalence of obesity in children increased with age. Boys had a significantly higher incidence rate of obesity than girls (p<0.05). The proportion of children with moderate and severe obesity showed a downward trend. Intervention measures for childhood obesity in primary community health service centers and kindergartens are constantly being implemented.

CONCLUSIONS

The prevalence of obesity in preschool children aged 3-6 years in Hangzhou exhibited a decreasing tendency. This research has identified that child care administration, particularly the implementation of the Electronic Health-care System, demonstrates effectiveness in handling overweight and obesity amongst children.

Association of Peer Network with Childhood Obesity in DECIDE-Children Program

Some studies have found associations between the peer network and childhood obesity. The present study aimed to analyze the association of the peer network with obesity-related cognition, behaviors and adiposity indicators, and explore whether peer network influences the effect of a childhood-obesity intervention. Based on DECIDE-Children, 1392 children's friendship nominations within the class were collected and peer network indicators including the network size, network density, and in- and out-degree centrality were calculated. The linear mixed model was used to analyze the association between peer network indicators and children's cognition, behaviors and adiposity indicators (body mass index (BMI), BMI z score, the prevalence of overweight and obesity). Children with a higher in-degree centrality had 34.4% (95%CI: 17.4% to 48.1%) lower risk of overweight or obesity. The baseline degree centrality was inversely associated with the BMI and BMI z score at the end of the trial. For each unit increase in in-degree centrality at baseline, the BMI at the end of the trial decreased by 0.047 (95%CI: 0.015 to 0.080), and the BMI z score decreased by 0.015 (95%CI: 0.003 to 0.028). Children's popularity reflected by centrality in their peer network was associated with cognition, behaviors, and adiposity indicators. Future childhood-obesity intervention research could pay more attention to socially inactive children.

Effect of a Multifaceted Intervention on Children's Body Image and the Mediating Role of Body Image in Changes in Adiposity Indicators

Besides genetic factors and energy-related behaviors, psycho-cultural factors are also important in obesity etiology. Previous studies have suggested that improving body image might be an effective method for managing body weight. Thus, this study aimed to evaluate the effects of a multifaceted intervention on the body image of children and explore whether body image played a mediating role in changes in adiposity indicators. This study was embedded in a cluster randomized controlled trial, involving 1287 children from 24 primary schools in three cities in China (Beijing, Changzhi and Urumqi). The 9-month multifaceted intervention on childhood obesity included five components (three targeted children and two targeted environments), and randomization was performed by an independent person who was blinded to the schools. Two indicators (body size perception and body size expectation) were chosen to characterize body image and were measured by Ma figural stimuli at baseline and the end of the trial. Changes in body image indicators were classified as conducive to weight loss or not. Other anthropometric measures and self-reported behaviors were also collected at both time points. Generalized linear mixed models were used in the analyses. Compared to the controls (n = 648), the proportion of body size perception conducive to weight loss increased in the intervention group (n = 639), with an odds ratio of 2.42 (95%CI: 1.70~3.45, p < 0.001). The proportion of body size expectation conducive to weight loss also increased more in the intervention group than in the controls (OR = 1.74, 95%CI: 1.14~2.66, p = 0.010). In children whose baseline nutritional status was "normal weight with higher BMI" or "overweight/obese", the improvements in body size perception and body size expectation partly mediated the association between the intervention and changes in BMI, BMI Z score, waist circumference and body fat percentage (p < 0.05). This multifaceted study effectively improved the body image of children, which, in turn, led to beneficial changes in adiposity indicators. For the first time, body size perception and body size expectation have been confirmed to be important factors associated with the beneficial effect of a childhood obesity intervention, suggesting that body image components should be generalized in the future.

Building a prototype of a continence goal-selection tool for children with spina bifida: Patient, parental and urology provider recommendations

INTRODUCTION

No tools exist to help children with spina bifida (SB) describe their incontinence concerns and to help their providers account for them when evaluating management success. Our aim was to understand patients', parents', and clinicians' preferences about how a SB continence goal-selection tool (MyGoal-C) should look and function, and to create a tool prototype.

METHODS

We used a qualitative research approach integrated with human-centered design methods. We recruited children with SB (8-17 years old), parents ( ≥ 18 years old) of children with SB (8-17 years old) in clinic and online, and urology healthcare providers at our institution. We surveyed children and parents, and conducted parent and provider Zoom-based prototyping sessions to iteratively design the app. Design researchers analyzed online activities using affinity diagramming, group analysis and modeling activities. Provider sessions were analyzed with qualitative thematic analysis based on grounded theory. Recruitment continued until saturation was reached.

RESULTS

Thirteen children with SB participated (median age: 10 years old, 4 female, 9 shunted, 10 using bladder catheterizations). Thirty-seven parents participated (33 mothers, median age: 43 years old). Children and parents unanimously recommended an app and their comments generated 6 major theme domains: goal-setting process, in-app content, working toward goals, urology provider check-in, app customization, and using big data to improve future functionality. Twenty-one of the parents participated in 3 prototyping sessions with 6 breakout groups. The remaining 16 parents and 13 children then completed the Prototype Testing Survey, leading to a refined prototype and a visual flow map of the app experience (Figure). Feedback from 11 urology healthcare providers (7 female, 6 advanced practice providers) generated 8 themes: patient engagement/autonomy, clearly displaying results, integration into clinic workflow, not increasing clinical staff burden, potential clinician bias, parental involvement, limitations of the app, and future app adaptation. These cumulative data allowed for a construction of a final app prototype.

COMMENT

Findings of our study lay the foundation for creating a goal-selection app that meets preferences and needs of children, parents, and providers. Next steps involve building the app, testing its usability and assessing it prospectively in a clinical setting.

CONCLUSIONS

Children with SB and parents preferred an app to help them set and track continence goals. All stakeholders, including urology providers, offered complementary and mutually reinforcing feedback to guide the creation of an app prototype that would ultimately be integrated into a clinic visit.

An mHealth-based school health education system designed to scale up salt reduction in China (EduSaltS): A development and preliminary implementation study

Background

High-salt diet is an important risk factor for several non-communicable diseases. School-based health education has been found effective in reducing salt intake among children and their families in China. However, no such interventions have been scaled up in the real world. For this purpose, a study was launched to support the development and scale-up of an mHealth-based system (EduSaltS) that integrated routine health education and salt reduction and was delivered through primary schools. This study aims to elaborate the framework, development process, features, and preliminary scaling-up of the EduSaltS system.

Methods

The EduSaltS system evolved from previously successfully tested interventions to reduce family salt intake by empowering schoolchildren through school health education. EduSaltS was designed by following the WHO's conceptual framework for developing a scaling-up strategy which accounted for the nature of the innovation, the capacity of the implementing organizations, the characteristics of the environment, the resources available, and type of scaling up. The system was then developed step by step from determination of online platform architecture, definition of component interventions and activities, development of specific educational materials and tools, to the development of the online/offline hybridized system. The system was tested and refined by a pilot in two schools and a preliminary scale-up in two cities in China.

Results

EduSaltS was developed as an innovative health education system, including an online WeChat-based education platform, a set of offline activities, and an actual administrative website showing the progress and setting the system. The WeChat platform could be installed on users' smartphones to automatically deliver 20 sessions of five-minute well-structured cartoon video classes, followed by other online interactive activities. It also helps support project implementation and real-time performance evaluation. As a first-stage roll-out, a one-year course has been successfully implemented among 54,538 children and their families from 209 schools in two cities, and the average course completion rate was 89.1%.

Conclusion

As an innovative mHealth-based health education system, EduSaltS was developed based on successfully tested interventions and an appropriate framework for scaling up. The early-stage roll-out has shown its preliminary scalability, and further evaluation is ongoing.

Prediction of body fat increase from food addiction scale in school-aged children and adolescents: A longitudinal cross-lagged study

Objective

Food addiction (FA) is associated with a higher body mass index z-score (BMIZ) in children and adolescents; however, whether these two aspects evolve interdependently remains unknown. This study aimed to address this question using a cross-lagged study.

Methods

Weight status, including BMIZ, fat content (FC), and visceral fat level (VFL), was determined in 880 children and adolescents (mean age = 14.02 years [range = 8.83-17.52 years]) at two-time points with an interval of 6 months. FA was characterized using the Chinese version of the dimensional Yale Food Addiction Scale for Children 2.0. Furthermore, FC and VFL were measured using direct segmental multi-frequency bioelectrical impedance analysis at each time point.

Results

Higher FA was associated with increased BMIZ, FC, and VFL (P < 0.05). FA at T0 could predict increased FC at T1 (P < 0.05). The characteristics of females, primary students, and living in urban areas may aggravate the adverse effect of FA on weight status over time and age, particularly the increased VFL in participants aged > 14 years.

Conclusion

Children and adolescents with a high FA level were at risk for weight gain attributed to increased FC, and the adverse effect could be aggravated with time and age. Novel FA-targeting interventions may help mitigate the risk of getting obesity.

School Gardening, Cooking and Sports Participation Intervention to Improve Fruits and Vegetables Intake and Moderate-to-Vigorous Physical Activity among Chinese Children: Study Protocol for a Cluster Randomized Controlled Trial

Inadequate intake of fruits and vegetables (FV) and moderate-to-vigorous physical activity (MVPA) in children has become a global public health problem. Therefore, school-based gardening and cooking (SGC) and sports participation (SP) interventions may be effective in improving children's FV intake and MVPA. The aim of this study is to develop and evaluate the effectiveness of SGC and SP interventions on FV intake and MVPA among Chinese children. In this cluster randomized controlled trial study, 237 children in grades 4-5 from six public primary schools from Changsha, Hunan Province, China will be randomly assigned to: (1) a SGC and SP combined intervention group; (2) a SP intervention group; (3) a regular practice group. The intervention clusters will be implemented for a period of 6 months and follow up will be carried out after 12 months. The outcome will be collected using a combination of self-reported and objective measures. Primary outcomes will include children's FV intake and duration of MVPA per day, and secondary outcomes will included frequency and attitudes of FV intake and SP, in addition to other measures. Finally, a process evaluation will be used to analyze the facilitators and barriers to intervention implementation. Trial Registration: (Registration Number: ChiCTR2200064141).

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to ‘over’ nutrition versus ‘under’ nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.

Effects of Family-Based Interventions Using Mobile Apps on Youth’s Physical Activity: A Systematic Review

Objective. This review synthesized the currently available literature on the effects of family-based interventions using smartphone apps on youth physical activity. Design. Systematic review. Data Sources. 1037 studies from eight databases were retrieved. Eligibility Criteria for Selecting Studies. The seven articles included in this review met the following inclusion criteria: (1) experimental studies, (2) using smartphone apps, and (3) involving families with healthy children/adolescents. Results. Studies were stratified according to whether they used smartphone apps only or the combination of sports wearables and their associated companion app. The smartphone app interventions showed significant improvements in youth’s PA levels. All but one of the studies reported no significant improvement in PA levels after the intervention. However, positive PA-related outcomes were found, and the combination of sports wearables and their associated companion app showed inconclusive results due to the small number of studies. A trend of the relevance of families in improving the PA levels of youths was found. Conclusions. The findings of this review indicate that more research is needed on the effects of family-based interventions using mobile apps on youth’s physical activity. Mixed results were found for variables related to the PA of the youth involved in these programs. Although strong evidence was found that youth’s physical activity levels do not always improve with the implementation of these programs, promising results were found for a positive impact on different variables related to physical activity. Therefore, more experimental studies using only a mobile app to promote PA as the main outcome are needed to understand the real effect of mobile apps on youth’s PA levels. Future studies need to further explore this topic by developing programs based on designs of high methodological quality.

The Effect of a Multifaceted Intervention on Dietary Quality in Schoolchildren and the Mediating Effect of Dietary Quality between Intervention and Changes in Adiposity Indicators: A Cluster Randomized Controlled Trial

Some studies have found associations between dietary quality and obesity and their concurrent changes were observed in a few interventions. The present study aimed to assess the effect of a multifaceted intervention for childhood obesity on dietary quality and examine the mediating effect of dietary quality between the intervention and changes in adiposity indicators. Based on the social ecological model, the cluster randomized controlled trial included five components (three targeted children and two targeted their environment). In total, 1176 children from three cities in China participated in a baseline (2018) and end-of-trial (2019) examination, including 605 children in the intervention group and 571 in the control group. Self-reported behavior and anthropometric measures were collected at both time points. The Diet Balance Index Revision (DBI-07) was calculated to assess dietary quality. Generalized linear mixed models were used to estimate the intervention effect on dietary quality and its mediating effects were examined. Compared to the controls, the proportion of sugar-sweetened beverage (SSB) intake (OR = 0.27, p < 0.001, corrected p < 0.001) decreased in the intervention group. Higher bound scores (HBS) of the DBI-07 indicating over-intake decreased in the intervention group compared to the controls (mean difference = −1.52, p = 0.005, corrected p = 0.015). Changes in the HBS partially mediated the associations between the intervention and changes in body mass index, waist circumference, and body fat percentage. Future intervention should promote knowledge, attitudes, and behaviors related to dietary quality.

The Relationship Between Exercise Intention and Exercise Behavior of Junior School Students: An Analysis of Chain Mediating Effect

Objective

This study explores the relationship between exercise intention and exercise behavior and constructs a chain mediating model through the mediating effect of implementation intention and self-identity.

Method

Through the stratified cluster sampling method, 1,573 junior school students (with an average age of 13.71 ± 0.891 years) were evaluated by the exercise intention scale, the implementation intention scale, the self-identity scale, and the physical exercise grade scale. For data analysis, the common method deviation test, Pearson correlation analysis, and Model 6 in the SPSS macro program compiled by Hayes for the chain mediating test were conducted.

Results

(1) There is a marked correlation between positive exercise intention and exercise behavior (r = 0.345, p < 0.01), and exercise intention has a significant effect on the direct path of exercise behavior (β = 0.162, t = 12.355, p < 0.01). (2) Exercise intention can positively predict implementation intention (β = 0.219, t = 10.006, p < 0.01) and self-identity (β = 0.160, t = 16.159, p < 0.01); implementation intention can significantly and positively predict exercise behavior (β = 0.230, t = 12.742, p < 0.01),and self-identity can significantly and positively predict exercise behavior (β = 0.273, t = 7.911, p < 0.01). (3) Implementation intention and self-identity play a significant mediating role between exercise intention and exercise behavior. The mediating effect consists of three indirect effects: exercise intention → implementation intention → exercise behavior (the mediating effect value is 0.050), exercise intention → self-identity → exercise behavior (the mediating effect value is 0.044), and exercise intention →implementation intention → self-identity → exercise behavior (the mediating effect value is 0.017).

Conclusion

(1) Exercise intention can significantly and positively predict exercise behavior. (2) Implementation intention and self-identity exert a significant mediating effect between exercise intention and exercise behavior, including the separate mediating effect of implementation intention and self-identity, as well as the chain mediating effect of implementation intention and self-identity.

Molecular and Phenotypic Expansion of Alström Syndrome in Chinese Patients

Alström syndrome (ALMS) is a rare inherited metabolic disease and ciliopathy. Large cohorts of ALMS are lacking around the world. Detailed genetic and phenotypic data were obtained from all affected individuals. Olfactory function was evaluated by the Chinese Smell Identification Test and facial pattern was analyzed with Face2gene. Fifty ALMS patients were included in this study, aged from 0.3 to 21.7 years old. Sixty-one ALMS1 variants in 50 patients from 47 different families were confirmed, including 59 truncating and two exon deletions. Twenty-four of those variants were novel. We also summarized all previously reported cases of Chinese ALMS patients (69 patients) and identified specific and common variants within the Chinese population. Besides, the Chinese Smell Identification Test scores in patients was lower than that in controls (11.97 Vs. 10.44, p < .05), indicating olfactory identification impairments in ALMS patients. The facial pattern in ALMS patients was also distinctive from that of the controls (p < .05). In conclusion, this is the largest cohort of Chinese ALMS patients. We have successfully identified both specific and common variants in our cohort. We found a new phenotype of olfactory impairments in ALMS patients through a case-control study.

Strategies and interventions for healthy adolescent growth, nutrition, and development

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.