Reliability of anthropometric measurements in European preschool children: the ToyBox-study

Reliability of Anthropometric Measurement of Young Children with Parent Involvement

Background: The purpose of this study was to determine the reliability of anthropometric measurements between two trained anthropometrists working in a team and one trained anthropometrist working with a child's parent/caregiver in a primary health care setting. Study Design: An observational study to determine measurement reliability was conducted in a primary care child research network in Canada. In total, 120 children 0-5 years old had their anthropometric measurement taken twice by two trained anthropometrists working in a team and twice by one trained anthropometrist working with a child's parent/caregiver. Inter- and intra-observer reliability was calculated using the technical error of measurement (TEM), relative TEM (%TEM), and the coefficient of reliability (R). Results: The %TEM values for length/height and weight were <2%, and the R coefficient values were >0.99, indicating a high degree of inter- and intra-observer reliability. The TEM values demonstrated a high degree of reliability for inter- and intra-observer measurement of length/height in comparison with other anthropometric measurement parameters. However, there was greater variation seen in the length measurement for children 0 to <2 years of age and in arm circumference measurement across both age-groups. Conclusion(s): This study suggests that anthropometric measurement taken by one trained anthropometrist with the assistance of a parent/caregiver is reliable. These findings provide evidence to support inclusion of a child's parent/caregiver with anthropometric measurement collection in clinical setting(s) to enhance feasibility and efficiency and reduce the research costs of including a second trained anthropometrist.

Longitudinal associations between food parenting practices and dietary intake in preschool children: The ToyBox Study

INTRODUCTION

Food Parenting Practices (FPPs) include the practices parents use in the act of feeding their children, which may further influence their health.

OBJECTIVES

To assess associations between changes in FPPs (permissiveness, food availability, guided choices, water encouragement, rules and limits and the use of food as reward) over 1 year and dietary intake (water, energy-dense/nutrient-poor and nutrient-dense foods) at follow-up in 4- to 6-year-old preschool-aged children.

METHODS

Longitudinal data from the control group of the ToyBox study, a cluster-randomized controlled intervention study, was used (NCT02116296). Multilevel ordinal logistic regression analyses including FPP as the independent variables and dietary intake as outcome.

RESULTS

Nine hundred sixty-four parent-child dyads (50.5% boys and 95.0% mothers) were included. Limited changes on the use of FPPs were observed over time. Nevertheless, in boys, often having F&V at home was associated with higher F&V consumption (OR = 6.92 [1.58; 30.38]), and increasing home availability of F&V was directly associated with higher water consumption (OR = 7.62 [1.63; 35.62]). Also, not having sweets or salty snacks available at home was associated with lower consumption of desserts (OR = 4.34 [1.75; 10.75]). In girls, having F&V availability was associated with higher F&V consumption (OR = 6.72 [1.52; 29.70]) and lower salty snack consumption (OR = 3.26 [1.50; 7.10]) and never having soft drinks at home was associated with lower consumption of sweets (OR = 7.89 [6.32; 9.86]). Also, never being permissive about soft drink consumption was associated with lower soft drink consumption (OR = 4.09 [2.44; 6.85]).

CONCLUSION

Using favorable FPPs and avoiding the negative ones is prospectively associated with healthier dietary intake, especially of F&V, and less intake of soft drinks, desserts, and salty snacks.

Statistical assessment of reliability of anthropometric measurements in the multi-site South African National Dietary Intake Survey 2022

BACKGROUND

Anthropometric data quality in large multicentre nutrition surveys is seldom adequately assessed. In preparation for the South African National Dietary Intake Survey (NDIS-2022), this study assessed site leads' and fieldworkers' intra- and inter-rater reliability for measuring weight, length/height, mid-upper arm circumference (MUAC), waist circumference (WC) and calf circumference (CC).

METHODS

Standardised training materials and measurement protocols were developed, and new anthropometric equipment was procured. Following two training rounds (12 site lead teams, 46 fieldworker teams), measurement reliability was assessed for both groups, using repeated measurements of volunteers similar to the survey target population. Reliability was statistically assessed using the technical error of measurement (TEM), relative TEM (%TEM), intra-class correlation coefficient (ICC) and coefficient of reliability (R). Agreement was visualised with Bland-Altman analysis.

RESULTS

By %TEM, the best reliability was achieved for weight (%TEM = 0.260-0.923) and length/height (%TEM = 0.434-0.855), and the poorest for MUAC by fieldworkers (%TEM = 2.592-3.199) and WC (%TEM = 2.353-2.945). Whole-sample ICC and R were excellent ( > 0.90) for all parameters except site leads' CC inter-rater reliability (ICC = 0.896, R = 0.889) and fieldworkers' inter-rater reliability for MUAC in children under two (ICC = 0.851, R = 0.881). Bland-Altman analysis revealed no significant bias except in fieldworkers' intra-rater reliability of length/height measurement in adolescents/adults ( + 0.220 (0.042, 0.400) cm). Reliability was higher for site leads vs. fieldworkers, for intra-rater vs. inter-rater assessment, and for weight and length/height vs. circumference measurements.

CONCLUSION

NDIS-2022 site leads and fieldworkers displayed acceptable reliability in performing anthropometric measurements, highlighting the importance of intensive training and standardised measurement protocols. Ongoing reliability assessment during data collection is recommended.

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Longitudinal associations between diet quality, sedentary behaviours and physical activity and risk of overweight and obesity in preschool children: The ToyBox-study

BACKGROUND

Lifestyle behaviours related to diet and physical activity are associated with increased risk of obesity and evidence suggests that associations might be stronger when a synergetic effect is examined.

OBJECTIVE

To examine the cross-sectional and longitudinal associations between diet, screen time (ST) and step recommendations and risk of overweight and obesity in European preschoolers participating in the ToyBox-study.

METHODS

In this cluster-randomized clinical trial, 718 children (51.4% boys) from six European countries participated. Parents filled out questionnaires with information on socio-demographic status, step recommendations and ST.

RESULTS

Longitudinal results indicate that participants having a low Diet Quality Index (DQI), not meeting ST and step recommendations at T0 and T1 had higher odds of having overweight/obesity at T1 (odds ratio [OR] = 1.116; 95% confidence interval [CI] = 1.104-2.562) than those children having a high DQI and meeting ST and step recommendations at T0 and T1. Similarly, participants having a high DQI, but not meeting ST and step recommendations at T0 and T1 had increased odds of having overweight/obesity (OR = 2.515; 95% CI = 1.171-3.021).

CONCLUSIONS

The proportion of participants having a low DQI, not adhering to both step and ST recommendations was very high, and it was associated with a higher probability of having overweight and obesity.

Prospective BMI changes in preschool children are associated with parental characteristics and body weight perceptions: the ToyBox-study

OBJECTIVE

To examine the effect of the intervention implemented in the ToyBox-study on changes observed in age- and sex-specific BMI percentile and investigate the role of perinatal factors, parental perceptions and characteristics on this change.

DESIGN

A multicomponent, kindergarten-based, family-involved intervention with a cluster-randomised design. A standardised protocol was used to measure children's body weight and height. Information was also collected from parents/caregivers via the use of validated questionnaires. Linear mixed effect models with random intercept for country, socio-economic status and school were used.

SETTING

Selected preschools within the provinces of Oost-Flanders and West-Flanders (Belgium), Varna (Bulgaria), Bavaria (Germany), Attica (Greece), Mazowieckie (Poland) and Zaragoza (Spain).

PARTICIPANTS

A sample of 6268 preschoolers aged 3·5-5·5 years (51·9 % boys).

RESULTS

There was no intervention effect on the change in children's BMI percentile. However, parents' underestimation of their children's actual weight status, parental overweight and mothers' pre-pregnancy overweight/obesity were found to be significantly and independently associated with increases in children's BMI percentile in multivariate modelling.

CONCLUSIONS

As part of a wide public health initiative or as part of a counseling intervention programme, it is important to assist parents/caregivers to correctly perceive their own and their children's weight status. Recognition of excessive weight by parents/caregivers can increase their readiness to change and as such facilitate higher adherence to favourable behavioural changes within the family.

Breastfeeding and Overweight in European Preschoolers: The ToyBox Study

The benefits of breastfeeding (BF) include risk reduction of later overweight and obesity. We aimed to analyse the association between breastfeeding practices and overweight/obesity among preschool children participating in the ToyBox study. Data from children in the six countries, participating in the ToyBox-study (Belgium, Bulgaria, Germany, Greece, Poland, and Spain) 7554 children/families and their age is 3.5–5.5 years, 51.9% were boys collected cross-sectionally in 2012. The questionnaires included parents’ self-reported data on their weight, height, socio-demographic status, and infant feeding practices. Measurements of preschool children’s weight and height were done by trained researchers using standard protocols and equipment. The ever breastfeeding rate in the total sample was 85.0% (n = 5777). Only 6.3% (n = 428) of the children from the general sample were exclusively breastfed (EBF) for the duration of the first six months. EBF for four to six months was significantly (p < 0.001) less likely among mothers with formal education < 12 years (adjusted Odds Ratio (OR) = 0.61; 95% Confidence interval (CI) 0.44–0.85), smoking throughout pregnancy (adjusted OR = 0.39; 95% CI 0.24–0.62), overweight before pregnancy (adjusted OR = 0.67; 95%CI 0.47–0.95) and ≤25 years old. The median duration of any breastfeeding was five months. The prevalence of exclusive formula feeding during the first five months in the general sample was about 12% (n = 830). The prevalence of overweight and obesity at preschool age was 8.0% (n = 542) and 2.8% (n = 190), respectively. The study did not identify any significant association between breastfeeding practices and obesity in childhood when adjusted for relevant confounding factors (p > 0.05). It is likely that sociodemographic and lifestyle factors associated with breastfeeding practices may have an impact on childhood obesity. The identified lower than desirable rates and duration of breastfeeding practices should prompt enhanced efforts for effective promotion, protection, and support of breastfeeding across Europe, and in particular in regions with low BF rates.

Compliance with the 24-Hour Movement Behavior Guidelines and Associations with Adiposity in European Preschoolers: Results from the ToyBox-Study

In 2019, the World Health Organization (WHO) published 24 h movement behavior guidelines for preschoolers with recommendations for physical activity (PA), screen time (ST), and sleep. The present study investigated the proportion of preschoolers complying with these guidelines (on a total week, weekdays and weekend days), and the associations with adiposity. This cross-sectional study included 2468 preschoolers (mean age: 4.75 years; 41.9% boys) from six European countries. The associations were investigated in the total sample and in girls and boys separately. PA was objectively assessed by step counts/day. Parent-reported questionnaires provided ST and sleep duration data. Generalized estimating equations were used to analyze the association between guideline compliance and adiposity indicators, i.e., body mass index (BMI) z-score and waist to height ratio (WHR). Only 10.1% of the preschoolers complied with the 24 h movement behavior guidelines, 69.2% with the sleep duration guideline, 39.8% with the ST guideline and 32.7% with the PA guideline. No association was found between guideline compliance with all three movement behaviors and adiposity. However, associations were found for isolated weekday screen time (BMI z-scores and WHR: p = 0.04) and weekend day sleep duration (BMI z-scores and WHR: p = 0.03) guideline compliance with both lower adiposity indicators. The latter association for sleep duration was also found in girls separately (BMI z-scores: p = 0.02; WHR: p = 0.03), but not in boys. Longitudinal studies, including intervention studies, are needed to increase preschoolers’ guideline compliance and to gain more insight into the manifestation of adiposity in children and its association with 24 h movement behaviors from a young age onwards.

Parental perceptions, attitudes and knowledge on European preschool children's total screen time: the ToyBox-study

BACKGROUND

Preschool children spend a significant proportion of their waking hours being sedentary. Parents play a critical role in developing and shaping their children's lifestyle behaviours, particularly in the early years of life. This study aims to assess parental perceptions, attitudes and knowledge of their preschool children's sedentary behaviours and the association with children's television (TV)/video/DVDs viewing and total screen time.

METHODS

Data were obtained from a sample of 4836 children (3.5-5.5 years), participating in the multi-centre ToyBox-study at baseline (T0) and at 1-year follow-up (T1) periods. Data on children's sedentary behaviours were collected via a standardized proxy-administered primary caregiver's questionnaire.

RESULTS

Regarding total screen time, 66.6% of the children at T0 and 71.8% at T1 in the control group exceeded the recommendations, whereas the proportion in the intervention group varied from 69.7% at T0 to 72.5% at T1. The odds of exceeding total screen time recommendations were significantly higher when parental perceptions towards limiting the total screen time were negative [(both T0 and T1 and in the intervention and control groups (P < 0.05)]. Similarly, the odds of exceeding TV/video/DVDs viewing recommendations were significantly higher (both T0 and T1 is observed in both groups) when parental knowledge of recommendation were absent.

CONCLUSIONS

Preschool children whose caregivers stated rules limiting their sedentary screen time were less likely to spend a high amount of time watching TV/video/DVDs. Interventions to increase parental practices may be a promising approach to decrease total screen time of preschool children but studies are needed to confirm this.

Integrating anthropometric and cardiometabolic health methods in stress, early experiences, and development (SEED) science

Within Stress, Early Experiences, and Development (SEED) science, there is a growing body of research demonstrating complex associations not only between stress, development, and psychopathology, but also with chronic disease risk factors. We argue that it is important for SEED researchers to consider including child anthropometric and physical health measures to more comprehensively capture processes of risk and resilience. Broader adoption of harmonized anthropometry and health measures in SEED research will facilitate collaborations, yielding larger datasets for research in high-risk populations, and greater opportunity to replicate existing findings. In this review, we identify optimal anthropometric and cardiometabolic health measurement methods used from infancy through adolescence, including those that are low-burden and inexpensive. Methods covered include: waist, hip, and head circumference, height, length, weight, pubertal development, body composition, blood pressure, arterial stiffness, carotid intima media thickness, and serum measures of cardiometabolic risk and inflammation. We provide resources for SEED researchers to integrate these methods into projects or to better understand these methods when reading the literature as well as where to find collaborators for more in-depth studies incorporating these measures. With broader integration of psychological and physical health measures in SEED research, we can better inform theory and interventions to promote health and resilience in individuals who have experienced early stress.

Complementary Feeding and Overweight in European Preschoolers: The ToyBox-Study

Complementary feeding (CF) should start between 4–6 months of age to ensure infants’ growth but is also linked to childhood obesity. This study aimed to investigate the association of the timing of CF, breastfeeding and overweight in preschool children. Infant-feeding practices were self-reported in 2012 via a validated questionnaire by >7500 parents from six European countries participating in the ToyBox-study. The proportion of children who received breast milk and CF at 4–6 months was 51.2%. There was a positive association between timing of solid food (SF) introduction and duration of breastfeeding, as well as socioeconomic status and a negative association with smoking throughout pregnancy (p < 0.005). No significant risk to become overweight was observed among preschoolers who were introduced to SF at 1–3 months of age compared to those introduced at 4–6 months regardless of the type of milk feeding. Similarly, no significant association was observed between the early introduction of SF and risk for overweight in preschoolers who were breastfed for ≥4 months or were formula-fed. The study did not identify any significant association between the timing of introducing SF and obesity in childhood. It is likely that other factors than timing of SF introduction may have impact on childhood obesity.

Prevalence and factors associated with overweight and obesity in selected health areas in a rural health district in Cameroon: a cross-sectional analysis

Background

Overweight and obesity are major public health problems worldwide, with projections suggesting a proportional increase in the number of affected individuals in developing countries by the year 2030. Evidence-based preventive strategies are needed to reduce the burden of overweight and obesity in developing countries. We assessed the prevalence of, and factors associated with overweight and obesity in selected health areas in West Cameroon.

Methods

Data were collected from a community-based cross-sectional study, involving the consecutive recruitment of participants aged 18 years or older. Overweight and obesity were defined according to the WHO classification. The statistical software R (version 3.5.1, The R Foundation for statistical computing, Vienna, Austria) was used for statistical analysis. Multivariable logistic regression analysis was used to assess independent factors associated with overweight and obesity, and obesity.

Results

Records of 485 participants were included for analysis. The age and sex-standardized prevalence of overweight, obesity, and overweight and obesity were 31.1% (95% CI, 27.0–35.2), 18.9% (95% CI, 14.9–22.9), and 50.1% (95% CI, 45.7–54.6), respectively. In multivariable analysis, being female (adjusted OR [aOR] = 2.79, 95% CI = 1.69–4.63), married (aOR = 3.90, 95% CI = 2.23–6.95), and having secondary or tertiary education (aOR = 3.27, 95% CI = 1.77–6.17) were associated with higher odds of overweight and obesity, while current smokers had lower odds of overweight and obesity (aOR = 0.37, 95% CI = 0.16–0.82) when compared to their respective counterpart. Compared to their respective reference categories, being female being (aOR = 3.74, 95% CI = 2.01–7.30), married (aOR = 2.58, 95% CI = 1.37–5.05) and having secondary or tertiary education (aOR = 2.03, 95% CI = 1.00–4.23) were associated with higher odds of obesity after adjustments for confounding.

Conclusion

We observed a high prevalence of overweight and obesity in this study. The odds of overweight and obesity was higher in females, married participants, and those with higher levels of education. Community-based interventions to control overweight and obesity should consider targeting these groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10403-w.

Prediction of clinical height gain from surgical posterior correction of idiopathic scoliosis

OBJECTIVE

The best predictors of height gain due to surgical correction are the number of fused vertebrae and the degrees of the corrected Cobb angle. Existing studies of predictive models measured the radiographic spinal height and did not report the clinical height gain. The aims of this study were to determine the best predictive factors of clinical height gain before surgical correction, construct a predictive model using patient population data for machine learning, and test the performance of this model on a validation population.

METHODS

The authors reviewed 145 medical records of consecutive patients who underwent surgery that included placement of posterior spinal instrumentation and fusion for idiopathic scoliosis between 2012 and 2016. Standing and sitting clinical heights were measured before and after surgery in patients who had been surgically treated under similar conditions. Multivariate analysis was then performed and the results were used to develop a predictive model for height gain after surgery. The data from the included patients were randomly assigned to a learning set or a test set.

RESULTS

In total, 116 patients were included in the analysis, for whom the average postoperative clinical height gain in a standing position was 4.2 ± 1.8 cm (range 0-11 cm). The best prediction model was calculated as follows: standing clinical height gain (cm) = 1 - 0.023 × sitting clinical height (cm) - 0.19 × Risser stage + 0.058 × Cobb preoperative angle (°) + 0.021 × T5-12 kyphosis (°) + 0.14 × number of levels fused. In the validation cohort, 91% of the predicted values had an error of less than one-half of the actual height gain.

CONCLUSIONS

This predictive model formula for calculating the potential postoperative height gain after surgical treatment can be used preoperatively to inform idiopathic scoliosis patients of what outcomes they may expect from posterior spinal instrumentation and fusion (taking into account the model's uncertainty).

Correlates of Meeting the Physical Activity, Sedentary Behavior, and Sleep Guidelines for the Early Years among Belgian Preschool Children: The ToyBox-Study

Physical activity, sedentary behavior, and sleep guidelines for preschool children were already established and integrated into the 24 h movement behavior guidelines in 2017. The aim of the current study was to investigate correlates of meeting or not meeting the physical activity, sedentary behavior, and sleep guidelines in Belgian preschool children. In total, 595 preschool children (53.3% boys, 46.7% girls, mean age: 4.2 years) provided complete data for the three behaviors and potentially associated correlates. Physical activity was objectively measured with accelerometers. Screen time, sleep duration, and correlates were reported by parents with the use of a questionnaire. Backward logistic regression was used to identify factors associated with meeting all guidelines for weekdays and weekend days. In the final model, older preschoolers (OR = 1.89), having a normal weight compared to being underweight (OR = 0.30), having parents that do not watch a lot of television (OR = 0.99), and having a father that attained higher education (OR = 1.91) were associated with meeting all guidelines on weekdays. For weekend days, a significant association was found for attending a sports club (OR = 1.08). Overall, only a few factors were associated with meeting the guidelines. A more comprehensive measurement of preschool children’s potential correlates of physical activity, sedentary behavior, and sleep is warranted.

Intra- and inter- observer reliability of anthropometric measurements and blood pressure in primary schoolchildren and adults: the Feel4Diabetes-study

BACKGROUND

Feel4Diabetes was a large-scale, multicenter lifestyle intervention aiming to prevent type 2 diabetes among families from vulnerable population groups in six European countries (Belgium, Bulgaria, Finland, Greece, Hungary and Spain). The current study aimed to describe the process that was followed to harmonize and standardize the measurement of anthropometric (weight, height and waist circumference) and blood pressure (systolic and diastolic) indices, as well as to assess the intra- and inter- observer reliability of these measurements.

METHODS

A central training workshop was conducted prior to the baseline measurements of the Feel4Diabetes-intervention. One researcher from each intervention country, as well as 12 adults and 12 children (for the anthropometric measurements) and 21 adults (for the blood pressure measurements) participated in this workshop. Technical Error of Measurement (TEM) and reliability (%R) were calculated to assess the reliability of the indices which were assessed to evaluate the outcome of the Feel4Diabetes-intervention. The Feel4Diabetes-intervention is registered at https://clinicaltrials.gov/ (NCT02393872).

RESULTS

Intra-observer reliability was found to be higher than 99.5% for all anthropometric measurements in both children and adults. Inter-observer reliability was found to be higher than 98% regarding the anthropometric measurements, while for blood pressure measurements %R was 76.62 and 91.38% for systolic and diastolic blood pressure measurements, respectively.

CONCLUSION

The central training of the Fee4Diabetes-intervention ensured that the data collected for the outcome evaluation of the Feel4Diabetes-intervention in the six European countries at three different time points (baseline, follow-up 1 and follow-up 2) were valid and comparable.

Feasibility and Reliability of Physical Fitness Tests among Colombian Preschool Children

The aim of the study was to assess the feasibility and reliability of physical fitness field tests used in the "Fuprecol kids" study among Colombian preschool children aged 3-5 years. A total of 90 preschoolers aged 3-5 years participated in the study. Weight, height, waist circumference, cardiorespiratory fitness (CRF), musculoskeletal fitness (handgrip strength and standing broad jump), speed-agility (4 × 10 m shuttle run), and flexibility (sit and reach test) components were tested twice (two weeks apart). The feasibility of the tests (preschoolers able to complete the test) ranged from 96% in the CRF test to 100% in the musculoskeletal fitness, speed-agility, and flexibility tests. Overall, the %TEMs were 0.625% for the weight, 0.378% for the height, 1.035% for the body mass index, and 0.547 % for the waist circumference. In addition, all tests were substantial reliable, for CRF (in stages and laps, concordance correlation coefficient = 0.944 and 0.941, respectively) in both sexes and flexibility (concordance correlation coefficient = 0.949) in girls. There were no significant differences in fitness test-retest mean differences in the boys (P > 0.05), except in CRF (laps P = 0.017). In girls, there were differences in CRF (stages (P = 0.017) and laps (P= 0.013)), and flexibility (P = 0.002) variables. The results from this study indicate that the "Fuprecol kids" battery of tests, administered by physical education teachers, was reliable and feasible for measuring components of physical fitness in preschoolers in a school setting in Colombia.

Associations between Otitis media, taste sensitivity and adiposity: Two studies across childhood

BACKGROUND

Otitis media (OM), or middle ear infections, are one of the most common diseases during early childhood. OM has been linked to changes in food preferences through potential effects on taste signalling, and thereby, to increased weight.

OBJECTIVES

We investigated the associations between OM, taste sensitivity and adiposity across two studies in early childhood and conducted exploratory post-hoc analyses of sex differences.

METHODS

Study I assessed 101 children between 2 and 3 years old (59.0% boys). Children were weighed and their height was measured to estimate BMI centiles. Waist measurements were taken to calculate Waist-to-Height Ratio (WHtR). Child's taste sensitivity was assessed using Short Sensory Profile questionnaire. Study II included 95 children between 5 and 9 years old (52.9% boys). Children were weighed and their height was measured to calculate their BMI. Children took part in a Sucrose Detection Threshold (SDT) assessment to establish their taste sensitivity. In both studies parents reported child's history of OM.

RESULTS

In Study I OM was associated with higher WHtR (p=0.047), though this was observed among girls (p=0.011), but not boys (p=0.53). OM was not linked to BMI centiles or taste sensitivity (all p>0.05). In Study II children with OM history had higher BMI centiles (p=0.010), and this effect was stronger in boys (p=0.037) than girls (p=0.17). Multiple OM exposure increased the odds of overweight by 6.2 times (95%CI [1.46, 26.50]). Boys with multiple OM exposure had higher SDT (p=0.022) compared to boys not exposed to OM, akin to lower taste sensitivity. This was not observed in girls (p=0.67).

CONCLUSIONS

OM history was associated with higher BMI among 5-9 year old children and this may be linked to taste impairments. This association was not observed in 2-3 year old children. Potential sex differences in these associations require further investigation.

Combined Longitudinal Effect of Physical Activity and Screen Time on Food and Beverage Consumption in European Preschool Children: The ToyBox-Study

Lifestyle behavioral habits such as excess screen time (ST), a lack of physical activity (PA), and high energy-dense food consumption are associated with an increased risk of children being overweight or obese. This study aimed to (1) track longitudinal adherence to PA and ST recommendations at baseline (T0) and follow-up (T1) and (2) assess the association between changes in adherence to PA and ST recommendations and food and beverage consumption at follow-up. The present study included 2321 preschool children (3.5 to 6) participating in the multicenter ToyBox-study. A lineal mixed effects model was used to examine the association between different types of food and beverages and their relationship with changes in adherence to PA and ST recommendations. Approximately half of the children (50.4%) did not meet the PA and ST recommendations at both baseline and follow-up. However, only 0.6% of the sample met both PA and ST recommendations. Preschool children who met both recommendations consumed fewer fizzy drinks, juices, sweets, desserts, and salty snacks and consumed more water, fruits and vegetables, and dairy products than did those not meeting both recommendations. In conclusion, the proportion of European preschool children adhering to both PA and ST recommendations was very low and was associated with a low consumption of energy-dense foods.

Prevalence and sociodemographic correlates of overweight and obesity in a large Pan-European cohort of preschool children and their families: the ToyBox study

OBJECTIVES

Health inequalities are observed among different regions and socioeconomic groups. The present study aimed to record the prevalence of overweight and obesityamong preschoolers across six European countries in relation to sociodemographic and family factors.

METHODS

A total of 7554 preschool-aged children and their parents participated in the ToyBox-study. Children's weight and height were measured and parents self-reported their weight, height, and family sociodemographic data using questionnaires. Data were obtained in May and June 2012.

RESULTS

The prevalence of overweight and obesity ranged from 10.0% in Germany to 20.6% in Greece and was found to be higher in children from low socioeconomic status (SES) families as well as children with two overweight or obese parents. Children from low-SES families and children with overweight or obese parents were more likely to be overweight or obese compared with their peers from medium- or high-SES families or those with normal-weight parents, respectively.

CONCLUSIONS

In a large sample of European preschoolers, the prevalence of overweight and obesity was found to be higher in Southern and Eastern European countries compared with Central and Northern European countries. Higher prevalence was recorded among low-SES families and in children with overweight or obese parents, which indicates that these areas and vulnerable groups need to be prioritized to close the gap in health and social inequalities and provide more effective prevention of early childhood obesity.

Clustering of energy balance-related behaviours and parental education in European preschool children: the ToyBox study

Energy balance-related behaviours (EBRB) are established in childhood and seem to persist through to adulthood. A lower parental educational level was associated with unhealthy behavioural patterns. The aim of the study is to identify clusters of EBRB and examine their association with preschool children’s BMI and maternal, paternal and parental education. A subsample of the ToyBox study (n 5387) conducted in six European countries was used. Six behavioural clusters (‘healthy diet and low activity’, ‘active’, ‘healthy lifestyle’, ‘high water and screen time; low fruits and vegetables (F&V) and physical activity (PA)’, ‘unhealthy lifestyle’ and ‘high F&V consumers’) emerged. The healthiest group characterised by high water and F&V consumption and high PA z scores (‘healthy lifestyle’) was more prevalent among preschool children with at least one medium- or higher-educated parent and showed markedly healthier trends for all the included EBRB. In the opposite, the ‘unhealthy lifestyle’ cluster (characterised by high soft drinks and screen time z scores, and low water, F&V and PA z scores) was more prevalent among children with lower parental, paternal and maternal education levels. OR identified that children with lower maternal, paternal and parental education levels were less likely to be allocated in the ‘healthy lifestyle’ cluster and more likely to be allocated in the ‘unhealthy lifestyle’ cluster. The ‘unhealthy lifestyle’ cluster was more prevalent among children with parents in lower parental educational levels and children who were obese. Therefore, parental educational level is one of the key factors that should be considered when developing childhood obesity prevention interventions.

Perinatal and lifestyle factors mediate the association between maternal education and preschool children's weight status: the ToyBox study

OBJECTIVE

This study aimed to explore the associations among perinatal, sociodemographic, and behavioral factors and preschool overweight/obesity.

METHODS

Data were collected from 7541 European preschoolers in May/June 2012. Children's anthropometrics were measured, and parents self-reported all other data via questionnaires. Level of statistical significance was set at P ≤ 0.05.

RESULTS

Certain perinatal factors (i.e., maternal prepregnancy overweight/obesity, maternal excess gestational weight gain, excess birth weight, and "rapid growth velocity"), children's energy balance-related behaviors (i.e., high sugar-sweetened beverage consumption, increased screen time, reduced active-play time), family sociodemographic characteristics (i.e., Eastern or Southern Europe, low maternal and paternal education), and parental overweight/obesity were identified as correlates of preschoolers' overweight/obesity. Furthermore, maternal prepregnancy overweight/obesity, children's "rapid growth velocity," and increased screen time mediated by 21.2%, 12.5%, and 5.7%, respectively, the association between maternal education and preschoolers' body mass index.

CONCLUSION

This study highlighted positive associations of preschooler's overweight/obesity with excess maternal prepregnancy and gestational weight gain, excess birth weight and "rapid growth velocity," Southern or Eastern European region, and parental overweight/obesity. Moreover, maternal prepregnancy overweight/obesity, children's "rapid growth velocity," and increased screen time partially mediated the association between maternal education and preschoolers' body mass index. The findings of the present study may support childhood obesity prevention initiatives, because vulnerable population groups and most specifically low-educated families should be prioritized. Among other fields, these intervention initiatives should also focus on the importance of normal prepregnancy maternal weight status, normal growth velocity during infancy, and retaining preschool children's screen time within recommendations.

Home-based anthropometric, blood pressure and pulse measurements in young children by trained data collectors in the National Children's Study

OBJECTIVE

The current study assessed whether home-based data collection by trained data collectors can produce high-quality physical measurement data in young children.

DESIGN

The study assessed the quality of intra-examiner measurements of blood pressure, pulse rate and anthropometric dimensions using intra-examiner reliability and intra-examiner technical error of measurement (TEM).

SETTING

Non-clinical, primarily private homes of National Children's Study participants in twenty-two study locations across the USA.

SUBJECTS

Children in four age groups: 5-7 months (n 91), 11-16 months (n 393), 23-28 months (n 1410) and 35-40 months (n 800).

RESULTS

Absolute TEM ranged in value from 0·09 to 16·21, varying widely by age group and measure, as expected. Relative TEM spanned from 0·27 to 13·71 across age groups and physical measures. Reliabilities for anthropometric measurements by age group and measure ranged from 0·46 to >0·99 with most exceeding 0·90, suggesting that the large majority of anthropometric measures can be collected in a home-based setting on young children by trained data collectors. Reliabilities for blood pressure and pulse rate measurements by age group ranged from 0·21 to 0·74, implying these are less reliably measured with young children when taken in the data collection context described here.

CONCLUSIONS

Reliability estimates >0·95 for weight, length, height, and thigh, waist and head circumference, and >0·90 for triceps and subscapular skinfolds, indicate that these measures can be collected in the field by trained data collectors without compromising data quality. These estimates can be used for interim evaluations of data collector training and measurement protocols.

Utility of body mass index, waist circumference and waist-to-height ratio as screening tools for hyperglycemia in young people

OBJECTIVES

To evaluate the ability of BMI, WC and WHtR to discriminate hyperglycemia in young people, and to determine whether there is an increase in the accuracy with the addition of WC and/or WHtR to BMI.

SUBJECTS AND METHODS

A cross-sectional study was conducted on 1,139 schoolchildren aged 6 to 17 years from Northeastern Brazil. Body weight, height, WC and fasting glucose levels were measured, and the BMI and WHtR were calculated. The presence of hyperglycemia was defined as a fasting glucose level ≥ 100 mg/dL.

RESULTS

The prevalence of hyperglycemia was 6.6%. Strong correlations were observed between the anthropometric indicators studied (BMI vs. WC = 0.87; BMI vs. WHtR = 0.87; WC vs. WHtR = 0.90). Hyperglycemia was more likely to be present in young people with excess weight (PR = 1.70), high WC (PR = 1.85), and high WHtR (PR = 1.91). The accuracies to discriminate hyperglycemia were significant, but low, for the individual (BMI = 0.56; WC = 0.53; WHtR = 0.55) and combined indicators (BMI + WC = 0.55; BMI + WHtR = 0.55).

CONCLUSION

Our findings do not support the use of BMI, WC or WHtR as screening tools for hyperglycemia in children and adolescents.

A systematic review of methods to assess intake of sugar-sweetened beverages among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

OBJECTIVE

Research indicates that intake of sugar-sweetened beverages (SSB) may be associated with negative health consequences. However, differences between assessment methods can affect the comparability of intake data across studies. The current review aimed to identify methods used to assess SSB intake among children and adults in pan-European studies and to inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies.

DESIGN

A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed SSB consumption were included in the review.

SETTING

Studies involving two or more European countries were included in the review.

SUBJECTS

Healthy, free-living children and adults.

RESULTS

The review identified twenty-three pan-European studies which assessed intake of SSB. The FFQ was the most commonly used (n 24), followed by the 24 h recall (n 6) and diet records (n 1). There were several differences between the identified FFQ, including the definition of SSB used. In total, seven instruments that were tested for validity were selected as potentially suitable to assess SSB intake among adults (n 1), adolescents (n 3) and children (n 3).

CONCLUSIONS

The current review highlights the need for instruments to use an agreed definition of SSB. Methods that were tested for validity and used in pan-European populations encompassing a range of countries were identified. These methods should be considered for use by future studies focused on evaluating consumption of SSB.

Clinical height measurements are unreliable: a call for improvement

Height measurements are currently used to guide imaging decisions that assist in osteoporosis care, but their clinical reliability is largely unknown. We found both clinical height measurements and electronic health record height data to be unreliable. Improvement in height measurement is needed to improve osteoporosis care.

INTRODUCTION

The aim of this study is to assess the accuracy and reliability of clinical height measurement in a university healthcare clinical setting.

METHODS

Electronic health record (EHR) review, direct measurement of clinical stadiometer accuracy, and observation of staff height measurement technique at outpatient facilities of the University of Wisconsin Hospital and Clinics. We examined 32 clinical stadiometers for reliability and observed 34 clinic staff perform height measurements at 12 outpatient primary care and specialty clinics. An EHR search identified 4711 men and women age 43 to 89 with no known metabolic bone disease who had more than one height measurement over 3 months. The short study period and exclusion were selected to evaluate change in recorded height not due to pathologic processes.

RESULTS

Mean EHR recorded height change (first to last measurement) was -0.02 cm (SD 1.88 cm). Eighteen percent of patients had height measurement differences noted in the EHR of ≥2 cm over 3 months. The technical error of measurement (TEM) was 1.77 cm with a relative TEM of 1.04 %. None of the staff observed performing height measurements followed all recommended height measurement guidelines. Fifty percent of clinic staff reported they on occasion enter patient reported height into the EHR rather than performing a measurement. When performing direct measurements on stadiometers, the mean difference from a gold standard length was 0.24 cm (SD 0.80). Nine percent of stadiometers examined had an error of >1.5 cm.

CONCLUSIONS

Clinical height measurements and EHR recorded height results are unreliable. Improvement in this measure is needed as an adjunct to improve osteoporosis care.

A systematic review of methods to assess intake of fruits and vegetables among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

Objective

Evidence suggests that health benefits are associated with consuming recommended amounts of fruits and vegetables (F&V), yet standardised assessment methods to measure F&V intake are lacking. The current review aims to identify methods to assess F&V intake among children and adults in pan-European studies and inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies.

Design

A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed F&V intake were included in the review.

Setting

Studies involving two or more European countries were included in the review.

Subjects

Healthy, free-living children or adults.

Results

The review identified fifty-one pan-European studies which assessed F&V intake. The FFQ was the most commonly used (n42), followed by 24 h recall (n11) and diet records/diet history (n7). Differences existed between the identified methods; for example, the number of F&V items on the FFQ and whether potatoes/legumes were classified as vegetables. In total, eight validated instruments were identified which assessed F&V intake among adults, adolescents or children.

Conclusions

The current review indicates that an agreed classification of F&V is needed in order to standardise intake data more effectively between European countries. Validated methods used in pan-European populations encompassing a range of European regions were identified. These methods should be considered for use by future studies focused on evaluating intake of F&V.

Diet quality in European pre-schoolers: evaluation based on diet quality indices and association with gender, socio-economic status and overweight, the ToyBox-study

OBJECTIVE

To study diet quality among pre-schoolers using the Diet Quality Index (DQI) and to investigate differences according to gender, socio-economic status (SES) and overweight/obesity status.

DESIGN

Kindergarten-based cross-sectional survey within the ToyBox-study. A standardized protocol was used and parents/caregivers self-reported sociodemographic data and a semi-quantitative FFQ. A total DQI and its four subcomponents (diversity, quality, equilibrium and meal index) were calculated based on this FFQ. High total DQI scores indicate better diet quality than low scores. Results of the total DQI and the subcomponents were reported as percentages of maximum scores (100 %).

SETTING

Kindergartens in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain).

SUBJECTS

European pre-schoolers (aged 3·5-5·5 years) and their parents/caregivers (n 7063).

RESULTS

The mean total DQI score was 68·3 %. Mean scores of the subcomponents were 61·7 % for diversity, 56·5 % for quality, 65·4 % for equilibrium and 89·7 % for the meal index. Pre-schoolers of lower-SES backgrounds had lower scores on the total DQI and all its subcomponents. No clear differences were found by gender and overweight status. Results differed slightly according to country.

CONCLUSIONS

Pre-schoolers scored low on the total DQI and especially on dietary quality, as energy-dense, low-nutritious food items were more often consumed than highly nutritious food items. Furthermore, already in pre-schoolers lower-SES mothers were less likely to provide a good diet quality and this was consistent for all four subcomponents of the total DQI. Food intake in pre-schoolers should be enhanced, especially in pre-schoolers of lower-SES backgrounds.

Associations between food and beverage consumption and different types of sedentary behaviours in European preschoolers: the ToyBox-study

OBJECTIVE

To examine the association between food and beverage consumption and time spent in different sedentary behaviours such as watching TV and DVDs, playing computer/video games and quiet play/activities in preschoolers.

METHODS

A sample of 6431 (51.8 % males) European preschoolers aged 3.5-5.5 years from six survey centres was included in the data analyses. Data on dietary habits and sedentary behaviours [watching TV, playing computer and quiet play (both during weekdays and weekend days)] were collected via standardized proxy-administered questionnaires. One-way analysis of covariance and general linear model (adjusted for sex, maternal education, body mass index and centre) were conducted.

RESULTS

The results of the generalized linear model showed that the more strong associations in both males and females who were watching TV for > 1 h/day during weekdays were positively associated with increased consumption of fizzy drinks (β = 0.136 for males and β = 0.156 for females), fresh and packed juices (β = 0.069, β = 0.089), sweetened milk (β = 0.119, β = 0.078), cakes and biscuits (β = 0.116, β = 0.145), chocolate (β = 0.052, β = 0.090), sugar-based desserts and pastries (β = 0.234, β = 0.250), salty snacks (β = 0.067, β = 0.056), meat/poultry/processed meat (β = 0.067, β = 0.090) and potatoes (β = 0.071, β = 0.067), and negative associations were observed for the consumption of fruits (β = -0.057, β = -0.099), vegetables (β = -0.056, β = -0.082) and fish (β = -0.013, β = -0.013). During weekend days, results were comparable.

CONCLUSIONS

In European preschoolers, sedentary behaviours were associated with consumption of energy-dense foods and fizzy drinks. The present findings will contribute to improve the strategies to prevent overweight, obesity and nutrition-related chronic diseases from early childhood.

Health Related Behaviours in Normal Weight and Overweight Preschoolers of a Large Pan-European Sample: The ToyBox-Study

The aim of this study was to investigate the associations of health related behaviours (HRB) with Body Mass Index (BMI) in preschoolers, and to study the likelihood of being overweight/obese in relation to compliance with recommended HRB. The sample consisted of 3301 normal weight and overweight/obese preschoolers (mean age: 4.7 years; 52% boys, 85% normal weight) from six European countries (Belgium, Bulgaria, Germany, Greece, Poland, Spain). Height and weight were measured, total daily step counts were registered during six days, and HRB were assessed with validated parental surveys in 2012. Multiple linear and logistic regression analyses were performed. Only few HRB were significantly associated with BMI. In boys, higher water intake and higher soft drink and higher fruit consumption were significantly associated with higher BMI. Boys drinking less water than recommended were less likely to be overweight/obese (OR = 0.60), while boys who consume soft drinks were more likely to be overweight/obese (OR = 1.52). In girls, higher water intake, higher vegetable consumption, and more TV time on weekend days were significantly associated with higher BMI. Girls eating less vegetables than recommended were less likely to be overweight/obese (OR = 0.62), and girls who engaged in quiet play for more than 90 minutes on weekend days were more likely to be overweight/obese (OR = 1.64). In general, the associations between HRB and BMI or being overweight/obese were limited and mainly related to dietary intake. Awareness campaigns for caregivers should stress that HRB of young children are important and independent of children’s weight status.

Body mass index and treatment outcomes following neoadjuvant therapy in women aged 45 y or younger: Evidence from a historic cohort

PURPOSE

Large and consistent evidence supports the role of body mass index (BMI) as a prognostic and predictive indicator in breast cancer. However, there is paucity of data specifically referred to women diagnosed at a young age across the different disease settings. We investigated the impact of BMI on treatment outcomes in 86 breast cancer patients aged 45 y or less treated with neoadjuvant chemotherapy (CT) followed by surgery.

METHODS

Pathologic complete response (pCR) was defined as the eradication of cancer from both breast and lymph nodes. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier product-limit method. Curves were compared by long rank test for significance. Potential predictors of survival were tested in Cox models.

RESULTS

We observed a pCR in 19 patients (22%). Lower values of BMI were more commonly associated with pCR (p = 0.05). Results from univariate, but not multivariate, models were somewhat supportive of higher pCR rates in leaner women (p = 0.06). None of the variables impacted DFS. OS was longer in leaner patients (medians and 95%CI: 74.6 months, 66.2-82.9 and 58.5 months, 49.6-67.4, p = 0.009). Longer OS was also related to lower T-stage, adjuvant radiotherapy (RT), and non triple negative (TN) subtype (p = 0.046, p = 0.024, and p = 0.015, respectively). Cox models confirmed the protective role of lower BMI (Hazard Ratios: 0.30, 95%CI: 0.12-0.71, p = 0.007), non TN subtype and adjuvant RT (p = 0.008 and p = 0.024).

CONCLUSIONS

In young breast cancer patients treated with neoadjuvant CT followed by surgery, lower values of BMI are associated with longer OS. Our data also showed longer OS in association with a non TN molecular subtype and adjuvant RT. The modifiable nature of BMI and aggressive biologic behavior of the disease diagnosed at a young age encourage further studies to corroborate our findings.

The effect of a cluster randomised control trial on objectively measured sedentary time and parental reports of time spent in sedentary activities in Belgian preschoolers: the ToyBox-study

BACKGROUND

In preschoolers, high levels of sedentary behaviour are associated with several adverse health outcomes. The purpose of this study is to report the effects of the ToyBox-intervention (a European 24-week cluster randomised controlled trial) on sedentary behaviour in preschoolers.

METHODS

In Belgium, 859 preschoolers from 27 kindergartens (15 intervention and 12 control) wore an accelerometer to objectively measure their sedentary time and 1715 parents/caregivers completed a questionnaire to assess sedentary activities in which preschoolers participate at home. Main outcomes were objectively measured sedentary time, time spent watching TV, using the computer and time spent in quiet play. Multilevel repeated measures analyses were conducted to take clustering into account. Intention to treat analysis was used to handle missing data.

RESULTS

A sample of 859 (29.5% of all contacted children) preschoolers (4.4 ± 0.6 years, 54.4% boys) provided valid accelerometer data at either baseline or follow-up and parents of 1715 (58.9% of all contacted children) preschoolers (4.4 ± 0.5 years, 52.5% boys) completed a questionnaire at either baseline or follow-up. No intervention effects were found on objectively and subjectively measured total sedentary time in the total sample. However, some effects on objectively and subjectively measured sedentary time were found in specific subgroups. Preschoolers from the intervention group from high SES kindergartens and preschoolers with high levels of sedentary time at baseline decreased their sedentary time, while preschoolers from the control group increased their sedentary time. Girls in the intervention group decreased their TV viewing time during weekend days (-5.83 min/day), while girls' &TV viewing in the control group increased (+4.15 min/day). In low SES kindergartens, a smaller increase for computer time during weekend days was found in preschoolers in intervention kindergartens (+6.06 min/day) than in control kindergartens (+12.49 min/day).

CONCLUSION

While some small positive effects were found in some sub-groups, the ToyBox-intervention had no effect on objectively and subjectively measured sedentary time in the total sample. A longer period to implement the intervention and a more active involvement of parents/caregivers might enhance intervention effects. The ToyBox-study is registered with the clinical trials registry clinicaltrials.gov, ID: NCT02116296.

Water intake and beverage consumption of pre-schoolers from six European countries and associations with socio-economic status: the ToyBox-study

OBJECTIVE

To study the quantity and quality of water intake from beverages among pre-schoolers and investigate associations with gender and socio-economic status (SES).

DESIGN

Kindergarten-based cross-sectional survey within the large-scale European ToyBox-study. A standardized protocol was used and parents/caregivers filled in sociodemographic data and a semi-quantitative FFQ.

SETTING

Kindergartens in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain).

SUBJECTS

European pre-schoolers (aged 3·5-5·5 years) and their parents/caregivers (n 7051).

RESULTS

Mean water intake was 1051 ml/d; plain water, 547 ml/d; plain milk, 241 ml/d; other fruit juice, 104 ml/d; pure fruit juice, 59 ml/d; soft drinks, 55 ml/d; tea, 45 ml/d; sugared and chocolate milk, 37 ml/d; smoothies, 15 ml/d; and light soft drinks, 6 ml/d. Boys had a higher water intake than girls due to a higher consumption of plain water, but more importantly to the consumption of beverages of less quality. Lower-SES pre-schoolers scored better on quantity than high-SES pre-schoolers, but as a consequence of consumption of sugared beverages. Nevertheless, the associations differed by country.

CONCLUSIONS

The water intake from beverages did not meet the European Food Safety Authority standard of 1280 ml/d; especially in Western European countries water intake from beverages was low. The most important water sources were plain water, milk and fruit juices. Interventions aiming at a proper and sufficient water intake should focus on both quantity and quality. Messages about water and water sources should be clear for everyone and interventions should be sufficiently tailored.

Reliability of Health-Related Physical Fitness Tests among Colombian Children and Adolescents: The FUPRECOL Study

Substantial evidence indicates that youth physical fitness levels are an important marker of lifestyle and cardio-metabolic health profiles and predict future risk of chronic diseases. The reliability physical fitness tests have not been explored in Latino-American youth population. This study’s aim was to examine the reliability of health-related physical fitness tests that were used in the Colombian health promotion “Fuprecol study”. Participants were 229 Colombian youth (boys n = 124 and girls n = 105) aged 9 to 17.9 years old. Five components of health-related physical fitness were measured: 1) morphological component: height, weight, body mass index (BMI), waist circumference, triceps skinfold, subscapular skinfold, and body fat (%) via impedance; 2) musculoskeletal component: handgrip and standing long jump test; 3) motor component: speed/agility test (4x10 m shuttle run); 4) flexibility component (hamstring and lumbar extensibility, sit-and-reach test); 5) cardiorespiratory component: 20-meter shuttle-run test (SRT) to estimate maximal oxygen consumption. The tests were performed two times, 1 week apart on the same day of the week, except for the SRT which was performed only once. Intra-observer technical errors of measurement (TEMs) and inter-rater (reliability) were assessed in the morphological component. Reliability for the Musculoskeletal, motor and cardiorespiratory fitness components was examined using Bland–Altman tests. For the morphological component, TEMs were small and reliability was greater than 95% of all cases. For the musculoskeletal, motor, flexibility and cardiorespiratory components, we found adequate reliability patterns in terms of systematic errors (bias) and random error (95% limits of agreement). When the fitness assessments were performed twice, the systematic error was nearly 0 for all tests, except for the sit and reach (mean difference: -1.03% [95% CI = -4.35% to -2.28%]. The results from this study indicate that the “Fuprecol study” health-related physical fitness battery, administered by physical education teachers, was reliable for measuring health-related components of fitness in children and adolescents aged 9–17.9 years old in a school setting in Colombia.

Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children's Healthy Living Program

OBJECTIVES

Anthropometric standardization is essential to obtain reliable and comparable data from different geographical regions. The purpose of this study is to describe anthropometric standardization procedures and findings from the Children's Healthy Living (CHL) Program, a study on childhood obesity in 11 jurisdictions in the US-Affiliated Pacific Region, including Alaska and Hawai'i.

METHODS

Zerfas criteria were used to compare the measurement components (height, waist, and weight) between each trainee and a single expert anthropometrist. In addition, intra- and inter-rater technical error of measurement (TEM), coefficient of reliability, and average bias relative to the expert were computed.

RESULTS

From September 2012 to December 2014, 79 trainees participated in at least 1 of 29 standardization sessions. A total of 49 trainees passed either standard or alternate Zerfas criteria and were qualified to assess all three measurements in the field. Standard Zerfas criteria were difficult to achieve: only 2 of 79 trainees passed at their first training session. Intra-rater TEM estimates for the 49 trainees compared well with the expert anthropometrist. Average biases were within acceptable limits of deviation from the expert. Coefficient of reliability was above 99% for all three anthropometric components.

CONCLUSIONS

Standardization based on comparison with a single expert ensured the comparability of measurements from the 49 trainees who passed the criteria. The anthropometric standardization process and protocols followed by CHL resulted in 49 standardized field anthropometrists and have helped build capacity in the health workforce in the Pacific Region. Am. J. Hum. Biol. 28:364-371, 2016. © 2015 Wiley Periodicals, Inc.

Automated anthropometric phenotyping with novel Kinect-based three-dimensional imaging method: comparison with a reference laser imaging system

BACKGROUND/OBJECTIVES

Anthropometry for measuring body composition, shape, surface area and volume is important for human clinical research and practice. Although training and technical skills are required for traditional tape and caliper anthropometry, a new opportunity exists for automated measurement using newly developed relatively low-cost three-dimensional (3D) imaging devices. The aim of this study was to compare results provided by a Kinect-based device to a traditional laser 3D reference system.

SUBJECTS/METHODS

Measurements made by the evaluated device, a hybrid of commercially purchased hardware (KX-16; TC(2), Cary, NC, USA) with our additional added software, were compared with those derived by a high-resolution laser scanner (Vitus Smart XXL; Human Solutions North America, Cary, NC, USA). Both imaging systems were compared with additional linear (stadiometer-derived height) and volumetric (total volume, air-displacement plethysmography) measurements. Subjects (n=101) were healthy children (age ≥5 years) and adults varying in body mass index.

RESULTS

Representative linear (4), circumferential (6), volumetric (3) and surface area (1) measurements made by the Kinect-based device showed a consistent pattern relative to the laser system: high correlations (R(2)s= 0.70-0.99, all P<0.001); 1-3% differences for large linear (for example, height, X±s.d., -1.4±0.5%), circumferential (for example, waist circumference, -2.1±1.8%), volume (for example, total body, -0.8±2.2%) and surface area (whole-body, -1.7±2.0%) estimates. By contrast, mean measurement differences were substantially larger for small structures (for example, forearm volume, 31.3±31.4%).

CONCLUSIONS

Low-cost 3D Kinect-based imaging systems have the potential for providing automated accurate anthropometric and related body measurements for relatively large components; further hardware and software developments may be able to improve system small-component resolution.

The reliability of body mass index in the diagnosis of obesity and metabolic risk in children

BACKGROUND

Body mass index (BMI) is the most widespread and the simplest method for the evaluation of body mass; it is often used as a sole technique in the diagnosis of obesity in children. The objective of the study was to evaluate the relationship between anthropometric and biochemical parameters and the incidence of the metabolic syndrome in obese children.

METHODOLOGY

A total of 110 children, aged 2-17 years, participated in the study. No overweight children (BMI 85-95 percentiles) were included. BMI was interpreted using the 2000 Centers for Disease Control and Prevention Growth Charts. The skinfold measurements were performed using an John Bull British Indicators Ltd. calipers, and interpreted using an the reference table values.

RESULTS

In addition to lower sensitivity (mentioned in several earlier studies), BMI also shows a lower specificity in the diagnosis of obesity in children: BMI showed at least 10% of non-concomitance with skinfold thickness and waist circumferences and 8% with waist-to-height ratio. In addition, subscapular skinfold thickness, waist circumference, and waist/height ratio showed stronger correlations with serum insulin levels, low-density lipoprotein cholesterol, and family history than BMI itself.

CONCLUSION

The unreliability of BMI as the sole parameter for diagnosing obesity in children was found in our study. Even when overweight children were excluded from the study, the lack of specificity of BMI was demonstrated. We propose utilization of waist circumference and waist/height ratio along with the BMI for definitive diagnosis instead of relying on BMI only. In addition, waist circumference and subscapular fold thickness may be even better in estimation of metabolic risk than BMI.

Developing the intervention material to increase physical activity levels of European preschool children: the ToyBox-study

Early childhood is an important period for adopting positive health-related behaviours. More than 95% of European preschool children attend kindergartens, making these settings ideal for the implementation of health promotion interventions. The ToyBox-intervention addressed preschool children, their parents/caregivers and teachers. The aim of the intervention was to improve four energy balance-related behaviours (i.e. healthy snacking, water consumption, physical activity and sedentary behaviour) by implementing a kindergarten-based, family-involved intervention in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain). The intervention material was developed following the intervention mapping protocol, taking into account local and cultural differences among the intervention countries. The present paper focuses on the development of the physical activity component of the intervention. Parental involvement was addressed by providing parents/caregivers with two newsletters, two tip cards and a poster. Teachers received a handbook with guidance on environmental changes in the classroom, 26 physical education sessions and suggestions for fun, interactive classroom activities aiming at total class participation to increase preschoolers' physical activity levels. The ToyBox-intervention material was distributed according to a standard time frame. Teachers received their material prior to the start of the intervention and parents/caregivers received their material during the intervention when each energy balance-related behaviour was implemented.

Designing and implementing a kindergarten-based, family-involved intervention to prevent obesity in early childhood: the ToyBox-study

The development of the ToyBox-intervention was based on the outcomes of the preliminary phase of the ToyBox-study, aiming to identify young children's key behaviours and their determinants related to early childhood obesity. The ToyBox-intervention is a multi-component, kindergarten-based, family-involved intervention with a cluster-randomized design, focusing on the promotion of water consumption, healthy snacking, physical activity and the reduction/ breaking up of sedentary time in preschool children and their families. The intervention was implemented during the academic year 2012-2013 in six European countries: Belgium, Bulgaria, Germany, Greece, Poland and Spain. Standardized protocols, methods, tools and material were used in all countries for the implementation of the intervention, as well as for the process, impact, outcome evaluation and the assessment of its cost-effectiveness. A total sample of 7,056 preschool children and their parents/caregivers, stratified by socioeconomic level, provided data during baseline measurements and participated in the intervention. The results of the ToyBox-study are expected to provide a better insight on behaviours associated with early childhood obesity and their determinants and identify effective strategies for its prevention. The aim of the current paper is to describe the design of the ToyBox-intervention and present the characteristics of the study sample as assessed at baseline, prior to the implementation of the intervention.

Tools, harmonization and standardization procedures of the impact and outcome evaluation indices obtained during a kindergarten-based, family-involved intervention to prevent obesity in early childhood: the ToyBox-study

The ToyBox-intervention is a kindergarten-based, family-involved intervention targeting multiple lifestyle behaviours in preschool children, their teachers and their families. This intervention was conducted in six European countries, namely Belgium, Bulgaria, Germany, Greece, Poland and Spain. The aim of this paper is to provide a descriptive overview of the harmonization and standardization procedures of the baseline and follow-up evaluation of the study (and substudies). Steps related to the study's operational, standardization and harmonization procedures as well as the impact and outcome evaluation assessment tools used are presented. Experiences from the project highlight the importance of safeguarding the measurement process to minimize data heterogeneity derived from potential measurement error and country-by-country differences. In addition, it was made clear that continuing quality control and support is an important component of such studies. For this reason, well-supported communication channels, such as regular email updates and teleconferences, and regular internal and external meetings to ensure smooth and accurate implementation were in place during the study. The ToyBox-intervention and its harmonized and standardized procedures can serve as a successful case study for future studies evaluating the efficacy of similar interventions.

Applying the Intervention Mapping protocol to develop a kindergarten-based, family-involved intervention to increase European preschool children's physical activity levels: the ToyBox-study

Although sufficient physical activity is beneficial for preschoolers' health, activity levels in most preschoolers are low. As preschoolers spend a considerable amount of time at home and at kindergarten, interventions should target both environments to increase their activity levels. The aim of the current paper was to describe the six different steps of the Intervention Mapping protocol towards the systematic development and implementation of the physical activity component of the ToyBox-intervention. This intervention is a kindergarten-based, family-involved intervention implemented across six European countries. Based on the results of literature reviews and focus groups with parents/caregivers and kindergarten teachers, matrices of change objectives were created. Then, theory-based methods and practical strategies were selected to develop intervention materials at three different levels: (i) individual level (preschoolers); (ii) interpersonal level (parents/caregivers) and (iii) organizational level (teachers). This resulted in a standardized intervention with room for local and cultural adaptations in each participating country. Although the Intervention Mapping protocol is a time-consuming process, using this systematic approach may lead to an increase in intervention effectiveness. The presented matrices of change objectives are useful for future programme planners to develop and implement an intervention based on the Intervention Mapping protocol to increase physical activity levels in preschoolers.