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Hunt ET, Brazendale K, De Moraes AC, Malkani R, Heredia NI, Pfledderer CD, Brown DM, Hoelscher DM, Beets MW, Weaver RG. Physical Activity and Sedentary Time Among U.S. Adolescents Before and During COVID-19: Findings From a Large Cohort Study. AJPM FOCUS 2024; 3:100253. [PMID: 39175501 PMCID: PMC11340494 DOI: 10.1016/j.focus.2024.100253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Introduction Evidence suggests that adolescents engage in less physical activity during the summer break. Less is known regarding physical activity during the summer months of the COVID-19 pandemic. Methods Utilizing data from the Adolescent Brain Cognitive Development study, the authors examined daily activity measured by Fitbit Charge 2 devices before and after the onset of the COVID-19 pandemic during school and summer months. Linear models estimated activity during pre-COVID-19 school, pre-COVID-19 summer, COVID-19 school, and COVID-19 summer. Results Participants (N=7,179, aged 11.96 years, 51% female, 51% White) accumulated 8,671.0 (95% CI=8,544.7; 8,797.3) steps, 32.5 (95% CI=30.8, 32.3) minutes of moderate-to-vigorous physical activity, and 507.2 (95% CI=504.2, 510.2) minutes of sedentary time. During COVID-19 school, adolescents accumulated fewer daily steps and minutes of moderate-to-vigorous physical activity (-1,782.3 steps [95% CI= -2,052.7; -1,511.8] and -6.2 minutes [95% CI= -8.4, -4.0], respectively). Adolescents accumulated more minutes of daily sedentary time (29.6 minutes [95% CI=18.9, 40.3]) during COVID-19 school months than during the pre-COVID-19 school months. During pre-COVID-19 summer months, adolescents accumulated 1,255.1 (95% CI=745.3; 1,765.0) more daily steps than during COVID-19 months. Boys accumulated more daily steps and moderate-to-vigorous physical activity (2,011.5 steps [95% CI=1,271.9; 2,751.0] and 7.9 minutes [95% CI=1.4, 14.4], respectively) during the summer before COVID-19 than in summer during COVID-19. Both girls and boys accumulated more minutes of sedentary time during COVID-19 school months (47.4 [95% CI=27.5, 67.3] and 51.2 [95% CI=22.8, 79.7], respectively) than during COVID-19 summer months. Conclusions Societal restrictions during COVID-19 negatively impacted activity levels in the U.S., particularly during the summer months during COVID-19.
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Affiliation(s)
- Ethan T. Hunt
- Michael and Susan Dell Center for Healthy Living, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
- Department of Health Promotion and Behavioral Science, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
| | - Keith Brazendale
- Department of Health Sciences, UCF College of Health Professions and Sciences, University of Central Florida, Orlando, Florida
| | - Augusto C.F. De Moraes
- Michael and Susan Dell Center for Healthy Living, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
- Department of Epidemiology, Human Genetics and Environmental Science, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
| | - Raja Malkani
- Michael and Susan Dell Center for Healthy Living, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
| | - Natalia I. Heredia
- Department of Health Promotion and Behavioral Science, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
| | - Christopher D. Pfledderer
- Michael and Susan Dell Center for Healthy Living, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
- Department of Health Promotion and Behavioral Science, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
| | - Denver M. Brown
- Department of Psychology, The University of Texas at San Antonio, San Antonio, Texas
| | - Deanna M. Hoelscher
- Michael and Susan Dell Center for Healthy Living, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
- Department of Health Promotion and Behavioral Science, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Austin, Texas
| | - Michael W. Beets
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Robert G. Weaver
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
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Toomer-Mensah N, O'Neil M, Blacutt M, Quinn L. Measuring Physical Activity in Children Who Do Not Walk and With Cerebral Palsy: An Exploratory Case Series. Pediatr Phys Ther 2024; 36:353-362. [PMID: 38758603 DOI: 10.1097/pep.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
AIM The purpose of this case series was to describe physical activity (PA) amount and intensity in the home and school environment. Accelerometers and heart rate (HR) monitors are reliable and valid measures of PA in children with cerebral palsy (CP) who can walk. There is limited research on PA measures in children with CP who cannot walk. METHODS Three 9-year-old boys with CP, Gross Motor Function Classification System levels IV and V, participated in a 1-week measurement period wearing waist- and wrist-worn triaxial accelerometers to measure PA counts and a wrist-worn HR monitor to measure PA intensity. PA intensity was calculated using an estimated HR max. Accelerometer counts were reported. Parents and school staff completed activity and eating journals. RESULTS Six days of PA and HR data were analyzed. Two participants spent more time in moderate/vigorous PA intensity during school compared to at home. Activities with greatest PA intensity included oral eating, communication, and social engagement. Higher activity counts were recorded from the wrist compared with the waist accelerometers. PA and eating journal adherence were high in both settings. CONCLUSION The findings provide preliminary data to evaluate PA amount and intensity in children with CP who have little walking ability. It is important to consider PA levels in daily activity for youth with CP when designing plans of care.
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Affiliation(s)
- Nia Toomer-Mensah
- Department of Biobehavioral Sciences, Teachers College, Columbia University, New York, New York (Drs Toomer-Mensah and Quinn); Program in Physical Therapy, Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, Massachusetts (Dr O'Neil); Department of Physical Therapy, Long Island University, Brooklyn, New York (Dr Toomer-Mensah).; Department of Psychology, Doctoral Program, Notre Dame, Notre Dame, Indiana (Mr Blacutt)
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Carter M, Zeineddin S, Bai I, Pitt JB, Hua R, Kwon S, Ghomrawi HMK, Abdullah F. Step cadence as a novel objective postoperative recovery metric in children who undergo laparoscopic appendectomy. Surgery 2024; 175:1176-1183. [PMID: 38195303 DOI: 10.1016/j.surg.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/28/2023] [Accepted: 12/12/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Daily step counts from consumer wearable devices have been used to objectively assess postsurgical recovery in children. However, step cadence, defined as steps taken per minute, may be a more specific measure of physiologic status. The purpose of this study is to define objective normative physical activity recovery trajectories after laparoscopic appendectomy using this novel metric. We hypothesized that patients would have a progressive increase in peak cadence until reaching a plateau representing baseline status, and this would occur earlier for simple compared with complicated appendicitis. METHODS Children aged 3 to 18 years were enrolled after laparoscopic appendectomy for simple or complicated appendicitis between March 2019 and December 2022 at a tertiary children's hospital. Participants wore a Fitbit for 21 postoperative days. The peak 1-minute cadence and peak 30-minute cadence were determined each postoperative day. Piecewise linear regression was conducted to generate normative peak step cadence recovery trajectories for simple and complicated appendicitis. RESULTS A total of 147 children met criteria (53.7% complicated appendicitis). Patients with simple appendicitis reached plateau postoperative day 10 at a mean peak 1-minute cadence of 111 steps/minute and a mean peak 30-minute cadence of 77 steps/minute. The complicated appendicitis recovery trajectory reached a plateau postoperative day 13 at a mean peak 1-minute cadence of 106 steps/minute and postoperative day 15 at a mean peak 30-minute cadence of 75 steps/minute. CONCLUSION Using step cadence, we defined procedure-specific normative peak cadence recovery trajectories after laparoscopic appendectomy. This can empower clinicians to set data-driven expectations for recovery after surgery and establish the groundwork for consumer wearable devices as a post-discharge remote monitoring tool.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Iris Bai
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Rui Hua
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Shirley Ryan AbilityLab, Chicago, IL
| | - Soyang Kwon
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hassan M K Ghomrawi
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Medicine (Rheumatology), Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
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Clanchy K, Stanfield M, Smits E, Liimatainen J, Ritchie C. Calibration and validation of physical behaviour cut-points using wrist-worn ActiGraphs for children and adolescents: A systematic review. J Sci Med Sport 2024; 27:92-104. [PMID: 38087661 DOI: 10.1016/j.jsams.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/02/2023] [Accepted: 11/14/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVES To review cut-points calibrated and independently validated from wrist-worn ActiGraph accelerometers to measure moderate to vigorous physical activity (MVPA) and time spent sedentary (SED) in children and adolescents. DESIGN Systematic literature review. METHODS Five databases were searched for relevant cut-point calibration and independent validation studies relating to wrist worn ActiGraphs in children and adolescents from inception through 30 April 2022. Extracted data included: country of publication; study name; population; device model; wear location; sampling frequency; epoch length; activity protocol; criterion method and definitions used to classify PA intensity; statistical methods for calibration; statistical methods for validation/cross-validation; and MVPA and SED outcome. RESULTS Fourteen calibration studies and seven independent validation studies were identified. Calibrated cut-points for MVPA vector magnitude counts ranged from 7065 to 9204 counts per minute (cpm) and 63.5 to 201 milli-gravitational units (mg). For SED, calibrated cut-points ranged from <2556 cpm to 4350 cpm and 30.8 to 48.1 mg. Classification accuracy values determined by independent validation studies varied, with kappa values ranging from 0.31 to 0.60 and area under the curve statistics ranging from 0.51 to 0.84 for MVPA and kappa values ranging from 0.31 to 0.44 and area under the curve statistics ranging from 0.70 to 0.85 for SED. CONCLUSIONS The results of this systematic literature review support the use of the Crouter and colleagues cut-points for the measurement of MVPA and SED for children and adolescents aged 6-12 years. Further work is required to independently validate cut-points developed in younger children and older adolescents.
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Affiliation(s)
- Kelly Clanchy
- School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Australia; Menzies Health Institute of Queensland, Griffith University, Gold Coast Campus, Australia.
| | - Matthew Stanfield
- School of Human Movement and Nutrition Sciences, University of Queensland, Australia
| | - Esther Smits
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre for Research Excellence: Better Health Outcomes After Compensable Injury, University of Queensland, Australia
| | - Jenna Liimatainen
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre for Research Excellence: Better Health Outcomes After Compensable Injury, University of Queensland, Australia
| | - Carrie Ritchie
- RECOVER Injury Research Centre and National Health and Medical Research Council (NHMRC) Centre for Research Excellence: Better Health Outcomes After Compensable Injury, University of Queensland, Australia
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Carter M, Linton S, Zeineddin S, Pitt JB, Figueroa A, Perez A, Park E, DeTella M, Kwon S, Goldstein SD, Ghomrawi H, Abdullah F. Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure. J Surg Res 2023; 292:7-13. [PMID: 37567031 DOI: 10.1016/j.jss.2023.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Angie Figueroa
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erica Park
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mia DeTella
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Soyang Kwon
- The Smith Child Health Research Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Hassan Ghomrawi
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Medicine (Rheumatology) and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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Ghomrawi HMK, O'Brien MK, Carter M, Macaluso R, Khazanchi R, Fanton M, DeBoer C, Linton SC, Zeineddin S, Pitt JB, Bouchard M, Figueroa A, Kwon S, Holl JL, Jayaraman A, Abdullah F. Applying machine learning to consumer wearable data for the early detection of complications after pediatric appendectomy. NPJ Digit Med 2023; 6:148. [PMID: 37587211 PMCID: PMC10432429 DOI: 10.1038/s41746-023-00890-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/01/2023] [Indexed: 08/18/2023] Open
Abstract
When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.
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Affiliation(s)
- Hassan M K Ghomrawi
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Global Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medicine (Rheumatology), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michela Carter
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Rushmin Khazanchi
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Christopher DeBoer
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Samuel C Linton
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Suhail Zeineddin
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - J Benjamin Pitt
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Megan Bouchard
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Angie Figueroa
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Soyang Kwon
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jane L Holl
- Department of Neurology and Center for Healthcare Delivery Science and Innovation, Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Arun Jayaraman
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Fizan Abdullah
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Center for Global Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 63, Chicago, IL, 60611, USA.
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Mayorga-Vega D, Casado-Robles C, Guijarro-Romero S, Viciana J. Validity of activity wristbands for estimating daily physical activity in primary schoolchildren under free-living conditions: School-Fit study. Front Public Health 2023; 11:1211237. [PMID: 37554735 PMCID: PMC10405174 DOI: 10.3389/fpubh.2023.1211237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/10/2023] [Indexed: 08/10/2023] Open
Abstract
Introduction The use of activity wristbands to monitor and promote schoolchildren's physical activity (PA) is increasingly widespread. However, their validity has not been sufficiently studied, especially among primary schoolchildren. Consequently, the main purpose was to examine the validity of the daily steps and moderate-to-vigorous PA (MVPA) scores estimated by the activity wristbands Fitbit Ace 2, Garmin Vivofit Jr 2, and the Xiaomi Mi Band 5 in primary schoolchildren under free-living conditions. Materials and methods An initial sample of 67 schoolchildren (final sample = 62; 50% females), aged 9-12 years old (mean = 10.4 ± 1.0 years), participated in the present study. Each participant wore three activity wristbands (Fitbit Ace 2, Garmin Vivofit Jr 2, and Xiaomi Mi Band 5) on his/her non-dominant wrist and a research-grade accelerometer (ActiGraph wGT3X-BT) on his/her hip as the reference standard (number of steps and time in MVPA) during the waking time of one day. Results Results showed that the validity of the daily step scores estimated by the Garmin Vivofit Jr 2 and Xiaomi Mi Band 5 were good and acceptable (e.g., MAPE = 9.6/11.3%, and lower 95% IC of ICC = 0.87/0.73), respectively, as well as correctly classified schoolchildren as meeting or not meeting the daily 10,000/12,000-step-based recommendations, obtaining excellent/good and good/acceptable results (e.g., Garmin Vivofit Jr 2, k = 0.75/0.62; Xiaomi Mi Band 5, k = 0.73/0.53), respectively. However, the Fitbit Ace 2 did not show an acceptable validity (e.g., daily steps: MAPE = 21.1%, and lower 95% IC of ICC = 0.00; step-based recommendations: k = 0.48/0.36). None of the three activity wristbands showed an adequate validity for estimating daily MVPA (e.g., MAPE = 36.6-90.3%, and lower 95% IC of ICC = 0.00-0.41) and the validity for the MVPA-based recommendation tended to be considerably lower (e.g., k = -0.03-0.54). Conclusions The activity wristband Garmin Vivofit Jr 2 obtained the best validity for monitoring primary schoolchildren's daily steps, offering a feasible alternative to the research-grade accelerometers. Furthermore, this activity wristband could be used during PA promotion programs to provide accurate feedback to primary schoolchildren to ensure their accomplishment with the PA recommendations.
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Affiliation(s)
- Daniel Mayorga-Vega
- Departamento de Didáctica de las Lenguas, las Artes y el Deporte, Facultad de Ciencias de la Educación, Universidad de Málaga, Málaga, Spain
| | | | - Santiago Guijarro-Romero
- Department of Didactic of Musical, Plastic and Corporal Expression, University of Valladolid, Valladolid, Spain
| | - Jesús Viciana
- Department of Physical Education and Sport, University of Granada, Granada, Spain
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Algheryafi RA, Bevans KB, Hiremath SV, Lai JS, Tucker CA. Convergent Validity of the Patient Reported Outcome Measurement Information System-Pediatric Physical Activity Instrument (PROMIS ®-PA) with Wearable Devices in Adolescents. CHILDREN (BASEL, SWITZERLAND) 2023; 10:940. [PMID: 37371172 DOI: 10.3390/children10060940] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023]
Abstract
The study was conducted mainly to examine the convergent validity of the Patient Reported Outcome Measurement Information System-Pediatric Physical Activity instrument (PROMIS®®®-PA) with step counts from wearable devices and another validated self-reported outcome measure. As a secondary aim, we explored the effect of different recall time frames (7-day, end-of-day [EoD], and ecological momentary assessment [EMA] time frames during the day) in terms of their feasibility and associations with each other and with step counts. This was a prospective cohort study that examined the associations between measures of PA in school-age children and adolescents (n = 84, aged 10-20). The participants wore Fitbit devices for 7 consecutive days, and then completed the 7-day-recall PROMIS-PA short form and Youth Activity Profile (YAP). Additional analyses were completed in a sub-sample (n = 25, aged 11-18 years) using the PROMIS-PA for the EMA at five intervals during the day (shorter form) and at the EoD. In the total sample, the PROMIS-PA results showed positive moderate correlations with the YAP and average daily steps (r = 0.533, p < 0.001 and r = 0.346, p = 0.002, respectively). In the sub-sample, the 7-day PROMIS-PA was highly correlated with the averaged EMA or EoD ratings for the week, and moderately correlated with the daily step counts. These findings support the validity of the PROMIS-PA as a measure of self-reported physical activity. Adolescents demonstrated higher compliance rates and preference for the 7-day recall and EoD assessments compared to more frequent EMA reporting.
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Affiliation(s)
- Reem A Algheryafi
- Department of Physical Therapy, Mohammed Al-Mana College for Medical Sciences, Dammam 34222, Saudi Arabia
| | - Katherine B Bevans
- Patient Reported Outcomes, Janssen Global Services LLC, Horsham, PA 19044, USA
| | - Shivayogi V Hiremath
- Department of Health & Rehabilitation Sciences, Temple University, Philadelphia, PA 19122, USA
| | - Jin-Shei Lai
- Department of Medical Social Sciences, Northwestern University, Chicago, IL 60611, USA
| | - Carole A Tucker
- Nutrition, Metabolic & Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch, Galveston, TX 77555, USA
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Pedometer Efficacy for Clinical Care in Pediatric Cardiology. J Phys Act Health 2023; 20:418-422. [PMID: 36848901 DOI: 10.1123/jpah.2022-0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 11/16/2022] [Accepted: 01/11/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Physical activity is essential to the long-term health of children living with cardiac disease. The simplicity and cost of pedometers make them an attractive alternative to accelerometers for monitoring the physical activity behaviors of these children. This study compared measures obtained from commercial-grade pedometers and accelerometers. METHODS Pediatric cardiology outpatients (n = 41, mean age = 8.4 [3.7] y, 61% female) wore a pedometer and accelerometer daily for 1 week. Step counts and minutes of moderate to vigorous physical activity were compared between devices, accounting for age group, sex, and diagnostic severity, using univariate analysis of variance. RESULTS While pedometer data were significantly correlated with accelerometers (r > .74, P < .001), measurements obtained were significantly different between devices. Overall, pedometers overestimated physical activity data. The overestimation of moderate to vigorous physical activity was significantly less among adolescents than younger age groups (P < .01, ηp2=.38). For step counts, there was a significant age by sex interaction observed where preschool and adolescent males tended to have greater differences between accelerometer and step count data than females (P < .01, ηp2=.33). Differences between devices were not associated with severity of diagnosis. CONCLUSIONS The distribution of pedometers in a pediatric outpatient clinic was feasible, yet the data collected significantly overestimated physical activity, especially among younger children. Practitioners who want to introduce objective measurements as part of their physical activity counseling practice should use pedometers to monitor individual changes in physical activity and consider patient age before administering these devices for clinical care.
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Impact of an exercise program in children with inflammatory bowel disease in remission. Pediatr Res 2022:10.1038/s41390-022-02362-8. [PMID: 36319697 PMCID: PMC9628325 DOI: 10.1038/s41390-022-02362-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/20/2022] [Accepted: 10/17/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The aim of our study was to investigate the impact of a structured exercise program on bone mineral density (BMD) and body composition parameters in children and adolescents with IBD in remission. METHODS Patients were recruited to participate in a 6-month exercise program. Total body less head (TLBH) dual energy X-ray absorptiometry (DXA) was used to measure BMD. The same method was used to assess fat mass (FM) and lean body mass (LBM) at baseline and at the completion of the program. RESULTS Based on the baseline and endpoint TBLH DXA measurements, a total of 42 study participants (25 boys; aged 15.3 ± 2.08 years) experienced an increase in BMD (from 0.959 ± 0.023 g/cm2 to 0.988 ± 0.025 g/cm2, p < 0.001) and LBM (from 37.12 ± 1.43 kg to 38.75 ± 1.61 kg, p = 0.012). Age- and sex-based BMD Z-score increased significantly (from -0.35 ± 0.15 to -0.28 ± 0.17, p = 0.020), whilst LBM Z-score did not significantly change (from -1.78 ± 0.23 to -1.71 ± 1.49, p = 0.908). CONCLUSIONS There was a significant improvement in BMD, age- and sex-based BMD Z-score, and LBM amongst study participants. Subgroup analysis showed that patients with CD and male study participants experienced significant improvement in all parameters, whilst patients with UC and IBD-U and female patients experienced improvement solely in BMD. IMPACT STATEMENT Children and adolescents with IBD, regardless of disease activity, are under increased risk of secondary osteoporosis and lean body mass deficits. A 6-month home-based structured exercise program leads to a significant improvement in bone mineral density and lean body mass. Exercise therapy should be explored as a potentially adjacent to standard treatment modalities.
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Schmidt MD, Rathbun SL, Chu Z, Boudreaux BD, Hahn L, Novotny E, Johnsen K, Ahn SJ(G. Agreement between Fitbit and ActiGraph Estimates of Physical Activity in Young Children. MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE 2022; 27:171-180. [PMID: 37377882 PMCID: PMC10292760 DOI: 10.1080/1091367x.2022.2125319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Physical activity (PA) estimates from the Fitbit Flex 2 were compared to those from the ActiGraph GT9X Link in 123 elementary school children. Steps and intensity-specific estimates of PA and 3-month PA change were calculated using two different ActiGraph cut-points (Evenson and Romanzini). Fitbit estimates were 35% higher for steps compared to the ActiGraph. Fitbit and ActiGraph intensity-specific estimates were closest for sedentary and light PA while estimates of moderate and vigorous PA varied substantially depending upon the ActiGraph cut-points used. Spearman correlations between device estimates were higher for steps (rs=.70) than for moderate (rs =.54 to .55) or vigorous (rs =.29 to .48) PA. There was low concordance between devices in assessing PA changes over time. Agreement between Fitbit Flex 2 and ActiGraph estimates may depend upon the cut-points used to classify PA intensity. However, there is fair to good agreement between devices in ranking children's steps and MVPA.
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Affiliation(s)
| | | | - Zhixuan Chu
- Department of Epidemiology and Biostatistics, University of Georgia
| | | | - Lindsay Hahn
- Department of Communication, University at Buffalo, State University of New York
| | - Eric Novotny
- Grady College of Journalism & Mass Communication, University of Georgia
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Viciana J, Casado-Robles C, Guijarro-Romero S, Mayorga-Vega D. Are Wrist-Worn Activity Trackers and Mobile Applications Valid for Assessing Physical Activity in High School Students? Wearfit Study. J Sports Sci Med 2022; 21:356-375. [PMID: 36157395 PMCID: PMC9459775 DOI: 10.52082/jssm.2022.356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/26/2022] [Indexed: 05/27/2023]
Abstract
The purpose was to examine the validity of three wrist-worn commercial activity trackers (Samsung Galaxy Watch Active 2, Apple Watch Series 5, and Xiaomi Mi Band 5) and six mobile apps (Pedometer and Pacer for android and iPhone mobiles, Google Fit for android, and Apple Health for iPhone mobiles) for estimating high school students' steps and physical activity (PA) under free-living conditions. A sample of 56 (27 females; mean age = 14.7 years) and 51 (25 females; mean age = 14.0 years) high school students participated in Study 1 and 2, respectively. Study 1: Students performed a 200-meter course in four different conditions while wearing the wearables. Step counting through a video record was used as the golden standard. Study 2: Students wore the three wrist-worn commercial activity trackers during the waking time of one day, considering ActiGraph model wGT3X-BT accelerometers as a standard of reference. Afterward, the agreement between the PA scores measured by the commercial activity trackers and the video (study 1) or accelerometers (study 2) were calculated as follows: Equivalence test, Limits of Agreement (LOA); Mean Absolute Error (MAE); Mean Absolute Percentage Error (MAPE); and Intraclass Correlation Coefficient (ICC). Results showed that all the wearables presented excellent validity for assessing steps in structured free-living conditions (study 1; MAPE < 5%), although their validity was between poor-excellent based on ICC (95% confidence interval) values (ICC = 0.56-1.00). Regarding Study 2, the Xiaomi wristband and the Samsung Watch presented acceptable-excellent (MAPE = 9.4-11.4%; ICC = 0.91-0.97) validity for assessing steps under unstructured free-living conditions (study 2). However, the Apple Watch presented questionable-excellent validity (MAPE = 18.0%; ICC = 0.69-0.95). Regarding moderate-to-vigorous PA (MVPA) and total PA, only the Apple Watch showed low-acceptable validity for MAPE value and questionable-excellent validity for the ICC values for MVPA assessment (MAPE = 22.6; ICC = 0.67-0.93). All wearables checked in this study have shown adequate validity results in order to assess steps in both structured and unstructured free-living conditions for both continuous and dichotomous variables. Moreover, for assessing MVPA, only the Apple Watch reported valid results for compliance or non-compliance with the daily PA recommendations. However, the results showed low validity for total PA and MVPA as continuous variables. In conclusion, depending on the user's/researcher's aim and context, one or another wearable activity tracker could be more adequate, mainly because of its valid measurements and its costs.
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Affiliation(s)
- Jesús Viciana
- Department of Physical Education and Sport, University of Granada, Granada, Spain
| | | | - Santiago Guijarro-Romero
- Department of Didactic of Musical, Plastic and Corporal Expression, University of Valladolid, Valladolid, Spain
| | - Daniel Mayorga-Vega
- Departamento de Didáctica de las Lenguas, las Artes y el Deporte, Facultad de Ciencias de la Educación, Universidad de Málaga, Málaga, España
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Martinko A, Karuc J, Jurić P, Podnar H, Sorić M. Accuracy and Precision of Consumer-Grade Wearable Activity Monitors for Assessing Time Spent in Sedentary Behavior in Children and Adolescents: Systematic Review. JMIR Mhealth Uhealth 2022; 10:e37547. [PMID: 35943763 PMCID: PMC9399884 DOI: 10.2196/37547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background A large number of wearable activity monitor models are released and used each year by consumers and researchers. As more studies are being carried out on children and adolescents in terms of sedentary behavior (SB) assessment, knowledge about accurate and precise monitoring devices becomes increasingly important. Objective The main aim of this systematic review was to investigate and communicate findings on the accuracy and precision of consumer-grade physical activity monitors in assessing the time spent in SB in children and adolescents. Methods Searches of PubMed (MEDLINE), Scopus, SPORTDiscus (full text), ProQuest, Open Access Theses and Dissertations, DART Europe E-theses Portal, and Networked Digital Library of Theses and Dissertations electronic databases were performed. All relevant studies that compared different types of consumer-grade monitors using a comparison method in the assessment of SB, published in European languages from 2015 onward were considered for inclusion. The risk of bias was estimated using Consensus-Based Standards for the Selection of Health Status Measurement Instruments. For enabling comparisons of accuracy measures within the studied outcome domain, measurement accuracy interpretation was based on group mean or percentage error values and 90% CI. Acceptable limits were predefined as –10% to +10% error in controlled and free-living settings. For determining the number of studies with group error percentages that fall within or outside one of the sides from previously defined acceptable limits, two 1-sided tests of equivalence were carried out, and the direction of measurement error was examined. Results A total of 8 studies complied with the predefined inclusion criteria, and 3 studies provided acceptable data for quantitative analyses. In terms of the presented accuracy comparisons, 14 were subsequently identified, with 6 of these comparisons being acceptable in terms of quantitative analysis. The results of the Cochran Q test indicated that the included studies did not share a common effect size (Q5=82.86; P<.001). I2, which represents the percentage of total variation across studies due to heterogeneity, amounted to 94%. The summary effect size based on the random effects model was not statistically significant (effect size=14.36, SE 12.04, 90% CI −5.45 to 34.17; P=.23). According to the equivalence test results, consumer-grade physical activity monitors did not generate equivalent estimates of SB in relation to the comparison methods. Majority of the studies (3/7, 43%) that reported the mean absolute percentage errors have reported values of <30%. Conclusions This is the first study that has attempted to synthesize available evidence on the accuracy and precision of consumer-grade physical activity monitors in measuring SB in children and adolescents. We found very few studies on the accuracy and almost no evidence on the precision of wearable activity monitors. The presented results highlight the large heterogeneity in this area of research. Trial Registration PROSPERO CRD42021251922; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=251922
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Affiliation(s)
| | - Josip Karuc
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
- Proprio Centre, Physical Rehabilitation Centre, Zadar, Croatia
| | - Petra Jurić
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
| | - Hrvoje Podnar
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
| | - Maroje Sorić
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
- Faculty of Sport, University of Ljubljana, Ljubljana, Slovenia
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Kasparian AM, Badawy SM. Utility of Fitbit devices among children and adolescents with chronic health conditions: a scoping review. Mhealth 2022; 8:26. [PMID: 35928511 PMCID: PMC9343978 DOI: 10.21037/mhealth-21-28] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 05/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background While Fitbit® devices were initially intended for leisurely, consumer use, there has been recent interest among scientific and medical communities in the prospective use of Fitbit devices for clinical and research purposes. Those who have chronic health conditions are often required to spend considerable amounts of money and time undergoing physiological tests and activity monitoring to support, stabilize, and manage their health. This disease burden is only amplified in pediatric populations. Devices that are used to collect these data can be invasive, uncomfortable, and disconcerting. Using the Fitbit tracker to acquire such biometric data could ease this burden. Our scoping review seeks to summarize the research that has been conducted on the utilization of Fitbit devices in studies of children and adolescents with chronic health conditions and the feasibility, accuracy, and potential benefits of doing so. Methods Searches were conducted on PubMed for articles relating pediatric health to Fitbit device usage (using a Boolean search strategy). The eligibility criteria included trials being clinical and/or randomized controlled and articles being in English. Once articles were obtained, they underwent screening and exclusion processes and were charted for their titles, authors, objectives, results, and respective chronic illnesses. In the subsequent full-text review, further charting was conducted, collecting study designs, Fitbit parameters, feasibility, accuracy, and related health and clinical outcomes. Results Fitbit trackers were unanimously demonstrated to be feasible devices in this population for physical activity monitoring and were determined to be potentially beneficial in measuring and improving overall wellbeing and physical health in children with chronic illness. Nevertheless, sufficient evidence was not found in support of Fitbit accuracy. Additional biases were identified against the population of children with chronic health conditions that may further enable inaccurate data. Conclusions While Fitbit devices may be beneficial for those interested in improving physical health, discretion is advised for those seeking to collect accurate and/or medically necessitated data. Given the existing literature evaluated, medical-grade technologies are preferred in instances of the latter, as Fitbit devices have not been found to provide reliably accurate data.
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Affiliation(s)
- Alexandra M. Kasparian
- Department of Biology, Lafayette College, Easton, PA, USA
- Department of Physician Assistant Studies, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sherif M. Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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Trivić I, Sila S, Batoš AT, Mišak Z, Kolaček S, Hojsak I. Moderate-to-Vigorous Physical Activity Is Associated With Higher Bone Mineral Density in Children With Inflammatory Bowel Disease. J Pediatr Gastroenterol Nutr 2022; 74:54-59. [PMID: 34321428 DOI: 10.1097/mpg.0000000000003258] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Decreased mineral bone density (BMD) and reduced lean body mass (LBM) are common amongst children with inflammatory bowel disease (IBD). The aim of our cross-sectional, observational study was to evaluate the relationship between BMD, body composition and physical activity (PA) in children with IBD in remission. METHODS Total body less head (TLBH) dual energy X-ray absorptiometry (DXA) was used to measure BMD, fat mass (FM) and lean body mass (LBM). Triaxial accelerometer for five consecutive days was used to objectivize PA. RESULTS Forty pediatric IBD patients in clinical remission (24 boys; age 15.3 ± 0.4 years; Crohn disease [CD], n = 20, ulcerative colitis [UC], n = 18, inflammatory bowel disease-unclassified [IBD-U], n = 2) were recruited. Mean BMD was 0.940 g/cm2 and mean BMD z score was -0.42 ± 0.14. Patients with CD had significantly lower BMD than UC counterparts (P < 0.001). Average time spent in PA was 247.24 ± 16.71 min/day with 45.73 ± 8.22 min/day spent in moderate-to-vigorous PA (MVPA). We observed a significant positive correlation between the time spent in MVPA and BMD z score (P = 0.003) and LBM z score (P = 0.026). Multivariate analysis confirmed that the positive correlation of MVPA and BMD z score. There was no significant correlation between daily protein intake and BMD. Cumulative glucocorticoid dose negatively correlated with LBM z score (P = 0.003), but not with BMD z score (P = 0.069). CONCLUSIONS This study points to a strong positive relationship between MVPA, LBM and BMD. Longitudinal studies are required in order to elucidate the modifiable processes that determine body health and favorable body composition.
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Affiliation(s)
- Ivana Trivić
- Referral Center for Pediatric Gastroenterology and Nutrition
| | - Sara Sila
- Referral Center for Pediatric Gastroenterology and Nutrition
| | | | - Zrinjka Mišak
- Referral Center for Pediatric Gastroenterology and Nutrition
| | - Sanja Kolaček
- Referral Center for Pediatric Gastroenterology and Nutrition
- School of Medicine, University of Zagreb, Zagreb
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition
- School of Medicine, University of Zagreb, Zagreb
- School of Medicine, University J.J. Strossmayer Osijek, Osijek, Croatia
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