Report on Childhood Obesity in China (1) Body Mass Index Reference for Screening Overweight and Obesity in Chinese School-age Children

Purpose To establish and propose a national body mass index （BMI） reference for screening overweight and obesity in Chinese school-age children and adolescents. Methods 2000 CNSSCH （Chinese National Survey on Students Constitution and Health） data, including 216 620 primary and secondary school students aged 7 to 18 years old, were used as a reference population. Compared with those of the NCHS intematioanl reference, three temporary sets of cut-off BMI were proposed by testing different combinations of P85, P90, and P95. When physiological and biochemical measures between and among “obesity” “overweight”, and “normal weight” groups were taken into consideration, set Ⅱ was selected to be the most appropriate one. The sex-age-specific curves were then plotted and smoothed by using B-spline method. Results Based on the samples from costal developed metropolis, the BMI curves successfully overcame the shortcomings of lower and level-off tendency of the Chinese total population. Temporary set H, composed by cut-offs of P85 for overweight and P95 for obesity, was finally selected by its sensitivity and peculiarity. BMI 24 and 28 were used as cut-offs for overweight and obesity for both males and females aged 18 years old. These cut-offs, consistent with Chinese Adult＇s Reference, was proposed as the Body mass index reference for screening overweight and obesity in Chinese school-age children and adolescents. Conehlsion The new reference clearly showed its superiorty in both prospectivity and actuality. The proposed reference minimized the gaps of the BMI curve between Chinese adolescents and the international reference. Most importantly was that it was consistent with the Eastern Asia ethnic characteristics of body fatness growth. It was therefore proposed by the Working Group on Obesity in China （WGOC） to use it as an nationwide reference for screening overweight and obesity of school-age children and adolescents in China.

A Scan of Obesogenic Environments and a Spatial Inference of Obesity Prevalence in Chinese Children and Adolescents: Based on the Chinese Health and Nutrition Survey 2011 Data

Objective To identify the characteristics of Chinese obesogenic environments at a provincial level, infer a spatial distribution map of obesity prevalence in 31 provinces, and provide a foundation for development of policy to reduce obesity in children and adolescents. Methods After scanning obesity data on subjects aged 7-17 years from 12 provinces in the China Health and Nutrition Survey 2011 and environmental data on 31 provinces from the China Statistical Yearbook 2011 and other sources, we selected 12 predictors. We used the 12 surveyed provinces as a training sample to fit an analytical model with partial least squares regression and prioritized the 12 predictors using variable importance in projection. We also fitted a predictive model with Bayesian analysis. Results We identified characteristics of obesogenic environments. We fitted the predictive model with a deviance information criterion of 61.96 and with statistically significant（P 〈 0.05） parameter estimates of intercept [95% confidence interval（CI）： 329.10, 963.11], log（oil）（CI： 13.11, 20.30）, log（GDP）（CI： 3.05, 6.93）, log（media）（CI：-234.95,-89.61）, and log（washing-machine）（CI： 0.92, 5.07）. The total inferred average obesity prevalence among those aged 7-17 was 9.69% in 31 Chinese provinces in 2011. We also found obvious clustering in occurrences of obesity in northern and eastern provinces in the predicted map. Conclusion Given complexity of obesity in children and adolescents, concerted efforts are needed to reduce consumption of edible oils, increase consumption of vegetables, and strengthen nutrition, health, and physical activity education in Chinese schools. The northern and eastern regions are the key areas requiring intervention.

Secular Changes on the Distribution of Body Mass Index among Chinese Children and Adolescents, 1985-2010

Objective To analyze the change in Body Mass Index （BMI） distribution among Chinese children and adolescents for the development of more effective intervention for childhood obesity. Methods Data on the national students＇ constitution and health survey between 1985 and 2010 was used for this study. Subjects were students aged 7-18 randomly selected from 30 provinces in China. BMI for-age curves were developed by LMS method, and the trend of BMI distribution was determined by comparing the upper BMI percentiles and analyzing the skew shift of distribution between 2985 and 2010. Results An overall positive swift trend of BMI between 1985 and 2010 was observed among the Chinese school-age children and adolescents. The average median of the BMI increased from 16.8 and 17.0 ks/m2 to 18.2 and 17.9 kg/m2 in 25 years, with increments 0.56 and 0.36 kg/m2 per decade for males and females, respectively. The more obvious increments were found at the high BMI. The total increments of BMI in this period were 4.03 and 2.20 kg/m2 at the 85th, 6.24 and 3.57 kg/m2 at the 95th, and 6.99 and 4.27 kg/m2 at the 97th percentiles, for males and females, respectively. Conclusion Obvious increments were observed at high BMI of the Chinese children and adolescents. More effective interventions should be taken for control and prevention of obesity and its health consequence for these subgroups. It is necessary to establish a risk-complex system consisting of the identification of BMI scope, the screen of the disease risk factors and the assessment of excessive adiposity.

Working-memory training improves developmental dyslexia in Chinese children

Although plasticity in the neural system underlies working memory, and working memory can be improved by training, there is thus far no evidence that children with developmental dyslexia can benefit from working-memory training. In the present study, thirty dyslexic children aged 8-11 years were recruited from an elementary school in Wuhan, China. They received working-memory training including training in visuospatial memory, verbal memory, and central executive tasks. The difficulty of the tasks was adjusted based on the performance of each subject, and the training sessions lasted 40 minutes per day, for 5 weeks. The results showed that working-memory training significantly enhanced performance on the nontrained working memory tasks such as the visuospatial, the verbal domains, and central executive tasks in children with developmental dyslexia. More importantly, the visual rhyming task and reading fluency task were also significantly improved by training. Progress on working memory measures was related to changes in reading skills. These experimental findings indicate that working memory is a pivotal factor in reading development among children with developmental dyslexia, and interventions to improve working memory may help dyslexic children to become more proficient in reading.

Improving school physical education to increase physical activity and promote healthy growth of Chinese school-aged children Time for action

Throughout its more than 5000-year history,China has a long tradition of encouraging active engagement in physical and sport activities.1,2This enduring tradition,however,has been facing some major headwinds as China continues to experience demographic and environmental changes related to aging,urbanization,and lifestyle shifts.3-5Mounting evidence indicates increasing levels of sedentary behaviors。

Eye-movement Patterns of Chinese Children with Developmental Dyslexia during the Stroop Test

Objective To compare the eye-movement patterns of Chinese children with developmental dyslexia（DD children） with those of non-dyslexic children as they perform the Stroop Color and Word Test（SCWT）, and to explore the relationship between their eye-movement patterns and interference effect. Methods An EyeLink II was used to record the eye-movement parameters of 32 DD children and 37 non-dyslexic children as they performed the SCWT. The independent samples t-test and repeated measures were used to analyze behavioral and eye-movement parameters. Results Compared to the control group, Chinese DD children presented lower accuracy（F = 8.488）, slower response time（F = 25.306）, and larger interference effect（t = 2.29）; Chinese DD children also exhibited lower frequency of fixations（F = 6.069）, greater numbers of saccades（F = 7.914） and fixations（F = 5.272）, and shorter mean saccade distance（F = 4.03）. All behavioral and eye-movement parameters differed significantly among the three tasks in the SCWT. There was significant interaction between groups and tasks in accuracy（F = 5.844）, and marginally significant interaction in response time（F = 3.040）. Chinese DD children tended to have lower accuracy and longer response time than the control group in the ＇color-word naming＇ task. Conclusion Compared to non-dyslexic children, Chinese DD children are subject to a stronger interference effect. When performing the SCWT, Chinese DD children exhibit abnormal eye-movement patterns, namely shorter mean saccade distance, lower frequency of fixations, and more fixations and saccades. These abnormal eye movements may be relatively stable oculomotor patterns of DD children performing visual processing, and not influenced by impaired interference effect.

Possible PKHD1 Hot-spot Mutations Related to Early Kidney Function Failure or Hepatofibrosis in Chinese Children with ARPKD:A Retrospective Single Center Cohort Study and Literature Review

PKHD1 mutations are generally considered to cause autosomal recessive polycystic kidney disease(ARPKD).ARPKD is a rare disorder and one o f the most severe conditions leading to end-stage renal disease in childhood.With the biallelic deletion mutation,patients have difficulty in surviving the perinatal period,resulting in perinatal or neonatal death.This study retrospectively analyzed patient characteristics,imaging characteristics,laboratory examinations and family surveys from 7 Chinese children with different PKHD1 gene mutations diagnosed by high-throughput sequencing from January 2014 to February 2018.O f the 7 children,there were 3 males and 4 females.Eight missense mutations,two frameshift mutations,two deletion mutations,and two intronic slicing mutations were identified.Six of the mutations have not previously been identified.In the literature search,we identified a total of 29 Chinese children with PKHD1 mutations.The missense mutation c.2507T>C in exon 24 was found in one patient in our study,and five patients with liver fibrosis but normal renal function were reported in the literature.The missense mutation c.5935G>A in exon 37 was found in two patients in our study and three cases in the literature.Four patients had renal failure at an age as young as 1 year of those five patients with the missense mutation c.5935G>A in exon 37.It was concluded that:(1)Kidney length more than 2-3 SDs above the mean and early-onset hypertension might be associated with PKHDI-associated ARPICD;(2)The more enlarged the kidney size is,the lower the renal function is likely to be;(3)c.5935G>A may be a hot spot that leads to early renal failure in Chinese children with PKHD1 mutations;(4)c.2507T>C may be a hot-spot mutation associated with hepatic lesions in Chinese children with PKHD1.

Surgical correction of recurrent epiblepharon in Chinese children using modified skin re-draping epicanthoplasty

AIM:To evaluate the clinical efficacy of the modified skin re-draping epicanthoplasty procedure for correction of recurrent lower lid epiblepharon in Chinese children.METHODS:From 2016 to 2018,18 children(10 males and 8 females,average age 6.2±1.7 y;30 eyes)with recurrent epiblepharon who attended Beijing Children’s Hospital were included in the study.All the children had undergone lower eyelid surgery for epiblepharon.Surgical design included using an additional incision along the upper palpebral margin,to avoid vertical scarring on the upper lid.The re-draping method was used to correct recurrent epiblepharon.Follow-up ranged from 3 to 24 mo.Postoperative surgical outcomes,complications,and subjective satisfaction were evaluated.RESULTS:Complete correction of cilia touching the cornea was observed in all patients during an average follow-up of 7.1 mo.No"dog ears"or obvious scars were formed after surgery.All parents were satisfied with the cosmetic results and none complained.Mean astigmatism decreased from 2.39±0.79 diopter(D)preoperatively to 2.19±0.79 D at 6 mo after surgery;however,the difference was not significant.Best-corrected visual acuity improved,although the change in mean visual acuity was not significant.No recurrence occurred during the follow-up period.CONCLUSION:This surgical modified skin re-draping technique is effective and highly satisfactory for correction of recurrent epiblepharon.The approach is characterized by a simple design,a straightforward procedure,inconspicuous scarring,and good postoperative appearance.

Addressing the public health concerns of physical inactivity, low levels of fitness, and unhealthy weight among Chinese school-aged children

In China,sports and physical activity(PA)have traditionally been an integral part of school curricula to promote fitness and enhance healthy growth among children and adolescents.Three decades of economic reforms,however,have brought major changes in social,economic,and built environments that have resulted in concerns about the general health of the Chinese population due to accumulating epidemiologic evidence of increased levels of physical inactivity,high rates of obesity,and unhealthy diet.With the emergence of a progressively obesogenic environment,lack of safe and acces-

Energy Balance-related Behaviors Are Related to Cardiometabolic Parameters and Predict Adiposity in 8-14-year-old Overweight Chinese Children One Year Later

To identify target energy balance-related behaviors（ERBs）,baseline data from 141overweight or obese schoolchildren（aged 8-14years old）was used to predict adiposity[body mass index（BMI）and fat percentage]one year later.The ERBs included a modified Dietary Approach to Stop Hypertension diet score（DASH score）,leisure-time physical activity（PA,days/week）,and leisure screen time（minutes/day）.Several cardiometabolic variables were measured in the fasting state, including systolic blood pressure （SBP）, diastolic blood pressure （DBP）, blood glucose （GLU）, total cholesterol （TC）, triglycerides （TG）, low-density lipoprotein （LDL-C）, and high-density lipoprotein （HDL-C）.

Estimation of Iron Physiological Requirement in Chinese Children using Single Stable Isotope Tracer Technique

Objective This study is to obtain precise data on iron physiological requirements in Chinese children using single stable isotope tracertechnique.Methods Thirty boys(10.6±0.2 years)and 27 girls(10.4±0.2 years)were received oral 6 mg ^(57)Fe each day for 5 consecutive days.Venous blood samples were subsequently drawn to examine the change of total iron concentration and ^(57)Fe abundance at day 0,14,28,60,90,180,360,450,540,630,720.The iron physiological requirement was calculated by iron loss combined with iron circulation rate once ^(57)Fe abundance stabilized in human body.Results The iron physiological requirement was significantly lower in boys than those values in girls(16.88±7.12 vs.18.40±8.81μg/kg per day,P<0.05).Correspondingly,the values were calculated as 722.46±8.43μg/day for boys and 708.40±7.55μg/day for girls,respectively.Considering nearly 10%iron absorption rate,the estimated average iron physiological requirement was 6.0 mg/day in boys and 6.2 mg/day in girls.Conclusion This study indicate that iron physiological requirement could require more daily iron intake in girls as compare with the values in boys having the same body weight.These findings would be facilitate to the new revised dietary reference intakes.

Peripapillary choroidal thickness in Chinese children using enhanced depth imaging optical coherence tomography

AIM：To evaluate the peripapillary choroidal thickness（PPCT） in Chinese children,and to analyze the influencing factors.METHODS： PPCT was measured with enhanced depth imaging optical coherence tomography（EDI-OCT） in 70children（53 myopes and 17 non-myopes） aged 7 to 18 y,with spherical equivalent refractive errors between 0.50and-5.87 diopters（D）.Peripapillary choroidal imaging was performed using circular scans of a diameter of 3.4 mm around the optic disc.PPCT was measured by EDI-OCT in six sectors： nasal（N）,superonasal（SN）,superotemporal（ST）,temporal（T）,inferotemporal（IT）and inferonasal（IN）,as well as global RNFL thickness（G）.RESULTS： The mean global PPCT was 165.49±33.76 μm.The temporal,inferonasal,inferotemporal PPCT were significantly thinner than the nasal,superonasal,superotemporal segments PPCT were significantly thinner in the myopic group at temporal,superotemporal and inferotemporal segments.The axial length was significantly associated with the average global（β=-0.419,P =0.014）,superonasal（β=-2.009,P=0.049） and inferonasal（β=-2.000,P=0.049） PPCT.The other factors（gender,age,SE） were not significantly associated with PPCT.CONCLUSION： PPCT was thinner in the myopic group at temporal,superotemporal and inferotemporal segments.The axial length was found to be negatively correlated to PPCT.We need more further studies about the relationship between PPCT and myopia.

Effect of Vitamin C Supplementations on Iron Deficiency Anemia in Chinese Children

A total of 65 children with mild iron deficiency anemia (IDA) were divided into 5 groups, and received 0, 25, 50, 100 and 150 mg/day of vitamin C (VC) respectively every day for 8 weeks. Hemoglobin, serum ferritin, free erythrocyte and hematocrit were determined every week. At a daily average intake of about 30 mg of VC and 7.5 mg of Fe, the results of the study indicate that: (1) VC supplement alone could effectively control children's IDA, and a dose-dependant relationship was observed. (2) 50 mg/day of VC is the most efficient dosage and 6 weeks is the shortest time for an effective therapy. (3) With a diet predominately comprised of plant foods, it is suggested that appropriate dose of VC should be supplemented for the children during winter and spring in northeastern areas of China.

An Empirical Study on Self-Efficacy of Online Learning of Overseas Chinese Children in Europe

In the post-Covid-19 pandemic era,it is more difficult for some Chinese schools in Europe to provide online extra classes for overseas Chinese children after school hours,as they did previously.To meet students'multifaceted learning needs,online extra classes teaching,including online Chinese language classes and some online art classes,is increasingly being offered as a supplement to the diversity of teaching activities in Chinese schools in Europe,with the ultimate goal of improving the learning abilities of overseas Chinese children while relieving pressure on teaching resources in schools.Children’s learning self-efficacy in online extracurricular courses has its own uniqueness,which can be considered from three dimensions,including learning confidence,learning ability,and self-assessment ability.This study aims to examine the factors influencing the self-efficacy of overseas Chinese children and to make optimization suggestions for better teaching methods.In search of that,an online questionnaire survey with 127 participants from overseas Chinese children aged􀀘to􀀔􀀘was collected.The findings indicate that the role of learning confidence in overseas Chinese children outweighs their learning ability and self-assessment ability.Gender and age have a negligible effect on self-efficacy but have an impact on learning confidence.Chinese schools in Europe do not need to show gender differences when conducting classroom activities in online teaching to improve the online self-efficacy of Chinese children,and efforts should also be made to keep the courage of older students to trial and error.Teachers are expected to investigate more aspects of their students'personalities in future classrooms rather than sticking to a consistent and unchanging teaching model.

Empirical Changes in the Prevalence of Overweight and Obesity among Chinese Students from 1985 to 2010 and Corresponding Preventive Strategies

Objective To determine the extent of the obesity epidemic in school‐aged Chinese children in 2010 and track the increasing trend in different socioeconomic regions over the preceding 25 years. Strategies for preventing childhood obesity are suggested. Methods We used a dataset provided by the Chinese National Survey on Students’ Constitution and Health from 1985‐2010. Subjects were 7‐18‐year‐old students randomly selected from urban and rural areas in 30 provinces. Eight subgroups were created according to region and socioeconomic status. Results Increased rates of the epidemic （overweight and obesity combined） were greatest in large coastal cities‐32.6% and 19.1% among males and females, respectively. These rates has neared that of developed countries. Similar increases were found in all other regions, including the once poverty‐stricken rural west. The epidemic in most of the rural areas began after 2000, but has spread swiftly over the last decade. In 2010, it was estimated that 9.9% of Chinese school‐aged children and adolescents were overweight and that an additional 5.1% were obese, representing an estimated 30.43 million individuals. Conclusion The prognosis for China＇s childhood‐obesity epidemic is dire. To prevent childhood obesity, we suggest several strategies, including reasonable dietary intake, increase physical activity, a change in sedentary lifestyles and corresponding behavioral modifications.

Disease Risks of Childhood Obesity in China

Objective To estimate the relative risks of dyslipidemia, hypertension, diabetes mellitus, and metabolic syndromes among overweight and obese Chinese children compared with their normal weight counterparts. Methods Overweight and obesity were defined by age- and sex-specific BMI classification reference for Chinese children and adolescents. Pediatric metabolic syndrome （MetS） and each risk factor for MetS were defined using the criteria for US adolescents. Definition of hyper-TC, LDL, and dyslipidemia for adults was applied as well. General linear model factor analysis and chi-square test were used to compare the difference in metabolic indicators among normal weight, overweight, and obese groups. Multiple logistic regression analysis was performed to estimate the odds ratio of metabolic abnormalities between obesity, overweight, and normal weight children, after adjustment for living area, family economic level, age, sex, and daily exercise time and TV watching time, as well as different dietary indices in the model. Results Significant increases in blood lipids, glucose, and blood pressure were found among overweight and obese children as compared with their counterparts with normal weight. By applying WGOC-recommended BMI classification, the risks for hypertriglyceridemia, low HDL and dyslipidemia among overweight children were 1.9, 1.4, and 1.5 times, and was 3.3, 1.5, and 1.8 times among obese groups compared to their counterparts with normal weight after adjustment for age, sex, region, socioeconomic status, physical activity, and dietary intakes. The overweight and obese children （15-17.9 years） had a high-risk of developing hypertension, which was 2.3 and 2.9 times higher than their counterparts with normal weight. Above 90% obese adolescents had abdominal obesity, while less than 1% normal weight ones had abdominal obesity. No obese adolescents were free from any risk factors for MetS, while 36.9% of normal weight adolescents were from the risk factors. 83.3% obese boys and all obese girls had metabolic syndrome, while only 15.5% normal weight boys and 18.8% normal weight girls had metabolic syndrome. Four risk factors for metabolic syndrome were found in 8.3% obese boys while none in normal weight boys and girls. The prevalence of MetS among normal weight, overweight, and obesity groups was 1.5%, 18.3%, and 38.1% respectively. Conclusion The cardiovascular disease （CVD） risk factors are clustered in obese Chinese children. Our observations strongly suggest that efforts should be made to prevent the onset of overweight and its associated diseases during early childhood.