出生体重与环境因素对儿童青少年超重肥胖影响的队列研究
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摘要
[研究背景]
肥胖己成为21世纪全球公共卫生的严重问题之一,中国儿童青少年肥胖也正进入高发期。经济增长和都市化进程,引起生活环境的改变,如过度能量摄入、低体力活动、静坐生活方式增多等,肥胖患病率也随之呈现明显增加趋势。儿童青少年肥胖危害深远,不仅导致身心疾患和生理功能障碍,影响学习能力,更为严重的是儿童青少年肥胖可发展为成人肥胖,引起高血压、心脏病、糖尿病等慢性疾病,从而导致长期病态和早期死亡。超重、肥胖是多种慢性病的主要危险因素之一,而儿童青少年肥胖已经成为这些疾病的隐患。因此对儿童青少年肥胖问题必须加以重视。
肥胖是遗传和环境因素综合作用的结果。大量研究表明,引起儿童青少年肥胖的危险因素多种多样且相互关联,主要包括遗传、出生体重、饮食、体育锻炼、父母行为意识、社会经济、精神心理等因素。肥胖是多因素、长期作用的结果,原因错综复杂。遗传因素决定个体肥胖发生的易感性,而各种环境因素则促进肥胖的发生。研究证实,从胎儿到成年期的各年龄阶段中,肥胖的发生和发展有鲜明的生长发育轨迹现象,探讨这些现象及其影响因素,不仅有助于为儿童青少年肥胖的预防提供理论依据,有效开展早期干预,而且对减少成年期肥胖相关疾病、保障终身健康都具有重要意义。
[研究目的]
本研究拟了解巨大儿和正常出生体重儿队列在儿童期和青少年期超重、肥胖发生的现况和相关危险因素：分析从出生到儿童期再到青少年期,儿童青少年体重变化趋势；探讨出生体重与生活行为因素之间的交互作用、父母超重肥胖对子代超重肥胖的影响以及超重肥胖和相关生活行为因素的家庭聚集性。
[研究方法]
本研究选择江苏省无锡市的一个县级市(江阴市)和两个中心行政区(惠山区和锡山区)出生于1993-1995年的活产婴儿作为研究对象,其中出生体重大于等于4000克者作为暴露组,小于4000克同时大于等于2500克者作为对照组。采用历史性队列研究设计,基线数据来源于这三个地区在90年代初建立的妇女围产保健数据库,包括母亲的一般人口学特征、健康状况、初次孕产期检查、产前复查、产时及围产期检查等。2005年10月至2006年10月期间进行儿童期随访,随访所用调查表的内容主要包括研究对象的个人生长发育情况、生活方式、饮食运动习惯及其家庭特征和父母生活方式等,同时进行体格检查(身高、体重、血压等)。在此基础上,于2010年10月至2011年10月期间再次对已进入青春期的研究对象进行第二次随访,除收集与上次随访类似的信息外,本次随访信息更具体化和详细化,增加收集父母的相关信息,仍然进行体格检查(身高、体重及血压等)。
采用体质指数(BMI)作为结局变量,并以中国肥胖工作组(WGOC)发表的中国儿童青少年性别年龄别BMI参考值作为判定超重与肥胖的标准。以超重肥胖者作为病例,按同性别、同年龄配以对照,进行病例对照研究。
应用Epidata3.1软件建立数据库和设置核查程序,双遍录入所有数据。运用SPSS16.0和SAS9.2等软件进行统计分析,主要方法包括t检验、方差分析、χ2检验、秩和检验、非条件Logistic回归分析、因子分析、相关分析、广义线性混合效应模型等。
[研究结果]
1.队列概况
本次队列研究起点为研究对象出生时,经过儿童期和青少年期两次随访,最终进入分析的合格对象为2236人,其中出生时1108人为巨大儿,1128人为正常出生体重儿；男生1488名,占66.55%(暴露组737名,对照组751名),女生748名,占33.45%(暴露组371名,对照组377名)。
2.基线调查结果
过期妊娠、母亲孕前BMI较高和母亲孕期增加体重较多均是婴儿高出生体重的危险因素,OR值分别为2.31(95%CI：1.48,3.63)、1.17(95%CI：1.07,1.27)、1.11(95%CI：1.08,1.14)。
3.儿童期随访调查结果
儿童期实际随访到2870人,年龄在10-13岁之间。本人群儿童期超重检出率为12.03%(男生15.66%,女生4.81%),肥胖检出率为2.15%(男生2.42%,女生1.61%),超重肥胖检出率为14.18%(男生18.08%,女生6.42%)；暴露组中超重检出率为13.45%,肥胖检出率为2.80%,对照组中超重检出率为10.64%,肥胖检出率为1.51%。
暴露组的超重肥胖检出率(16.25%)高于对照组的超重肥胖检出率(12.15%),差别有统计学意义(P=0.003)；暴露组与对照组相比,发生超重和肥胖的RR分别为1.26(95%CI：1.01,1.58)和1.86(95%CI：1.03,3.33),AR分别为2.81%和1.29%。不同出生体重组之间儿童BMI均值不同,超重率和肥胖率有明显的随出生体重增加而增高的趋势(P<0.01)。
儿童期超重肥胖的影响因素分析：多因素非条件Logistic回归分析表明,男性(OR=2.06)、高出生体重(OR=1.48)、母亲超重肥胖(OR=2.22)、婴儿期人工喂养(OR=2.80)和混合喂养(OR=2.70)、经常吃油炸食品(OR=1.41)、经常吃夜宵(OR=4.59)、看电视时间较长(OR=1.37)、收入较高(OR=1.47)、父亲饮酒(OR=1.34)均为儿童超重肥胖的危险因素。牛奶食用次数较多(OR=0.66)为保护因素。
4.青少年期随访调查结果
青少年期实际随访到2236人,随访率为77.91%,年龄在15-18岁之间。青少年期超重检出率为9.35%(男生10.28%,女生7.49%),肥胖检出率为1.83%(男生2.09%,女生1.34%),超重肥胖检出率为11.18%(男生12.37%,女生8.83%)；暴露组超重检出率为11.73%,肥胖检出率为2.44%,对照组超重检出率为7.00%,肥胖检出率为1.24%。
暴露组的超重肥胖检出率(14.17%)高于对照组的超重肥胖检出率(8.24%),差别有统计学意义(P<0.001)。暴露组与对照组相比,发生超重和肥胖的RR分别为1.68(95%CI：1.28,2.19)和1.96(95%CI：1.04,3.72),AR分别为4.73%和1.20%。不同出生体重组之间青少年BMI均值不同,超重率和肥胖率有明显的随出生体重增加而增高的趋势(P<0.05)。
青少年期超重肥胖的影响因素分析：多因素非条件Logistic回归分析表明,男性(OR=1.43)、高出生体重(OR=1.62)、双亲均超重肥胖(OR=2.56)、母亲超重肥胖(OR=1.87),父亲超重肥胖(OR=1.85)、经常每顿吃得很饱(OR=1.45)、进餐速度偏快(OR=1.34)、使用电脑时间较长(OR=1.40)、母亲中等文化程度(OR=1.46)和较高文化程度(OR=2.01)均为青少年超重肥胖的危险因素,校内活动时间较多(OR=0.69)、母亲对肥胖持反对态度(OR=0.65)为保护因素。
出生体重与生活行为因素的交互作用分析：采用因子分析方法,共提取蛋白类食物、静坐生活方式、果蔬类食物、体育活动、饮食习惯和饮食偏好6个公因子。二分类Logistic回归分析显示,出生体重分别与蛋白类食物、果蔬类食物对超重肥胖的发生有相乘交互作用；出生体重与蛋白类食物、果蔬类食物、饮食偏好的交互作用相对超额危险度分别为-1.65(95%CI：-3.29,-0.01)、1.36(95%CI：0.37,2.36)和1.19(95%CI：0.14,2.23),均具有统计学意义,表明两者之间存在相加交互作用。交互作用归因比分别为76.74%、55.06%、48.29%。
5.儿童青少年超重肥胖的队列分析
在所有研究对象2236人中,出生时1108人为巨大儿,进入儿童期有317(14.18%)名儿童超重或肥胖,进入青少年期有250(11.18%)名青少年超重或肥胖。按照性别分组,男生出生时49.53%为巨大儿,儿童期18.08%超重肥胖,青少年期12.37%超重肥胖；女生出生时49.60%为巨大儿,儿童期6.42%超重肥胖,青少年期8.82%超重肥胖。由此可见从儿童期到青少年期,男生的超重肥胖检出率降低,而女生的超重肥胖检出率升高。
研究对象在不同时间体重变化趋势分析：性别与时间有交互作用,即男生和女生的体重异常率随时间的变化趋势不同。出生体重与时间没有交互作用,说明两因素的作用效果相互独立。从儿童期至青少年期,从总体来看,BMI分级转好率大于转差率,差别有统计学意义(P=0.003)；分性别来看,男生BMI分级转好率大于转差率,差别有统计学意义(P=0.004),女生BMI分级虽转好率大于转差率,但差别无统计学意义(P=0.286)。
6.父母超重肥胖对子女超重肥胖影响的分析
父母超重肥胖状况为双亲均正常、父亲超重肥胖、母亲超重肥胖、双亲均超重肥胖,其子女超重肥胖检出率依次为：12.01%、14.20%、15.94%、29.09%(儿童期)和7.52%、13.34%、13.43%、16.67%(青少年期),总体均呈现增加趋势(P<0.01)。
青少年BMI与其父母超重肥胖状况关系的多元线性回归分析结果显示,青少年BMI与其父母超重肥胖状况呈显著正相关,偏回归系数为0.54(95%CI：0.37,0.71)；青少年超重肥胖与其父母超重肥胖状况关系的多因素Logistic回归分析结果显示,父亲超重肥胖、母亲超重肥胖、双亲均超重肥胖的家庭与双亲均正常的家庭相比,其子女超重肥胖的危险性(OR值)分别为1.73(95%CI：1.23,2.42)、1.89(95%CI：1.18,3.02)和2.36(95%CI：1.49,3.73)。进一步分析不同性别青少年超重肥胖与其父母超重肥胖状况的关系,结果显示,在男生组,父亲超重肥胖和双亲均超重肥胖与双亲均正常相比,其子女超重肥胖的危险性(OR值)分别为1.83(95%CI：1.24,2.71)和2.05(95%CI：1.17,3.61),但在母亲超重肥胖者中,未观察到此效应；在女生组,母亲超重肥胖和双亲均超重肥胖与双亲均正常相比,其子女超重肥胖的危险性(OR值)分别为2.49(95%CI：1.09,5.68)和3.07(95%CI：1.36,6.92),但在父亲超重肥胖者中,未观察到此效应；由此推测母亲超重肥胖可能对其女儿超重肥胖的影响较大,而父亲超重肥胖可能对其儿子超重肥胖的影响较大；与双亲体重均正常相比,双亲同时超重肥胖对女儿(OR=3.07)超重肥胖产生的影响可能大于对儿子(OR=2.05)的影响。
青少年与其父(母)亲在超重肥胖和生活行为因素等方面的相关关系：父(母)亲和子女在BMI、BMI分级、饮酒、饮茶、吃油炸食品、每顿吃得很饱、进餐速度、对肥胖的态度、对体型的评价、是否需减肥方面有正相关关系。
[结论]
1.该队列超重率较高,儿童期超重肥胖率均高于青少年期。控制超重向肥胖发展是一个重要的预防措施,儿童期是超重肥胖的高发阶段,应引起高度重视。
2.高出生体重是影响儿童、青少年超重肥胖的独立危险因素,肥胖的一级预防应从胎儿期抓起；生活行为因素可能修饰出生体重与肥胖的关系,高出生体重的儿童青少年应作为高危人群进行重点干预,通过改变其不良的生活行为习惯,来降低肥胖发生的危险性。
3.父母超重肥胖是儿童、青少年超重肥胖的独立危险因素,且关联存在性别差异；父母与子女超重肥胖及其生活行为因素存在相关性。对儿童青少年肥胖的预防和干预,应重视家庭环境因素。
[Background]
Obesity has been becoming one of the serious global public health problems in the21st century. Obesity of children and adolescents in China is entering a period of high incidence rate. With the change of living environment following economic growth and urbanization, such as excessive energy intake, low level of physical activity and more sedentary lifestyle, prevalence of obesity also showed a clear increasing trend. The damages are far-reaching for obese children and adolescents, not only leading to physical and mental disorders and physiological dysfunction obstacle, affecting the ability to learn. It is more serious that the obesity of children and adolescents can be carried to adults, leading to high blood pressure, heart disease, diabetes and other chronic diseases, even long-term morbidity and early death. Overweight and obesity is one of the major risk factors for many chronic diseases. The obesity of children and adolescents has become the hidden danger of these diseases. We must attach importance to the problems caused by the obesity of children and adolescents.
The pathogenesis of obesity may have a genetic and environmental basis. A lot of study results showed that the risk factors causing the obesity of children and adolescents were various and interrelated, mainly including heredity, birth weight, diet, physical exercise, parental behaviors and awareness, society and economy, mental and other factors. Obesity whose reasons are complex is the result of multifactorial, long-term effects. Genetic factors determine the obesity susceptibility for individuals and various environmental factors promote the occurrence of obesity. The study demonstrated that it was an obvious growth trajectory phenomenon for the incidence and development of obesity at each phase of the age from embryo to adulthood. To investigate these phenomena and their impact factors will help to provide a theoretical basis for the obesity prevention of children and adolescents and launch effective early intervention. It will be also a great significance in reducing obesity related diseases in adulthood and ensuring lifelong health.
[Objective]
This study intends to understand the situation and related risk factors about overweight and obesity of a birth cohort including high and normal birth weight babies in childhood and adolescence; To analyze the weight change trends from birth to childhood and adolescence; To explore the interaction of birth weight and lifestyle factors, the impact of parental overweight and obesity on offspring and familial clustering of overweight and obesity and related lifestyle factors.
[Methods]
Subjects were selected from a birth cohort who was born in1993-1995in Jiangyin city and two central districts (Huishan and Xishan) of Wuxi city, Jiangsu Province. Those with birth weight≥4000g were selected as exposed group and those with birth weight<4000g but≥2500g as non-exposed group. This was a historic cohort study design. The baseline data was from the database established in the early90s of the three areas for women'perinatal health caring. It included mother's demographic characteristics, the status of health, the primary inspection for gestation and parturition, prenatal checkup, producing and perinatal inspection and so on. We started a follow-up visit for the subjects in childhood during October2005to October2006. Information was collected on individual growth situation, life styles, diet, exercises, family characteristic of the subjects and life styles of their parents and so on. Physical examinations included height, weight and blood pressure, etc. Based on the first visit, these subjects were followed up again from October2010to October2011during their adolescence. In addition to the one similar to the previous visit, the information collected in this time is more specific and detailed. The more information of the parents was collected. The data including height, weight and blood pressure and so on was also measured in this visit.
The body mass index (BMI) was regarded as the outcome variable of this study. Overweight and obesity were diagnosed by the Chinese sex-and age-specific BMI reference range published by Working Group of Obesity in China (WGOC). Overweight and obese children were used as study group matched by subjects with the same sex and age as control group.
All data was double entered into a database using Epidata3.1and analyzed by SPSS16.0and SAS9.2. Varied statistical methods including t-test, ANOVA,χ2test, rank sum test, Logistic regression model, factor analysis, correlation analysis, and GLMMs were used in the analysis.
[Results]
1. Description of the cohort
The cohort study started when the subjects were born. Through two follow-ups in childhood and adolescence,2236subjects were eligible into the analysis sample, including1108macrosomia and1128babies with normal birth weight. This population included1488boys, accounting for66.55%(737in exposed group,751in control group) and748girls, accounting for33.45%(371in exposed group,377in control group).
2. Baseline survey results
Risk factors for high birth weight included post-term pregnancy, maternal high BMI before pregnancy, more amount of increased weight of mother during pregnancy. Their odds ratios were2.31(95%CI:1.48,3.63),1.17(95%CI:1.07,1.27) and1.11(95%CI:1.08,1.14) respectively.
3. The follow-up survey results during childhood
2870subjects aged between10and13were actual followed up. The incidences of overweight and obesity were12.03%(boys were15.66%, girls were4.81%) and2.15%(boys were2.42%, girls were1.61%) respectively during childhood. The combined incidence of overweight and obesity is14.18%(boys were18.08%, girls were6.42%). The incidences of overweight and obesity were13.45%and2.80%in exposed group and those in non-exposed group were10.64%and1.51%.
The combined incidence of overweight and obesity of the exposed group (16.25%) was much higher than that of the non-exposed group (12.15%)(P=0.003). Compared with the non-exposed group, the relative risks of overweight and obesity in the exposed group were1.26(95%CI:1.01,1.58) and1.86(95%CI:1.03,3.33) respectively. Their attributable risks were2.81%and1.29%respectively. The average BMIs were different among the different birth weight groups. The incidences of overweight and obesity increased with birth weight increasing (P <0.01).
Factors associated with overweight and obesity of children:Logistic regression results showed that men (OR=2.06), high birth weight (OR=1.48), mother overweight and obesity (OR=2.22), artificial feeding in infancy (OR=2.80) and mixed feeding (OR-2.70), often eat fried foods (OR=1.41), often eat late supper (OR=4.59), much watching TV time (OR=1.37), higher income (OR=1.47) and father drinking (OR=1.34) were risk factors of overweight and obesity of children. More frequent milk consumption (OR=0.66) was a protective factor.
4. The follow-up survey results during adolescence
77.91%(2236) of targeted2870subjects aged between15and18were actually followed up. The incidences of overweight and obesity were9.35%(boys were10.28%, girls were7.49%) and1.83%(boys were2.09%, girls were1.34%) respectively. The combined incidence of overweight and obesity is11.18%(boys were12.37%, girls were8.83%). The incidences of overweight and obesity were11.73%and2.44%in exposed group and those in non-exposed group were7.00%and1.24%.
The combined incidence of overweight and obesity of the exposed group (14.17%)was much higher than that of the non-exposed group (8.24%)(P<0.001). Compared with the non-exposed group, the relative risks of overweight and obesity in the exposed group were1.68(95%CI:1.28,2.19) and1.96(95%CI:1.04,3.72) respectively. Their attributable risks were4.73%and1.20%respectively. The average BMIs were different among the different birth weight groups. The incidences of overweight and obesity increased with birth weight increasing (P <0.05).
Factors associated with overweight and obesity of adolescents:Logistic regression results showed that men (OR=1.43), high birth weight (OR=1.62), weight of both parents were abnormal (OR=2.56), weight of mother was abnormal (OR=1.87), weight of father was abnormal (OR=1.85), very full per meal (OR=1.45), faster speed of meal (OR=1.34), more duration of computer using (OR=1.40), average status of education of mother (OR=1.46), high status of education of mother (OR=2.01) were risk factors of overweight and obesity of adolescents. Much physical activity time (OR=0.69) and attitude of mother towards obesity (OR=0.65) were protective factors.
Interaction between birth weight and lifestyle factors on overweight and obesity of adolescents:among all lifestyle factors collected, six common factors including protein foods, sedentary lifestyle, fruits and vegetables, physical exercise, eating habits and food preferences were extracted through factor analysis. Logistic regression analysis showed that there were multiplicative interaction between birth weight and protein foods, fruits and vegetables. Their relative excess risk of interaction between birth weight and protein foods, fruits and vegetables and food preferences were-1.65(95%CI:-3.29,-0.01),1.36(95%CI:0.37,2.36) and1.19(95%CI:0.14,2.23) respectively. It indicated that there were additive interactions between them. The attributable proportion of interaction were76.74%,55.06%and48.29%.
5. The cohort analysis about overweight and obesity of children and adolescents
Among all2236subjects,1108were macrosomia and1128were normal birth weight babies. There were317(14.18%) children who were overweight or obese in childhood and250(11.18%) adolescents who were overweight or obese in adolescence. For boys, there were49.53%macrosomia.18.08%were overweight or obese in childhood and12.37%in adolescence. For girls, there were49.60%macrosomia.6.42%were overweight or obese in childhood and8.82%in adolescence. It can be drawn from above that the combined incidence of overweight and obesity of boys decreased and that of girls increased from childhood to adolescence.
The weight change trend analysis of the cohort members:there was interaction between gender and time. That meant the weight change trend of boys and girls were different with time. There was no interaction between birth weight and time which indicated that the effects of two factors were independent. From childhood to adolescence, generally, the improvement rate of the BMI classification was greater than the deterioration rate and the difference was statistically significant (P=0.003). The improvement rate of the BMI classification was greater than the deterioration rate in boys and the difference was statistically significant (P=0.004). The improvement rate of the BMI classification was greater than the deterioration rate in girls, but the difference was not statistically significant (P=0.286).
6. Analysis of the affect of parents'overweight and obesity for children
Based on parents'BMI status, in groups including both parents with normal weight, father with abnormal weight, mother with abnormal weight, both parents with abnormal weight, the incidences of overweight and obesity in their offsprings were12.01%,14.20%,15.94%,29.09%(childhood) and7.52%、13.34%、13.43%、16.67%(adolescence). They both showed an increasing trend.
The result of multiple linear regression exploring the relationship between adolescents'BMI and their parents'overweight and obesity status showed partial regression coefficient of parents'overweight and obesity status is0.54(95%CI:0.37,0.71)). The result of Logistic regression exploring the relationship of overweight and obesity status between adolescents and their parents showed compared with parents with normal weights, the risks of overweight and obesity for children whose father with abnormal weight, mother with abnormal weight and parents with abnormal weights were1.73(95%CI:1.23,2.42),1.89(95%CI:1.18,3.02) and2.36(95%CI:1.49,3.73). By further exploring these association between different genders, it indicated for boys whose father or parents with abnormal weight, their risks of overweight and obesity were1.83(95%CI:1.24,2.71) and2.05(95%CI:1.17,3.61) but no this finding for those whose mother with abnormal weight; For girls whose mother or parents with abnormal weight, their risks of overweight and obesity were2.49(95%CI:1.09,5.68) and3.07(95%CI:1.36,6.92) but no this finding for those whose father with abnormal weight. It can conjectured from above that mother with abnormal might have bigger impact on their daughters while father might have bigger impact on their sons. Compared with children whose parents with normal weight, parents with abnormal weight would have bigger impact on daughter (OR=3.07) than son (OR=2.05).
The correlation of adolescents and their parents on overweight and obesity and lifestyle factors and so on:there might exist positive correlation for the factors including BMI, BMI classification, drink, tea, eating fried food, very full per meal, speed of meal, attitude towards obesity, evaluation to children's stature and whether children need lose weight between parents and their children.
[Conclusions]
1. The incidence of overweight of this cohort is higher. The combined incidence of overweight and obesity in childhood is higher than in adolescence. It is an important protective measure to control overweight developing to obesity. Childhood is a period with high incidence of overweight and obesity and it should be paid high attention.
2. High birth weight has direct influence on overweight and obesity of children and adolescents. The primary prevention of obesity should start from fetus. Lifestyle factors might modify the relationship of birth weight and obesity. The children with high birth weight should be intervened as high risk population by changing their unhealthy life habits to reduce the risk of overweight and obesity.
3. Parental overweight and obesity status is an independent risk factor of overweight and obesity children and adolescents and this association would be different by genders. Overweight and obesity and lifestyle in parents and children are associated. Therefore, family factors should be paid attention for prevention and intervention of obesity in children and adolescents.
肥胖己成为21世纪全球公共卫生的严重问题之一,中国儿童青少年肥胖也正进入高发期。经济增长和都市化进程,引起生活环境的改变,如过度能量摄入、低体力活动、静坐生活方式增多等,肥胖患病率也随之呈现明显增加趋势。儿童青少年肥胖危害深远,不仅导致身心疾患和生理功能障碍,影响学习能力,更为严重的是儿童青少年肥胖可发展为成人肥胖,引起高血压、心脏病、糖尿病等慢性疾病,从而导致长期病态和早期死亡。超重、肥胖是多种慢性病的主要危险因素之一,而儿童青少年肥胖已经成为这些疾病的隐患。因此对儿童青少年肥胖问题必须加以重视。
肥胖是遗传和环境因素综合作用的结果。大量研究表明,引起儿童青少年肥胖的危险因素多种多样且相互关联,主要包括遗传、出生体重、饮食、体育锻炼、父母行为意识、社会经济、精神心理等因素。肥胖是多因素、长期作用的结果,原因错综复杂。遗传因素决定个体肥胖发生的易感性,而各种环境因素则促进肥胖的发生。研究证实,从胎儿到成年期的各年龄阶段中,肥胖的发生和发展有鲜明的生长发育轨迹现象,探讨这些现象及其影响因素,不仅有助于为儿童青少年肥胖的预防提供理论依据,有效开展早期干预,而且对减少成年期肥胖相关疾病、保障终身健康都具有重要意义。
[研究目的]
本研究拟了解巨大儿和正常出生体重儿队列在儿童期和青少年期超重、肥胖发生的现况和相关危险因素：分析从出生到儿童期再到青少年期,儿童青少年体重变化趋势；探讨出生体重与生活行为因素之间的交互作用、父母超重肥胖对子代超重肥胖的影响以及超重肥胖和相关生活行为因素的家庭聚集性。
[研究方法]
本研究选择江苏省无锡市的一个县级市(江阴市)和两个中心行政区(惠山区和锡山区)出生于1993-1995年的活产婴儿作为研究对象,其中出生体重大于等于4000克者作为暴露组,小于4000克同时大于等于2500克者作为对照组。采用历史性队列研究设计,基线数据来源于这三个地区在90年代初建立的妇女围产保健数据库,包括母亲的一般人口学特征、健康状况、初次孕产期检查、产前复查、产时及围产期检查等。2005年10月至2006年10月期间进行儿童期随访,随访所用调查表的内容主要包括研究对象的个人生长发育情况、生活方式、饮食运动习惯及其家庭特征和父母生活方式等,同时进行体格检查(身高、体重、血压等)。在此基础上,于2010年10月至2011年10月期间再次对已进入青春期的研究对象进行第二次随访,除收集与上次随访类似的信息外,本次随访信息更具体化和详细化,增加收集父母的相关信息,仍然进行体格检查(身高、体重及血压等)。
采用体质指数(BMI)作为结局变量,并以中国肥胖工作组(WGOC)发表的中国儿童青少年性别年龄别BMI参考值作为判定超重与肥胖的标准。以超重肥胖者作为病例,按同性别、同年龄配以对照,进行病例对照研究。
应用Epidata3.1软件建立数据库和设置核查程序,双遍录入所有数据。运用SPSS16.0和SAS9.2等软件进行统计分析,主要方法包括t检验、方差分析、χ2检验、秩和检验、非条件Logistic回归分析、因子分析、相关分析、广义线性混合效应模型等。
[研究结果]
1.队列概况
本次队列研究起点为研究对象出生时,经过儿童期和青少年期两次随访,最终进入分析的合格对象为2236人,其中出生时1108人为巨大儿,1128人为正常出生体重儿；男生1488名,占66.55%(暴露组737名,对照组751名),女生748名,占33.45%(暴露组371名,对照组377名)。
2.基线调查结果
过期妊娠、母亲孕前BMI较高和母亲孕期增加体重较多均是婴儿高出生体重的危险因素,OR值分别为2.31(95%CI：1.48,3.63)、1.17(95%CI：1.07,1.27)、1.11(95%CI：1.08,1.14)。
3.儿童期随访调查结果
儿童期实际随访到2870人,年龄在10-13岁之间。本人群儿童期超重检出率为12.03%(男生15.66%,女生4.81%),肥胖检出率为2.15%(男生2.42%,女生1.61%),超重肥胖检出率为14.18%(男生18.08%,女生6.42%)；暴露组中超重检出率为13.45%,肥胖检出率为2.80%,对照组中超重检出率为10.64%,肥胖检出率为1.51%。
暴露组的超重肥胖检出率(16.25%)高于对照组的超重肥胖检出率(12.15%),差别有统计学意义(P=0.003)；暴露组与对照组相比,发生超重和肥胖的RR分别为1.26(95%CI：1.01,1.58)和1.86(95%CI：1.03,3.33),AR分别为2.81%和1.29%。不同出生体重组之间儿童BMI均值不同,超重率和肥胖率有明显的随出生体重增加而增高的趋势(P<0.01)。
儿童期超重肥胖的影响因素分析：多因素非条件Logistic回归分析表明,男性(OR=2.06)、高出生体重(OR=1.48)、母亲超重肥胖(OR=2.22)、婴儿期人工喂养(OR=2.80)和混合喂养(OR=2.70)、经常吃油炸食品(OR=1.41)、经常吃夜宵(OR=4.59)、看电视时间较长(OR=1.37)、收入较高(OR=1.47)、父亲饮酒(OR=1.34)均为儿童超重肥胖的危险因素。牛奶食用次数较多(OR=0.66)为保护因素。
4.青少年期随访调查结果
青少年期实际随访到2236人,随访率为77.91%,年龄在15-18岁之间。青少年期超重检出率为9.35%(男生10.28%,女生7.49%),肥胖检出率为1.83%(男生2.09%,女生1.34%),超重肥胖检出率为11.18%(男生12.37%,女生8.83%)；暴露组超重检出率为11.73%,肥胖检出率为2.44%,对照组超重检出率为7.00%,肥胖检出率为1.24%。
暴露组的超重肥胖检出率(14.17%)高于对照组的超重肥胖检出率(8.24%),差别有统计学意义(P<0.001)。暴露组与对照组相比,发生超重和肥胖的RR分别为1.68(95%CI：1.28,2.19)和1.96(95%CI：1.04,3.72),AR分别为4.73%和1.20%。不同出生体重组之间青少年BMI均值不同,超重率和肥胖率有明显的随出生体重增加而增高的趋势(P<0.05)。
青少年期超重肥胖的影响因素分析：多因素非条件Logistic回归分析表明,男性(OR=1.43)、高出生体重(OR=1.62)、双亲均超重肥胖(OR=2.56)、母亲超重肥胖(OR=1.87),父亲超重肥胖(OR=1.85)、经常每顿吃得很饱(OR=1.45)、进餐速度偏快(OR=1.34)、使用电脑时间较长(OR=1.40)、母亲中等文化程度(OR=1.46)和较高文化程度(OR=2.01)均为青少年超重肥胖的危险因素,校内活动时间较多(OR=0.69)、母亲对肥胖持反对态度(OR=0.65)为保护因素。
出生体重与生活行为因素的交互作用分析：采用因子分析方法,共提取蛋白类食物、静坐生活方式、果蔬类食物、体育活动、饮食习惯和饮食偏好6个公因子。二分类Logistic回归分析显示,出生体重分别与蛋白类食物、果蔬类食物对超重肥胖的发生有相乘交互作用；出生体重与蛋白类食物、果蔬类食物、饮食偏好的交互作用相对超额危险度分别为-1.65(95%CI：-3.29,-0.01)、1.36(95%CI：0.37,2.36)和1.19(95%CI：0.14,2.23),均具有统计学意义,表明两者之间存在相加交互作用。交互作用归因比分别为76.74%、55.06%、48.29%。
5.儿童青少年超重肥胖的队列分析
在所有研究对象2236人中,出生时1108人为巨大儿,进入儿童期有317(14.18%)名儿童超重或肥胖,进入青少年期有250(11.18%)名青少年超重或肥胖。按照性别分组,男生出生时49.53%为巨大儿,儿童期18.08%超重肥胖,青少年期12.37%超重肥胖；女生出生时49.60%为巨大儿,儿童期6.42%超重肥胖,青少年期8.82%超重肥胖。由此可见从儿童期到青少年期,男生的超重肥胖检出率降低,而女生的超重肥胖检出率升高。
研究对象在不同时间体重变化趋势分析：性别与时间有交互作用,即男生和女生的体重异常率随时间的变化趋势不同。出生体重与时间没有交互作用,说明两因素的作用效果相互独立。从儿童期至青少年期,从总体来看,BMI分级转好率大于转差率,差别有统计学意义(P=0.003)；分性别来看,男生BMI分级转好率大于转差率,差别有统计学意义(P=0.004),女生BMI分级虽转好率大于转差率,但差别无统计学意义(P=0.286)。
6.父母超重肥胖对子女超重肥胖影响的分析
父母超重肥胖状况为双亲均正常、父亲超重肥胖、母亲超重肥胖、双亲均超重肥胖,其子女超重肥胖检出率依次为：12.01%、14.20%、15.94%、29.09%(儿童期)和7.52%、13.34%、13.43%、16.67%(青少年期),总体均呈现增加趋势(P<0.01)。
青少年BMI与其父母超重肥胖状况关系的多元线性回归分析结果显示,青少年BMI与其父母超重肥胖状况呈显著正相关,偏回归系数为0.54(95%CI：0.37,0.71)；青少年超重肥胖与其父母超重肥胖状况关系的多因素Logistic回归分析结果显示,父亲超重肥胖、母亲超重肥胖、双亲均超重肥胖的家庭与双亲均正常的家庭相比,其子女超重肥胖的危险性(OR值)分别为1.73(95%CI：1.23,2.42)、1.89(95%CI：1.18,3.02)和2.36(95%CI：1.49,3.73)。进一步分析不同性别青少年超重肥胖与其父母超重肥胖状况的关系,结果显示,在男生组,父亲超重肥胖和双亲均超重肥胖与双亲均正常相比,其子女超重肥胖的危险性(OR值)分别为1.83(95%CI：1.24,2.71)和2.05(95%CI：1.17,3.61),但在母亲超重肥胖者中,未观察到此效应；在女生组,母亲超重肥胖和双亲均超重肥胖与双亲均正常相比,其子女超重肥胖的危险性(OR值)分别为2.49(95%CI：1.09,5.68)和3.07(95%CI：1.36,6.92),但在父亲超重肥胖者中,未观察到此效应；由此推测母亲超重肥胖可能对其女儿超重肥胖的影响较大,而父亲超重肥胖可能对其儿子超重肥胖的影响较大；与双亲体重均正常相比,双亲同时超重肥胖对女儿(OR=3.07)超重肥胖产生的影响可能大于对儿子(OR=2.05)的影响。
青少年与其父(母)亲在超重肥胖和生活行为因素等方面的相关关系：父(母)亲和子女在BMI、BMI分级、饮酒、饮茶、吃油炸食品、每顿吃得很饱、进餐速度、对肥胖的态度、对体型的评价、是否需减肥方面有正相关关系。
[结论]
1.该队列超重率较高,儿童期超重肥胖率均高于青少年期。控制超重向肥胖发展是一个重要的预防措施,儿童期是超重肥胖的高发阶段,应引起高度重视。
2.高出生体重是影响儿童、青少年超重肥胖的独立危险因素,肥胖的一级预防应从胎儿期抓起；生活行为因素可能修饰出生体重与肥胖的关系,高出生体重的儿童青少年应作为高危人群进行重点干预,通过改变其不良的生活行为习惯,来降低肥胖发生的危险性。
3.父母超重肥胖是儿童、青少年超重肥胖的独立危险因素,且关联存在性别差异；父母与子女超重肥胖及其生活行为因素存在相关性。对儿童青少年肥胖的预防和干预,应重视家庭环境因素。
[Background]
Obesity has been becoming one of the serious global public health problems in the21st century. Obesity of children and adolescents in China is entering a period of high incidence rate. With the change of living environment following economic growth and urbanization, such as excessive energy intake, low level of physical activity and more sedentary lifestyle, prevalence of obesity also showed a clear increasing trend. The damages are far-reaching for obese children and adolescents, not only leading to physical and mental disorders and physiological dysfunction obstacle, affecting the ability to learn. It is more serious that the obesity of children and adolescents can be carried to adults, leading to high blood pressure, heart disease, diabetes and other chronic diseases, even long-term morbidity and early death. Overweight and obesity is one of the major risk factors for many chronic diseases. The obesity of children and adolescents has become the hidden danger of these diseases. We must attach importance to the problems caused by the obesity of children and adolescents.
The pathogenesis of obesity may have a genetic and environmental basis. A lot of study results showed that the risk factors causing the obesity of children and adolescents were various and interrelated, mainly including heredity, birth weight, diet, physical exercise, parental behaviors and awareness, society and economy, mental and other factors. Obesity whose reasons are complex is the result of multifactorial, long-term effects. Genetic factors determine the obesity susceptibility for individuals and various environmental factors promote the occurrence of obesity. The study demonstrated that it was an obvious growth trajectory phenomenon for the incidence and development of obesity at each phase of the age from embryo to adulthood. To investigate these phenomena and their impact factors will help to provide a theoretical basis for the obesity prevention of children and adolescents and launch effective early intervention. It will be also a great significance in reducing obesity related diseases in adulthood and ensuring lifelong health.
[Objective]
This study intends to understand the situation and related risk factors about overweight and obesity of a birth cohort including high and normal birth weight babies in childhood and adolescence; To analyze the weight change trends from birth to childhood and adolescence; To explore the interaction of birth weight and lifestyle factors, the impact of parental overweight and obesity on offspring and familial clustering of overweight and obesity and related lifestyle factors.
[Methods]
Subjects were selected from a birth cohort who was born in1993-1995in Jiangyin city and two central districts (Huishan and Xishan) of Wuxi city, Jiangsu Province. Those with birth weight≥4000g were selected as exposed group and those with birth weight<4000g but≥2500g as non-exposed group. This was a historic cohort study design. The baseline data was from the database established in the early90s of the three areas for women'perinatal health caring. It included mother's demographic characteristics, the status of health, the primary inspection for gestation and parturition, prenatal checkup, producing and perinatal inspection and so on. We started a follow-up visit for the subjects in childhood during October2005to October2006. Information was collected on individual growth situation, life styles, diet, exercises, family characteristic of the subjects and life styles of their parents and so on. Physical examinations included height, weight and blood pressure, etc. Based on the first visit, these subjects were followed up again from October2010to October2011during their adolescence. In addition to the one similar to the previous visit, the information collected in this time is more specific and detailed. The more information of the parents was collected. The data including height, weight and blood pressure and so on was also measured in this visit.
The body mass index (BMI) was regarded as the outcome variable of this study. Overweight and obesity were diagnosed by the Chinese sex-and age-specific BMI reference range published by Working Group of Obesity in China (WGOC). Overweight and obese children were used as study group matched by subjects with the same sex and age as control group.
All data was double entered into a database using Epidata3.1and analyzed by SPSS16.0and SAS9.2. Varied statistical methods including t-test, ANOVA,χ2test, rank sum test, Logistic regression model, factor analysis, correlation analysis, and GLMMs were used in the analysis.
[Results]
1. Description of the cohort
The cohort study started when the subjects were born. Through two follow-ups in childhood and adolescence,2236subjects were eligible into the analysis sample, including1108macrosomia and1128babies with normal birth weight. This population included1488boys, accounting for66.55%(737in exposed group,751in control group) and748girls, accounting for33.45%(371in exposed group,377in control group).
2. Baseline survey results
Risk factors for high birth weight included post-term pregnancy, maternal high BMI before pregnancy, more amount of increased weight of mother during pregnancy. Their odds ratios were2.31(95%CI:1.48,3.63),1.17(95%CI:1.07,1.27) and1.11(95%CI:1.08,1.14) respectively.
3. The follow-up survey results during childhood
2870subjects aged between10and13were actual followed up. The incidences of overweight and obesity were12.03%(boys were15.66%, girls were4.81%) and2.15%(boys were2.42%, girls were1.61%) respectively during childhood. The combined incidence of overweight and obesity is14.18%(boys were18.08%, girls were6.42%). The incidences of overweight and obesity were13.45%and2.80%in exposed group and those in non-exposed group were10.64%and1.51%.
The combined incidence of overweight and obesity of the exposed group (16.25%) was much higher than that of the non-exposed group (12.15%)(P=0.003). Compared with the non-exposed group, the relative risks of overweight and obesity in the exposed group were1.26(95%CI:1.01,1.58) and1.86(95%CI:1.03,3.33) respectively. Their attributable risks were2.81%and1.29%respectively. The average BMIs were different among the different birth weight groups. The incidences of overweight and obesity increased with birth weight increasing (P <0.01).
Factors associated with overweight and obesity of children:Logistic regression results showed that men (OR=2.06), high birth weight (OR=1.48), mother overweight and obesity (OR=2.22), artificial feeding in infancy (OR=2.80) and mixed feeding (OR-2.70), often eat fried foods (OR=1.41), often eat late supper (OR=4.59), much watching TV time (OR=1.37), higher income (OR=1.47) and father drinking (OR=1.34) were risk factors of overweight and obesity of children. More frequent milk consumption (OR=0.66) was a protective factor.
4. The follow-up survey results during adolescence
77.91%(2236) of targeted2870subjects aged between15and18were actually followed up. The incidences of overweight and obesity were9.35%(boys were10.28%, girls were7.49%) and1.83%(boys were2.09%, girls were1.34%) respectively. The combined incidence of overweight and obesity is11.18%(boys were12.37%, girls were8.83%). The incidences of overweight and obesity were11.73%and2.44%in exposed group and those in non-exposed group were7.00%and1.24%.
The combined incidence of overweight and obesity of the exposed group (14.17%)was much higher than that of the non-exposed group (8.24%)(P<0.001). Compared with the non-exposed group, the relative risks of overweight and obesity in the exposed group were1.68(95%CI:1.28,2.19) and1.96(95%CI:1.04,3.72) respectively. Their attributable risks were4.73%and1.20%respectively. The average BMIs were different among the different birth weight groups. The incidences of overweight and obesity increased with birth weight increasing (P <0.05).
Factors associated with overweight and obesity of adolescents:Logistic regression results showed that men (OR=1.43), high birth weight (OR=1.62), weight of both parents were abnormal (OR=2.56), weight of mother was abnormal (OR=1.87), weight of father was abnormal (OR=1.85), very full per meal (OR=1.45), faster speed of meal (OR=1.34), more duration of computer using (OR=1.40), average status of education of mother (OR=1.46), high status of education of mother (OR=2.01) were risk factors of overweight and obesity of adolescents. Much physical activity time (OR=0.69) and attitude of mother towards obesity (OR=0.65) were protective factors.
Interaction between birth weight and lifestyle factors on overweight and obesity of adolescents:among all lifestyle factors collected, six common factors including protein foods, sedentary lifestyle, fruits and vegetables, physical exercise, eating habits and food preferences were extracted through factor analysis. Logistic regression analysis showed that there were multiplicative interaction between birth weight and protein foods, fruits and vegetables. Their relative excess risk of interaction between birth weight and protein foods, fruits and vegetables and food preferences were-1.65(95%CI:-3.29,-0.01),1.36(95%CI:0.37,2.36) and1.19(95%CI:0.14,2.23) respectively. It indicated that there were additive interactions between them. The attributable proportion of interaction were76.74%,55.06%and48.29%.
5. The cohort analysis about overweight and obesity of children and adolescents
Among all2236subjects,1108were macrosomia and1128were normal birth weight babies. There were317(14.18%) children who were overweight or obese in childhood and250(11.18%) adolescents who were overweight or obese in adolescence. For boys, there were49.53%macrosomia.18.08%were overweight or obese in childhood and12.37%in adolescence. For girls, there were49.60%macrosomia.6.42%were overweight or obese in childhood and8.82%in adolescence. It can be drawn from above that the combined incidence of overweight and obesity of boys decreased and that of girls increased from childhood to adolescence.
The weight change trend analysis of the cohort members:there was interaction between gender and time. That meant the weight change trend of boys and girls were different with time. There was no interaction between birth weight and time which indicated that the effects of two factors were independent. From childhood to adolescence, generally, the improvement rate of the BMI classification was greater than the deterioration rate and the difference was statistically significant (P=0.003). The improvement rate of the BMI classification was greater than the deterioration rate in boys and the difference was statistically significant (P=0.004). The improvement rate of the BMI classification was greater than the deterioration rate in girls, but the difference was not statistically significant (P=0.286).
6. Analysis of the affect of parents'overweight and obesity for children
Based on parents'BMI status, in groups including both parents with normal weight, father with abnormal weight, mother with abnormal weight, both parents with abnormal weight, the incidences of overweight and obesity in their offsprings were12.01%,14.20%,15.94%,29.09%(childhood) and7.52%、13.34%、13.43%、16.67%(adolescence). They both showed an increasing trend.
The result of multiple linear regression exploring the relationship between adolescents'BMI and their parents'overweight and obesity status showed partial regression coefficient of parents'overweight and obesity status is0.54(95%CI:0.37,0.71)). The result of Logistic regression exploring the relationship of overweight and obesity status between adolescents and their parents showed compared with parents with normal weights, the risks of overweight and obesity for children whose father with abnormal weight, mother with abnormal weight and parents with abnormal weights were1.73(95%CI:1.23,2.42),1.89(95%CI:1.18,3.02) and2.36(95%CI:1.49,3.73). By further exploring these association between different genders, it indicated for boys whose father or parents with abnormal weight, their risks of overweight and obesity were1.83(95%CI:1.24,2.71) and2.05(95%CI:1.17,3.61) but no this finding for those whose mother with abnormal weight; For girls whose mother or parents with abnormal weight, their risks of overweight and obesity were2.49(95%CI:1.09,5.68) and3.07(95%CI:1.36,6.92) but no this finding for those whose father with abnormal weight. It can conjectured from above that mother with abnormal might have bigger impact on their daughters while father might have bigger impact on their sons. Compared with children whose parents with normal weight, parents with abnormal weight would have bigger impact on daughter (OR=3.07) than son (OR=2.05).
The correlation of adolescents and their parents on overweight and obesity and lifestyle factors and so on:there might exist positive correlation for the factors including BMI, BMI classification, drink, tea, eating fried food, very full per meal, speed of meal, attitude towards obesity, evaluation to children's stature and whether children need lose weight between parents and their children.
[Conclusions]
1. The incidence of overweight of this cohort is higher. The combined incidence of overweight and obesity in childhood is higher than in adolescence. It is an important protective measure to control overweight developing to obesity. Childhood is a period with high incidence of overweight and obesity and it should be paid high attention.
2. High birth weight has direct influence on overweight and obesity of children and adolescents. The primary prevention of obesity should start from fetus. Lifestyle factors might modify the relationship of birth weight and obesity. The children with high birth weight should be intervened as high risk population by changing their unhealthy life habits to reduce the risk of overweight and obesity.
3. Parental overweight and obesity status is an independent risk factor of overweight and obesity children and adolescents and this association would be different by genders. Overweight and obesity and lifestyle in parents and children are associated. Therefore, family factors should be paid attention for prevention and intervention of obesity in children and adolescents.
引文
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