PhD Thesis. Summary in English and Danish. Correlates of objectively measured physical activity in Danish preschool children.
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1 PhD Thesis Summary in English and Danish Correlates of objectively measured physical activity in Danish preschool children. The Odense Preschool Study (TOPS) Line Grønholt Olesen The Department of Sports Science and Clinical Biomechanics Centre of Research in Childhood Health (RICH) Faculty of Health Sciences University of Southern Denmark Odense,
2 SUMMARY IN ENGLISH Introduction: The evidence of a positive connection between health outcomes and physical activity (PA) in preschool-age children is increasing. Similarly, the evidence that a large proportion of preschool children are not sufficiently physically active is growing. This knowledge has contributed to an increased interest in obtaining a basic understanding of preschool children s habitual PA patterns and factors explaining the variability in PA levels among children. Few studies on correlates of PA in preschool children have been conducted in Europe and knowledge is limited. Recently, a socioecological approach involving the simultaneous study of multiple potential correlates of PA has emerged. The approach is based on the theory that behaviour has multiple levels of influences. So far, important correlates such as gender (boy), outdoor time and the specific preschool have been identified as important predictors of preschool children s PA behaviour. Results between studies are inconsistent, and studies designed to replicate earlier findings in large cluster randomised controlled intervention studies have seen limited success. Thus, well-designed cross-sectional studies are still needed to identify potential correlates of PA in preschool children. Furthermore, there is a need to study basic sources of variation in preschool children s level of PA, including day type variations and variations across different settings (preschool versus leisure time environment), in order to obtain a better understanding of PA behaviour among this age group, and also to qualify the study of potential correlates of PA. From a health perspective, two of the most important potential correlates of MVPA among the preschool population are obesity and motor skills. In addition to studying the relationship between these variables and MVPA, representative prevalence estimates and comparisons to normreferenced data are needed in order to assist the continuous monitoring of overweight and motor skill difficulties among the preschool population. The primary aim of this PhD thesis, based on socioecological theory, was to identify potential correlates of 5- to 6-year-old Danish preschool children s level of daily MVPA at preschool and from a full-day perspective, respectively, as well as to determine the extent to which PA and MVPA levels vary between preschools and whether the variation is gender-dependent. The secondary aim was to provide gender-specific descriptive information on body weight and motor skills in 5- to 6-year-old children relative to norm-referenced data, and to study genderspecific patterns of PA by type of weekday and selected time periods of the day. Materials and Methods: The thesis is based on data from The Odense Preschool Study (TOPS), a cross-sectional population-based study. Participants were 607 children 5 6 years of age (born in 2
3 2003), their parents and the preschool staff in 43 randomly selected preschools. The preschools were stratified for location (urban, rural), socioeconomic position, and size. The children s PA patterns and percentage of daily time spend in MVPA were assessed objectively by ActiGraph GT1M/GT3X activity monitors in May and June The data collected were based on measurements, observations and questionnaires and tested in multilevel statistical models with preschool and individual child included as random effects. Results: The preschool accounted for 19% and 8% of the total variance in the children s habitual PA and MVPA, respectively, with significant gender differences (PA/MVPA: girls (42/27%), boys (6/4%)). Out of 37 potential correlates, we identified 9 significant correlates of child MVPA level at preschool. KTK motor coordination, location of the preschool building on the playground, gender (boy), percentage of preschool afternoon hours, and size of preschool indoor area (m 2 per child) were positively associated with child MVPA level, whereas preterm birth, vegetation on the playground, and rainy days were negatively associated with child MVPA. The associations with fixed sport equipment, location (rural), and size of playground area (m 2 ) approached significance (p<0.10). Out of 39 potential correlates of gender-specific MVPA from a full-day perspective, we identified 8 and 6 significant correlates for boys and girls, respectively. The gender-specific models consistently identified KTK motor coordination and parents perception of their child s activity preferences during free play to be positively associated with MVPA, whereas days with rain or days off (predominantly weekend days) were negatively associated with MVPA. In boys, living in a rural area and preschool playground area (m 2 ) were positively associated with MVPA. In girls, age and relative size of the preschool indoor area (m 2 per child) were positively associated with MVPA. A further reduction in the girls MVPA level was identified during rainy days off, as compared to weekdays. The prevalence of children at risk of overweight (9%) and obesity (2%) seem to be identical with other regions in Denmark and earlier cohorts in the municipality of Odense, Funen. The prevalence of children being at risk of underweight grades 1 and 2 was 7% and 1%, respectively. Relative to the norm-referenced motor skill classifications, the children performed well on the MABC-2 aiming and catching component, but performed more poorly on the KTK motor coordination test, similar to other countries. The preschool children were most physically active on weekdays, at preschool, and in the late afternoon during weekend days, in contrast to what has been reported in other countries. 3
4 Boys have a higher PA level in the morning hours at preschool. Furthermore, there are gender differences in time spent at different intensity levels, especially at preschool. The less physically active children, despite their lower PA levels, showed similar PA patterns to the more active children. However, we did detect a significant difference in the relative decrease in mean PA between preschool and weekday leisure time by quartiles of PA. This result indicated that the children in the lowest PA quartile reduced their mean PA level relatively more during the transition from preschool to weekday leisure time than did the children in the highest PA quartile. Conclusion: The specific preschool has significant impact on children s PA and MVPA levels, especially in girls. The correlates showing the strongest association with child MVPA were location of preschool on the playground, and parents perception of their child s activity preferences during free play. However, most of the correlates were not related to MVPA or showed limited associations with MVPA. Only a few of the identified correlates were modifiable, namely location of preschool, degree of vegetation on the playground and KTK motor coordination skills. It is possible that in this age group, interaction with peers and surrounding adults might contribute more to child MVPA than do factors in the physical environment, which this study mainly deals with. In relation to the selected health parameters and PA patterns, gender differences were not apparent, with few exceptions, in this group of Danish preschool children. The PA patterns indicated that weekday afternoons could be an important target setting for future studies aimed at increasing PA for the least active children, and overall weekends could also be an important target for PA and MVPA intervention. 4
5 SUMMARY IN DANISH Den videnskabelige dokumentation for en positiv sammenhæng mellem sundhedsparametre og fysisk aktivitet (FA) hos børn i børnehavealderen er stigende. Tilsvarende øges den videnskabelige dokumentation for, at en stor andel af børnehavebørnene ikke er tilstrækkeligt fysisk aktive. Denne viden har bidraget til en øget interesse i at opnå en grundlæggende viden om børnehavebørns fysiske aktivitetsmønstre og de faktorer, som kan forklare variationen i FA mellem børn. Der er begrænset viden generelt og særligt i Europa om faktorer, som kan associeres til børnehavebørns fysiske aktivitetsniveau. I nyere studier tages ofte udgangspunkt i den socio økologiske tilgang, hvor flere potentielle faktorer testes samtidigt ud fra den teori, at adfærd påvirkes af faktorer på flere niveauer samtidigt. Tidligere studier har vist, at vigtige prædiktorer for børnehavebørns FA adfærd er køn (dreng), tiden udenfor og den enkelte børnehave. Der er imidlertid inkonsistente resultater mellem studier, og effekten ved implementering af modificerbare faktorer i store randomiserede kontrollerede interventionsstudier er begrænset. Der er således behov for veldesignede tværsnitsundersøgelser til identifikation af potentielle faktorer, som kan associeres til FA hos børnehavebørn. Ligeledes er det er behov for at studere grundlæggende variationskilder i børnehavebørns fysiske aktivitetsmønstre, herunder variationer på tværs af dagstyper og lokalisationer (f.eks. børnehave versus fritid), med det formål at opnå en detaljeret forståelse for børnehavebørns fysisk aktivitetsadfærd, men også for at kunne kvalificere studiet af faktorer, som potentielt er associeret til FA hos børnehavebørn. To af de potentielle korrelater til fysisk aktivitet, som i et sundhedsperspektiv må betragtes som meget væsentlige er fedme og nedsatte motoriske evner. Udover at studere sammenhænge til fysisk aktivitet er der et udtalt behov for repræsentative prævalensestimater herunder sammenligninger til norm-baseret data for fremadrettet at kunne monitorere hyppigheden af overvægt og nedsatte motoriske evner hos børnehavebørn. Det primære formål med denne Ph.d. afhandling var med udgangspunkt i den socio økologiske teori, at identificere variabler, der kan associeres med danske børnehavebørns MHFA adfærd henholdsvis i børnehavetiden og i et heldagsperspektiv. Dette mål inkluderer også en bestemmelse af størrelsen af variationen i FA og MHFA mellem børnehaverne, herunder en undersøgelse af om denne variation er kønsspecifik. Det sekundære mål var, at beskrive kropsvægt- og motorik status hos 5-6 årige børn opdelt på køn og sammenligne med norm-baseret data, samt at studere 5
6 børnehavebørnenes aktivitetsmønstre på tværs af køn, dagstype og udvalgte tidsperioder over dagen. Metode: Afhandlingen er baseret på tværsnitsundersøgelsen: Odense børnehaveprojektet (TOPS). I alt deltog 607 børn i alderen 5-6 år (årgang 2003), samt deres forældre og personalet i 43 tilfældigt udvalgte børnehaver. Børnehaverne var stratificerede for område (by, land), socioøkonomisk status og areal. Børnenes FA mønstre og den procentvise daglige tid tilbragt ved MHFA blev målt objektivt med Actigraph GT1M/ GT3X aktivitetsmålere i maj/juni Data blev indsamlet ved målinger, observationer og spørgeskemaer og testet i multiple statistiske modeller med børnehave og det individuelle barn som random effects. Resultater: Børnehaven forklarede henholdsvis 19 % og 8 % af den totale variation i børnenes FA og MHFA niveau, dog med store kønsforskelle (FA/MHFA: Piger (42/27%), drenge (6/4%)). Ud af 37 faktorer, som potentielt kunne associeres til børnenes MHFA niveau i børnehavetiden blev 9 faktorer testet signifikante. KTK koordinations testen, børnehavernes placering på legepladsen, køn (dreng), procent af den samlede tid tilbragt i BH om eftermiddagen, og det totale indendørs areal (m 2 per barn) var positivt associeret med børnenes MHFA. Derimod var tidlig fødsel, vegetation på legepladsen og dage med regn negativt associeret med børnenes MHFA niveau. Associationen med sports udstyr, lokalisation (land), og udendørs areal (m 2 ) var borderline signifikant (p<0.10). Ud af 39 faktorer, identificerede vi 8 og 7 faktorer for henholdsvis piger og drenge, som kunne associeres til MHFA i et samlet dagsperspektiv. Samstemmende for piger og drenge var resultatet af KTK koordinations testen og forældrenes angivelse af barnets aktivitetspræferencer under fri leg positivt associeret med børnenes MHFA niveau, mens dage med regn og fridage (overvejende weekenddage) var negativt associeret med børnenes MHFA niveau. Specifikt for drenge, var lokalisation (rural), og størrelsen af børnehavens legeplads (m 2 ) positivt associeret med MHFA. Specifikt for piger, var alder og børnehavens totale indendørs areal (m 2 per barn) positivt associeret med MHFA. Pigernes MHFA niveau, blev sammenlignet med hverdage reduceret yderligere på fri dage. Prævalensen af overvægt (9%) og fedme (2%) i den undersøgte population er identisk med resultater fra andre dele af Danmark og tidligere kohorter i Odense kommune. For undervægt (grad 1 og 2) var de estimerede værdier henholdsvis 7% og 1%. Relativt til norm-materialet for de motoriske tests præsterede børnene godt i MABC-2 kaste- og gribetesten, men dårligere i KTK koordinationstesten - konsistent med observationer fra andre lande. 6
7 Børnene var mest fysisk aktive på hverdage, i børnehavetiden og sidst på eftermiddagen/aftenen i weekenden i modsætning til hvad der er rapporteret i andre lande. Drenge har det højeste FA niveau i formiddagstimerne i børnehaven og studiet afslørede yderligere kønsforskelle i tiden tilbragt ved forskellige intensiteter, særligt i børnehavetiden. De mindst fysisk aktive børn havde trods et lavere FA niveau samme aktivitetsmønster som mere aktive børn. En signifikant forskel blev dog påvist mellem grupper af børn med forskelligt gennemsnitligt fysisk aktivitetsniveau i forhold til den relative ændring i FA fra børnehavetid til fritid. Sammenlignet med gruppen af børn som var mest aktive, indikerede resultatet, at gruppen af de mindst aktive børn reducerede deres gennemsnitlige FA niveau relativt mere i transitionen fra børnehavetid til fritid i hverdagen. Konklusion: Børnehaven har betydelig indflydelse på børnehavebørnenes FA and MVPA niveau - det gælder særligt for pigerne. De faktorer som viste den stærkeste association med børnenes MVPA niveau var placeringen af børnehaven på legepladsen og forældrenes indikation af barnets aktivitets præferencer under fri leg. De fleste faktorer viste mod forventning ingen eller kun en svagere sammenhæng med MVPA. Der blev kun identificeret få modificerbare korrelater til MVPA: børnehavens lokalisation på legepladsen, graden af vegetation på legepladsen i børnehaven og motorisk koordination. Det er muligt at samværet med venner og de omgivende voksne har større indflydelse på barnets MVPA niveau i denne alder end de fysiske omgivelser, som dette studie primært beskæftiger sig med. Med få undtagelser syntes kønsforskelle i relation til de udvalgte sundhedsparametre og de overordnede FA mønstre ikke at være målbare i denne gruppe af børnehavebørn. Resultatet mht. mønstre i FA indikerede, at gruppen af børn som er mindst fysisk aktive særligt har et lavere aktivitetsniveau om eftermiddagen på hverdage sammenlignet med generelt mere aktive børn, og endvidere peger resultaterne på at weekenden kunne være et vigtigt mål for interventionsindsatser. 7
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