Effects of the COVID-19 pandemic on the physical activity and screen time habits of children aged 11-13 years in Sweden.

Introduction: Physical activity (PA), exercise, sedentary behavior and screen time are lifestyle factors that have been shown to significantly impact child health in different ways. These lifestyle factors were affected to different degrees by global restrictions during the COVID-19 pandemic. We investigated PA and screen time in a cohort of Swedish children in both 2019 and 2021, before and during the pandemic. Method: Adolescents born in 2008 in Halland, Sweden, and included in a previous longitudinal birth cohort study were invited to take part in follow-up questionnaires about PA, screen time and COVID-19. A total of 1041 children aged 11 (in 2019) and 13 years (in 2021) replied and 777 of them answered on both occasions. Results: Most children (42.1%) reported that their leisure time PA was unchanged from 2019 to 2021. Compared to unchanged PA 33.9% exercised more often (p = 0.011) and 23.9% exercised less (p < 0.001), both differences statistically significant. Roughly, 43.2% of boys and 34.9% of girls in 2021 exercised so that they became breathless or broke a sweat at least 4 times a week not counting physical education in school, corresponding figures for 2019 were 38.2% for boys and 35.2% for girls. The majority of children were able to continue attending leisure time sports clubs during the pandemic, but participation decreased from 88.3% to 76.3% from 11 to 13 years of age. Most reported that sports club routines changed during the pandemic, but only 40.9% reported fewer practice opportunities. Attending a sports club gave greater protection against loss of PA during the pandemic than not belonging to one (41.0% vs. 23.2%, p < 0.001). The majority (71.1%) of children spent more time on screens in 2021 than 2019, with a mean increase of 9.4 h (95% CI 8.6 to 10.2 h) from 20.7 to 30.1 hours per week (p < 0.001) during the study. Conclusions: Swedish children largely maintained their levels of PA during the pandemic at 13 years of age and these were possibly safeguarded by the comparably mild pandemic restrictions in Sweden in 2021. However, they did increase their screen time between 11 and 13 years of age.

Associations between pain, health, and lifestyle factors in 10-year-old boys and girls from a Swedish birth cohort.

BACKGROUND: Pain is common in children and its associations with various biopsychosocial factors is complex. Comprehensive pain assessments could contribute to a better understanding of pediatric pain, but these assessments are scarce in literature. The aim of this study was to examine differences in pain prevalence and pain patterns in 10-year-old boys and girls from a Swedish birth cohort and to study associations between pain, health-related quality of life and various lifestyle factors stratified by sex. METHODS: 866 children (426 boys and 440 girls) and their parents from the "Halland Health and Growth Study" participated in this cross-sectional study. Children were categorized into two pain groups, "infrequent pain" (never-monthly pain) or "frequent pain" (weekly-almost daily pain), based on a pain mannequin. Univariate logistic regression analyses, stratified by sex, were performed to study associations between frequent pain and children's self-reports of disease and disability and health-related quality of life (Kidscreen-27, five domains), and parents' reports of their child's sleep (quality and duration), physical activity time, sedentary time, and participation in organized physical activities. RESULTS: The prevalence of frequent pain was 36.5% with no difference between boys and girls (p = 0.442). Boys with a longstanding disease or disability had higher odds of being in the frequent pain group (OR 2.167, 95% CI 1.168-4.020). Higher scores on health-related quality of life in all five domains for girls, and in two domains for boys, was associated with lower odds of being categorized into the frequent pain group. Frequent pain was associated with poor sleep quality (boys OR 2.533, 95% CI 1.243-5.162; girls OR 2.803, 95% CI 1.276-6.158) and more sedentary time (boys weekends OR 1.131, 95% CI 1.022-1.253; girls weekdays OR 1.137, 95% CI 1.032-1.253), but not with physical activity. CONCLUSIONS: The high prevalence of frequent pain needs to be acknowledged and treated by school health-care services and the healthcare sector in order to prevent pain from influencing health and lifestyle factors negatively in children.

Study protocol for an effectiveness-implementation hybrid trial to evaluate a health promotion intervention in parents and their 5-year-old child: Saga Stories in health talks in Swedish child healthcare.

BACKGROUND: Unhealthy lifestyle behaviours such as a poor diet, inadequate physical activity, and excessive screen time have been shown to be established in childhood and track into adulthood, demonstrating the need for health promotion interventions in the pre-school years. The overall aim of this project is to: (i) evaluate the effectiveness of `Saga Stories in health talks´ within child healthcare (CHC) on parental self-efficacy to promote healthy diet, physical activity, and screen time behaviours in their child; children's intake of key dietary indicators and screen time and (ii) evaluate and explore the implementation of `Saga Stories in health talks´ with regards to acceptability, appropriateness, feasibility, fidelity, adoption, sustainability, satisfaction, and usage. METHODS: A hybrid type I effectiveness-implementation trial will be conducted. A cluster randomized controlled trial will be used to assess the effectiveness of `Saga Stories in health talks´ in 42 CHC centers across six regions in Sweden. `Saga Stories in health talks´ consists of material for CHC nurses to use to facilitate the health talk with both the child and parent(s) and is complemented with take-home material. Parent and child dyads are recruited (n = 450) from participating CHC centers when they attend their 5-year routine visit. The intervention group receives the health talk using Saga Stories and take-home material, whereas the control group receives the standard health talk. The primary outcome is parental self-efficacy to promote healthy diet, physical activity, and screen time behaviours in their child and secondary outcomes include children's intake of key dietary indicators and screen time. All outcomes are assessed at baseline and 2-months post-intervention. The implementation outcomes that will be assessed are: acceptability, appropriateness, feasibility, satisfaction, usage, fidelity, adoption, and sustainability (assessed quantitatively and qualitatively). DISCUSSION: The Swedish National Board of Health and Welfare have identified the need of more material, education, and working methods for promoting healthy lifestyle behaviours in CHC. Following this trial `Saga Stories in health talks´ has great potential to be implemented in CHC across Sweden to aid nurses to promote and support healthy lifestyle behaviours in pre-school children and their families. TRIAL REGISTRATION: ClinicalTrials.gov , NCT05237362 . Registered 2 February 2022.

Early rapid weight gain, parental body mass index and the association with an increased waist-to-height ratio at 5 years of age.

BACKGROUND/OBJECTIVES: Obesity-related adverse health consequences are closely associated with abdominal obesity. Risk factors for overweight and obesity have been studied but there is a lack of information regarding risk factors for abdominal obesity, especially in the preschool population. The aim of the present study was to examine early life risk factors for an increased waist-to-height ratio (WHtR) in children at five years of age and, in addition, to investigate if these risk factors also were associated with overweight or obesity. SUBJECTS/METHODS: The study population comprised 1,540 children from a population-based longitudinal birth cohort study that included 2,666 Swedish children. The children were included if they had complete growth data for the analyses used in this study. Children were classified as having WHtR standard deviation scores (SDS) ≥ 1 or < 1 at five years of age, according to Swedish reference values, and as having body mass index standard deviation scores (BMISDS) for overweight/obesity, or normal weight/underweight according to the International Obesity Task Force criteria. Associations between child-related, socioeconomic status-related, parental health-related and nutrition- and feeding practice-related factors during the first two years and a WHtRSDS ≥ 1 or a BMISDS for overweight/obesity at five years were investigated with logistic regression analyses. RESULTS: At five years of age, 15% of the children had WHtRSDS ≥ 1 and 11% had overweight or obesity. In multivariable analyses, rapid weight gain (RWG) during 0-6 months (OR: 1.90, 95% CI: 1.23-2.95, p = 0.004), maternal pre-pregnancy BMI (1.06, 1.01-1.11, p = 0.019) and paternal BMI (1.11, 1.01-1.21, p = 0.028) were associated with WHtRSDS ≥ 1. RWG during 0-6 months (2.53, 1.53-4.20, p<0.001), 6-12 months (2.82, 1.37-5.79, p = 0.005), and maternal pre-pregnancy BMI (1.11, 1.06-1.17, p<0.001) were associated with overweight or obesity. CONCLUSIONS: Early risk factors, including rapid weight gain, are associated with increased WHtRSDS and overweight or obesity at 5 years of age. Preventive interventions should target early RWG and parental overweight and obesity.

How to Support Child Healthcare Nurses in Sweden to Promote Healthy Lifestyle Behaviors from the Start of Life.

Child healthcare (CHC) nurses have a key role in promoting and supporting healthy lifestyle behaviors from a young age. Thus, this study aims to investigate the perspectives of CHC nurses regarding discussing food introduction, physical activity/active play, and screen time with parents; explore facilitators and barriers influencing the discussion of healthy lifestyle behaviors with parents; and explore the perspectives of CHC nurses regarding a complementary program to promote healthy lifestyle behaviors from the start of life. A total of fifteen nurses participated in semi-structured interviews, which were recorded, transcribed verbatim, and analyzed using thematic analysis. There were four themes that were generated: parental needs; facilitators and barriers; parental groups; and future working methods. This study found that CHC nurses have seen an increase in the need for support among today's parents. Time, the need to tailor information, and confidence to address sensitive topics were perceived as the largest barriers during daily work for the nurses. Furthermore, large variations in parental groups were found. Finally, the CHC nurses displayed a willingness and openness to change and develop current working methods using digital solutions. These solutions could possibly ease the workload and at the same time, support parents to create healthy lifestyle behaviors from the start of their child's life.

Depressive symptoms postpartum is associated with physical activity level the year prior to giving birth - A retrospective observational study.

OBJECTIVES: To examine physical activity level prior to pregnancy, during pregnancy and postpartum and investigate the association with depressive symptoms postpartum among women in Sweden. STUDY DESIGN: Retrospective observational study including 532 women on self-assessment of physical activity level before pregnancy, during pregnancy and postpartum, depressive symptoms postpartum as well as stressful life events in the past two years. MAIN OUTCOME MEASURES: Level and change of physical activity before pregnancy, during pregnancy and postpartum and depressive symptoms postpartum. RESULTS: Almost two-thirds of the women in the study reported that they were inactive or performed light physical activity (62.9%; n = 331) in the year prior to giving birth. Women with a sedentary lifestyle or performing light physical activity level reported depressive symptoms postpartum to a greater extent than active women. CONCLUSIONS: A higher level of physical activity during pregnancy was associated with a lower level of depressive symptoms postpartum. Physical activity is a contributing factor to promote a healthier lifestyle and can contribute to improve mental health for pregnant women, newly become mothers and their children.

Nutrition- and feeding practice-related risk factors for rapid weight gain during the first year of life: a population-based birth cohort study.

BACKGROUND: Rapid weight gain (RWG) during infancy increases the risk of excess weight later in life. Nutrition- and feeding practices associated with RWG need to be further examined. The present study aimed to examine nutrition- and feeding practice-related risk factors for RWG during the first year of life. METHODS: A population-based longitudinal birth cohort study of 1780 infants, classified as having RWG or non-RWG during 0-3-4, 0-6 and 6-12 months. RWG was defined as a change > 0.67 in weight standard deviation scores. Associations between nutrition- and feeding practice-related factors and RWG were examined with logistic regression models. RESULTS: Of the participating infants, 47% had RWG during 0-3-4 months, 46% during 0-6 months and 8% during 6-12 months. In the fully adjusted models, bottle-feeding at birth and at 3-4 months and nighttime meals containing formula milk were positively associated with RWG during 0-3-4 months (p < 0.05 for all). Breastfeeding at 3-4 months and nighttime meals containing breast milk were negatively associated with RWG during this period (p < 0.001). Bottle-feeding at birth, 3-4 and 6 months and nighttime meals containing formula milk at 3-4 months were positively associated with RWG during 0-6 months (p < 0.01 for all). Breastfeeding at 3-4 and 6 months was negatively associated with RWG (p < 0.01). During 6-12 months, only bottle-feeding at 3-4 months was positively associated with RWG (p < 0.05). CONCLUSIONS: RWG was more common during the first 6 months of life and bottle-feeding and formula milk given at night were risk factors for RWG during this period.

Consuming milk cereal drinks at one year of age was associated with a twofold risk of being overweight at the age of five.

AIM: We previously reported that consuming milk cereal drinks at six months of age was associated with a high body mass index (BMI) at 12 and 18 months. This study examined the association between daily consumption at 12 months of age and BMI at the age of five. METHODS: We followed up 1870/2666 (70%) children recruited at birth in 2007-2008 for the Swedish longitudinal population-based Halland Health and Growth Study a mean of 5.09 ± 0.28 years. Feeding practices were obtained from parental questionnaires, and anthropometric data were collected by child health nurses. RESULTS: At five years, 11.6% were overweight and 2.3% were obese. Milk cereal drinks were consumed by about 85% and 10% at one and five years of age, respectively. Consumption at 12 months was associated with almost double the risk of being overweight at five years of age (adjusted odds ratio 1.94, 95% confidence interval 1.08-3.50). Other risk factors were a family history of obesity, low paternal educational level and paternal smoking. CONCLUSION: Consuming milk cereal drinks daily at 12 months was associated with a twofold risk of being overweight at five years. These findings may affect the counselling guidelines used at child healthcare centres.

Infant body mass index growth patterns predicted overweight at five years, waist-to-height ratio did not add to this predictivity.

AIM: The aim of the present study was to examine body mass index (BMI) and waist-to-height ratio (WHtR) growth patterns from birth until five years regarding their ability to predict overweight or obesity in children at five years of age. METHODS: Population-based longitudinal birth cohort study of 1540 children from the south-west region of Sweden, recruited at the first visit to the child health care centres in 2007-2008. The children were followed for five years and classified into two weight groups according to the 2012 International Obesity Task Force criteria. BMI and WHtR standard deviation scores (SDS) were analysed with Student's t-tests and multiple logistic regression models. RESULTS: BMI-SDS and WHtR-SDS growth patterns were from an early age different in children with overweight or obesity, compared to in children with normal weight or underweight. Overweight or obesity was significantly predicted by BMI-SDS at 0-1 month (p < 0.001), ΔBMI-SDS between 0-1 and 12 months (p < 0.001) and between 18 and 48 months (p < 0.001), but not by WHtR-SDS, except for a negative association between 18 and 48 months in the boys (p = 0.040). CONCLUSION: Overweight or obesity at five years could be predicted by early BMI-SDS growth patterns, and WHtR-SDS did not add to the predictivity with regard to BMI-SDS.

Body mass index classification misses to identify children with an elevated waist-to-height ratio at 5 years of age.

BACKGROUND: Abdominal adiposity is an important risk factor in the metabolic syndrome. Since BMI does not reveal fat distribution, waist-to-height ratio (WHtR) has been suggested as a better measure of abdominal adiposity in children, but only a few studies cover the preschool population. The aim of the present study was to examine BMI and WHtR growth patterns and their association regarding their ability to identify children with an elevated WHtR at 5 years of age. METHODS: A population-based longitudinal birth cohort study of 1540 children, followed from 0 to 5 years with nine measurement points. The children were classified as having WHtR standard deviation scores (WHtRSDS) <1 or ≥1 at 5 years. Student's t-tests and Chi-squared tests were used in the analyses. RESULTS: Association between BMISDS and WHtRSDS at 5 years showed that 55% of children with WHtRSDS ≥1 at 5 years had normal BMISDS (p < 0.001). Children with WHtRSDS ≥1 at 5 years had from an early age significantly higher mean BMISDS and WHtRSDS than children with values <1. CONCLUSIONS: BMI classification misses every second child with WHtRSDS ≥1 at 5 years, suggesting that WHtR adds value in identifying children with abdominal adiposity who may need further investigation regarding cardiometabolic risk factors.

Parents with overweight children two and five years of age did not perceive them as weighing too much.

AIM: This study examined whether the parents of children who were overweight at two and five years of age perceived their children as being too heavy and related the findings to sociodemographic factors. METHODS: The data collection included parental questionnaires and anthropometric data from a longitudinal birth cohort of 2666 children born in the south-west region of Sweden in 2007-2008. RESULTS: We found that 14.9 and 11.8% of the children were considered overweight or obese at the age of two and five, but 96.4 and 87.1% of their parents perceived their weight to be just about right at these ages. The difference was statistically significant (p < 0.001). Parents who were overweight themselves and had a low educational level were associated with a higher probability of misperception: at two years of age, the odds ratio was 2.75 (95% confidence interval 1.80-4.21), and at the age of five, it was 1.92 (1.24-2.97). CONCLUSION: Most parents did not perceive that their overweight children weighed too much, but their judgement improved as the child got older. Parents who were overweight or had a low educational level were more likely to misperceive their child's weight. Health Care professionals need to be aware of this gap in perception.

Influence of neighbourhood purchasing power on breastfeeding at four months of age: a Swedish population-based cohort study.

BACKGROUND: Parental socioeconomic status (SES) is an important determinant in child health, influencing beneficial factors such as breastfeeding. A better understanding of the influence of neighbourhood-level SES measures, relating to spatial determinants, might lead to targeted actions to promote breastfeeding during infancy. METHODS: A cross-sectional study analysis the association between breastfeeding at four months of age and neighbourhood purchasing power, taking account of individual-level variables including maternal age, smoking and parental level of education. Data were obtained from a prospective population- based cohort study recruited from birth in 2007-2008 in the Halland region, southwestern Sweden. Questionnaire data on the individual-level variables and the outcome variable of breastfeeding at four months (yes/no) were used (n=2,407). Each mother was geo-coded with respect to her residential parish (there are 61 parishes in the region) and then stratified by parish-level household purchasing power. It emerged that four neighbourhood characteristics were reasonable to use, viz. <10%, 10-19%, 20-29% and ≥ 30% of the resident families with low purchasing power. RESULTS: The proportion of mothers not breastfeeding at four months of age showed a highly significant trend across the neighbourhood strata (p=0.00004): from 16.3% (< 10% with low purchasing power) to 29.4% (≥ 30% with low purchasing power), yielding an OR of 2.24 (95% confidence interval: 1.45-3.16). After adjusting for the individual-level variables, the corresponding OR=1.63 (1.07-2.56) was significant and the trend across the strata was still evident (p=0.05). A multi-level analysis estimated that, in the neighbourhoods with ≥ 30% of the families with low purchasing power, 20% more mothers than expected, taking account of the individual-level factors, reported no breastfeeding at four months of age (≥ 95% posterior probability of an elevated observed-to-expected ratio). CONCLUSION: The neighbourhood purchasing power provided a spatial determinant of low numbers of mothers breastfeeding at four months of age, which could be relevant to consider for targeted actions. The elevated observed-to-expected ratio in the neighbourhoods with the lowest purchasing power points toward a possible contextual influence.

Milk cereal drink increases BMI risk at 12 and 18 months, but formula does not.

AIM: Infant feeding affects growth, obesity and life-long health. This study examined the impact of dietary patterns on body mass index (BMI) at 12 and 18 months. METHODS: We followed a cohort of 2666 children recruited in 2007-2008. Feeding practices were obtained from parental questionnaires and anthropometric data collected by child health nurses. RESULTS: At 6 months, 58.3% of the infant were breastfed, but only 1.6% exclusively. Many had begun eating solids (91.8%), porridge (87.7%) or milk cereal drink (46.6%). Bottle-feeding at 4 months was not a risk factor for a high BMI (>1 SD) at 12 or 18 months. Milk cereal drink at six months increased the risk of a high BMI at 12 and 18 months, respectively (OR 1.58, 95% CI 1.12-2.22, and 1.52, 1.07-2.17). Milk cereal drink use was increased by low parental education and maternal obesity and reduced by troubled sleep and parental group participation. CONCLUSION: Formula at 4 months did not predict a high BMI at 12 or 18 months. Milk cereal drink use at 6 months was a risk factor for a high BMI at 12 and 18 months. The choice of milk cereal drink was influenced by parental factors, especially educational levels.