【作者】 杨丽萍；

【导师】 杜玉开；

【作者基本信息】 华中科技大学 ， 儿少卫生与妇幼保健学， 2013， 博士

【摘要】 目的：旨在了解学龄前单纯性肥胖和正常体重儿童的体格差异，探讨肥胖对3-6岁儿童健康的危害；明确导致儿童肥胖的环境影响因素并观察单纯性肥胖儿童血清瘦素及脂联素水平，探讨两者与儿童肥胖之间的关系。为从各个层面建立针对儿童早期肥胖的综合干预策略和措施提供理论基础；为以后建立长期的、有效的、科学的儿童肥胖健康促进与健康教育模式提供参考依据，更好的促进儿童的健康发育。方法：于2011年8月-10月间，选取湖北省荆州市沙市区、武汉市武昌区、汉口、江夏、蔡甸、东西湖6个市区。以调查日期作为标准，以现场流行病学方法为基础，用世界卫生组织2006年颁布儿童生长标准为标准（身高别体重+2SD及以上判断为肥胖），采取整群抽样的方法，以湖北省内6个市区所属当地幼儿园为单位（共计36所幼儿园），对3-6岁单纯性肥胖儿童进行流行病学调查，同时对每一个肥胖儿童选取一名对照儿童，对照儿童入选标准为居住在与肥胖儿童同一社区、性别相同、年龄相同（±3个月）、身高相同（±3厘米）、身高别体重在正常范围的健康儿童。采用自编问卷，由经过专业培训的调查员用统一的调查表对3-6岁儿童的家长或抚养人进行面对面询问。对所有儿童进行人体测量并采集外周静脉血3ml，用ELISA法测定血清瘦素及脂联素水平。利用卡方检验、t检验、1:1配对条件logistic回归、协方差分析对数据进行分析。结果：6个区县共调查467对肥胖-对照儿童。1.儿童各测量指标分析：肥胖儿童组及对照儿童组的胸围分别为58.68±5.10cm和49.93±3.50cm，腰围分别为60.61±6.85cm和50.78±3.12cm，臀围分别为66.06±5.12cm和55.60±3.50cm，收缩压分别为95.39±9.22mmHg和87.76±6.72mmHg，舒张压分别为62.06±6.25mmHg和58.49±6.13mmHg；肥胖儿童组和对照儿童组各皮褶厚度分别为：8.64±3.06mm和6.19±1.26mm（肱二头肌）、13.27±3.76mm和8.14±1.89mm（腹部）、19.41±3.46mm和11.12±2.95mm（大腿）、10.03±2.85mm和6.66±1.45mm（肩胛下）、12.11±3.58mm和7.58±2.28mm（腰部），各测量值在两组间均存在显著差异（P<0.001）。肥胖儿童组和对照儿童组的血红蛋白值分别为126.07±9.21g/L和123.12±8.89g/L、脂联素水平分别为8.93±5.11mg/L和13.60±5.81mg/L、瘦素水平分别为11.65±4.98μg/L和3.89±2.33μg/L，两组间差异亦具有统计学意义（P<0.05）。2.家庭基本特征：467对儿童中，肥胖儿童组母亲的生育年龄为27.02±3.85岁，稍高于对照组26.41±3.80岁，两组差异有统计学意义（t=2.453，P<0.05）。父亲的生育年龄分别为28.92±4.88岁和29.34±4.47岁，差异无统计学意义，P>0.05。肥胖儿童组和对照儿童组母亲文化程度主要是大专及以上，所占比例分别为49.5%和50.1%；其父亲的文化程度也主要集中分布在大专及以上，所占比例分别为54.6%和55.2%；两组儿童母亲的职业主要为商业或服务类人员，所占比例分别为35.8%和34.0%，父亲的职业则主要为技术人员，所占比例分别为35.8%和33.4%，差异均无统计学意义，P>0.05。肥胖儿童组和对照儿童组的家庭人均月收入分别集中在2000-<2500元和2500-<3000元（25.9%和28.9%），差异有统计学意义，P<0.05。3.儿童性格特点和生活习惯：对肥胖组儿童及对照组儿童的性格特点、饮食行为（早餐情况、食物偏好、宵夜习惯、进餐次数、洋快餐频率、零食摄入情况和进餐速度等）、体力活动情况（久坐静态行为、活动时间等）和睡眠时间进行分析。发现两组儿童在偏爱甜食（P=0.048）、肉类（P=0.000）、每日进餐次数（P=0.000）、进餐速度（P=0.000）、每日看电视时间（P=0.000）和运动时间（P=0.001）上的存在显著差异。4.母亲孕期情况分析：对肥胖儿童组及对照儿童组父母BMI、吸烟/饮酒情况、异常孕产史、孕早期阴道出血或损伤情况、妊娠期疾病、孕期母亲体重变化、孕期母亲生活习惯（各类食物摄入情况、情绪状态、活动情况、睡眠时间等）等方面进行分析。发现肥胖儿童组和对照儿童组母亲BMI分别为22.29±2.89和21.23±2.53（t=5.908，P<0.001）、父亲BMI分别为24.29±3.17和23.20±2.79（t=5.386，P<0.001）、母亲孕期增加的体重分别为17.26±6.34Kg和14.93±5.98Kg（t=5.658，P<0.001）、摄入豆类及其制品（P<0.001）和甜食（P<0.05）的频率、睡眠时间（P<0.05）和情绪状态（P<0.05）的差异具有统计学意义。5.儿童的出生史：对儿童出生时的体重、身长、分娩方式以及分娩时的胎龄情况做比较，发现肥胖组儿童出生时的体重高于对照组（3514.52±524.01g vs3263.90±446.77g，P<0.001），肥胖儿童组中巨大儿所占比例明显高于对照组（15.0%vs8.8%，P<0.05），出生时身长亦大于对照组儿童（50.84±1.81cm vs50.24±1.45cm，P<0.05）。肥胖儿童组中剖宫产比例明显高于对照儿童组（72.8%vs64.2%，P<0.05）。两组在分娩时胎龄上的差异不具有统计学意义（P>0.05）。6.儿童喂养史：肥胖组中纯母乳喂养的儿童有282例，占60.4%，混合喂养的儿童有107例，占22.9%，人工喂养的儿童有78例，占16.7%；对照组中母乳喂养的儿童有315例，占67.5%，混合喂养的儿童有97例，占20.8%，人工喂养的儿童有55例，占11.8%。肥胖儿童组中纯母乳喂养的比例明显低于对照组（60.4%vs67.5%，P<0.05）、母乳喂养时间≥6个月的比例明显低于对照组（43.7%vs51.9%，P<0.05）。两组在初次添加辅食时间（P=0.046）和初次添加固体辅食时间（P=0.010）上的差异亦具有统计学意义。7.家长对儿童肥胖相关知识的认识程度：两组家长在是否知晓体质指数（BMI）（P=0.040）以及对儿童肥胖所持态度（P=0.019）上的差异有统计学意义。8.肥胖影响因素分析结果：多因素条件logistic回归分析结果显示，儿童偏食肉类（OR=1.713）、每日看电视时间>3h（OR=7.820）、母亲BMI≥24（OR=3.884）、父亲BMI≥24（OR=3.905）、出生体重≥4000g（OR=2.108）、孕期增加体重在13-20kg（OR=1.960），孕期增加体重>20kg（OR=5.147）、血清瘦素水平>10.45μg/L（OR=2.697）均为儿童肥胖的危险因素。家庭人均月收入在2500-<3000元（OR=0.183）、家庭人均月收入≥3000元（OR=0.135）、儿童进餐速度较慢（OR=0.471）、孕期经常摄入豆类及其制品（OR=0.406）、母乳喂养时间≥6个月（OR=0.486）、初次添加辅食时间在4-6个月（OR=0.383）、初次添加辅食时间>6个月（OR=0.355）、血清瘦素水平<4.40μg/L（OR=0.516）、家长知晓儿童肥胖原因>3点（OR=0.222）均为儿童肥胖的保护因素。9.母乳喂养时间与儿童血清瘦素及脂联素水平：母乳喂养时间在4-<6个月和≥6个月者，其血清瘦素水平均低于无母乳喂养者，差异具统计学意义（P<0.05）。脂联素水平的差异则不具统计学意义（P>0.05）。结论：环境因素及血清瘦素水平对3-6岁儿童单纯性肥胖有影响作用。1.儿童肥胖不仅仅体现在高体重，过量的脂肪也在身体各不同部位聚积，在3-6岁的年龄段，肥胖已表现出了对儿童心血管的危害。2.影响学龄前儿童肥胖发生的因素是多方面的。儿童不良的饮食和生活方式是导致肥胖的主要原因。同时，儿童肥胖与父母体重密切相关，父母超重的儿童易患肥胖。孕期母亲的膳食习惯、体重增加、母乳喂养方式、辅食添加时间、家长对儿童肥胖知识的知晓情况、家庭经济情况均是影响儿童肥胖发生的因素。3.肥胖儿童存在血清脂联素水平偏低、瘦素水平偏高（瘦素抵抗）的现象，母乳喂养时间的延长可以降低儿童血清瘦素水平。4.儿童单纯性肥胖的发生应重在预防并且尽早预防，儿童的父母应接受健康科学的家庭喂养知识教育，同时帮助孩子在早期建立健康的饮食习惯和生活方式并长期保持下去，才能从根本上杜绝肥胖的发生。更多还原

【Abstract】 Objective: To investigate preschool physical differences between simple obese andnormal weight children, discuss the hazard of obesity to the health of children aged3-6; Tounderstand the risk factors leading to childhood obesity and observe blood levels of leptinand adiponectin among simple obesity children in order to explore their relationship withchildhood obesity; To provide the theoretical basis for integrated intervention strategies tochildhood obesity; To establish a long-term and effective scientific model of healthpromotion and health education for obese children in the future and promote the healthdevelopment of children.Methods: The investigation was performed in36kindergartens of Jingzhou city andWuchang, Hankou, Jiangxia, Caidian, Dongxihu districts of Wuhan city, Hubei provincefrom August to October2011based on a cluster sampling survey. The cases enrolled werethree to six years old simple obese children according to the Children Growth Standardsmade by WHO in2006(weight-for-height≥+2SD deemed to be obese), and the controlswere health normal weight children matched by community, gender, age (±3months),height (±3centimeters). The cases and controls were interviewed with the same self-madequestionnaires by professionally trained investigator.3ml of blood samples were collectedfrom children. Serum leptin and adiponectin concentrations were detected by ELISA. Thestatistical analyses were conducted by chi-square test, t test,1:1pair conditional logisticregression, and covariance analysis.Results: A total of467pairs of cases and controls were investigated.1. Analysis of the measurement index of the child: the chest circumferences of the obese group and the control group were58.68±5.10cm and49.93±3.50cm, the waistmeasurements of the obese group and the control group were60.61±6.85cm and50.78±3.12cm, the hiplines were66.06±5.12cm and55.60±3.50cm, the systolic and dilatepressure of the two groups were95.39±9.22mmHg and87.76±6.72mmHg,62.06±6.25mmHg and58.49±6.13mmHg; the Skinfold Thickness of the obese group andthe control group were8.64±3.06mm and6.19±1.26mm (bicipital muscle),13.27±3.76mmand8.14±1.89mm (abdomen),19.41±3.46mm and11.12±2.95mm (thigh),10.03±2.85mmand6.66±1.45mm (subscapular),12.11±3.58mm and7.58±2.28mm (waist). Themeasurement differences between the two groups were statistically significant (P<0.001).The hemoglobin values, adiponectin levels, and leptin levels of the obese group and thecontrol group were126.07±9.21g/L and123.12±8.89g/L,8.93±5.11mg/L and13.60±5.81mg/L,11.65±4.98μg/L and3.89±2.33μg/L. The measurement differencesbetween the two groups were statistically significant (P<0.05).2. The family characteristics: the childbearing age of the mothers in the obese groupand the control group were27.02±3.85years and26.41±3.80years, the difference hadstatistical significance (t=2.453, P<0.05). The childbearing age of the fathers in the obesegroup and the control group were28.92±4.88years and29.34±4.47years, the differencehad no statistical significance (P>0.05). The education level of the mothers in the obesegroup and the control group were mainly undergraduates which accounted for39.5%and50.1%respectively. The education level of the fathers in the obese group and the controlgroup were mainly undergraduates which accounted for54.6%and55.2%respectively. Themothers in the obese group and the control group were mainly business or service personnel,which accounted for35.8%and34.0%respectively. The fathers in the obese group and thecontrol group were mainly technical personnel, which accounted for35.8%and33.4%respectively. These differences showed no statistical significance. The family incomes ofthe obese group and the control group were concentrated distributed at2000-<2500Yuanand2500-<3000Yuan, and the difference was statistically significant (P<0.05).3. Children’s personality traits and living habits: Analysis of character, eating behavior(breakfast, food preferences, bedtime snacks, times of meal a day, frequency of having fastfood, snacks intake and eating speed, etc.), physical activity (sedentary static behavior, activity time, etc.) and sleep time in obese and control groups. There were significantdifferences of partiality for sweets (P=0.048) and meat (P=0.000), times of meal a day(P=0.000), eating speed (P=0.000), time of watching TV (P=0.000) and activity time(P=0.001) in both groups.4. Pregnancy: We analyzed the parents’ BMI, smoking/drinking, abnormal gestationand birth, first trimester vaginal bleeding or injury, mothers’ living habits (categories offood intake, emotional state, activity, sleeping time and etc), change of weight and diseasesduring pregnancy in both groups. Mothers’ BMI of the obese group and the control groupwere22.29±2.89and21.23±2.53(t=5.908, P<0.001), fathers’ BMI were24.29±3.17and23.20±2.79(t=5.386, P<0.001), weight gain during pregnancy were17.26±6.34Kg and14.93±5.98Kg(t=5.658, P<0.001). The difference of intake of bean products (P<0.001) andsweets (P<0.05), sleeping time (P<0.05) and emotional state (P<0.05) in both groups werestatistically significant.5. The children’s birth history: we analyzed the weight, length, mode of delivery andgestational age. We found that birth weight of the babies in the obese group were heavierthan the control group (3514.52±524.01g vs.3263.90±446.77g). The proportion ofmacrosomia in the obese group was obviously higher than that in control group (15.0%vs.8.8%). We also found analogous results about their height in both group (50.84±1.81cm vs.50.24±1.45cm). The proportion of cesarean section in obesity group was significantlyhigher than the control group (72.8%vs.64.2%). There was no significant difference withgestational age between the two groups (P>0.05).6. Feeding history of children: In the obese group, there were282children hadbreastfeeding history (60.4%),107children had mixed feeding (22.9%) and78children hadformula feeding (16.7%). In the control group, there were315children had breastfeedinghistory (67.5%),97children had mixed feeding (20.8%),55children had artificial feeding(11.8%). The proportion of breastfeeding children was obviously lower than the controlgroup(60.4%vs.67.5%, P<0.05). The proportion of breastfeeding for6or more months inthe obese group was significantly lower than control group (43.7%vs.51.9%, P<0.05).There were differences of the first time to have supplementary food (P=0.046) and solidcomplementary (P=0.010) in these two groups. 7. Parents’ awareness of children obesity related knowledge: Whether parents knowthe body mass index (BMI)(P=0.040) and attitudes of childhood obesity (P=0.019) in thesetwo groups had significant differences.8. Analysis of obesity affects factors: According to the multifactor conditional logisticregression analysis, Children partiality for meat (OR=1.713), daily TV time>3h(OR=7.820), mother’s BMI≥24(OR=3.884), the father’s BMI≥24(OR=3.905), birth weight≥4000g (OR=2.108), weight gain at13to20kg during pregnancy (OR=1.960), weightgain>20kg during pregnancy (OR=5.147), leptin level>10.45μg/L (OR=2.697) wereassociated with a higher childhood obesity risk. Average household income per head at2500-<3000Yua n (OR=0.183), and average household income per head≥3000Yua n(OR=0.135), slower eating speed of children (OR=0.471), often ingest beans and itsproducts during pregnancy (OR=0.406), time of breastfeeding≥6months(OR=0.486), firsttime to have supplementary food in4to6months (OR=0.383), first time to havesupplementary food>6months(OR=0.355), leptin level <4.40μg/L(OR=0.516), parentsknew more than3reasons that cause childhood obesity(OR=0.222) proved to be protectorfactors against childhood obesity.9. Duration of breast-feeding and leptin and adiponectin levels of children: Thechildren’s serum leptin level was lower than bottle feeding ones when they breastfed for4-<6months or≥6months. The difference had statistical significance (P<0.05). Thedifference of adiponectin level showed no statistical significance (P>0.05).Conclusions: Environmental factors and serum leptin level have influence on thesimple obesity of children aged3-6.1. The reflection of childhood obesity is not just on the higher and weight, excessiveamount of fat accumulates in different parts of the body. Obesity has been showncardiovascular risks on the children under3-6years old.2. There are many factors influencing the obesity of preschool children, and children’sunhealthy diet and lifestyle are the main causes. What’s more, the childhood obesity isclosely related to the weights of their parents, children with parents of overweight are proneto be obese. Mothers’ diet, weight gain during pregnancy, breastfeeding, the time to supplycomplementary food, knowledge of parents to childhood obesity, family economic situations are the influencing factors of childhood obesity.3. There is lower level of serum adiponectin and higher leptin level (leptin resistance)in obese children, prolonged breastfeeding could reduce serum leptin level in children.4. Emphasis on prevention of obesity in children is needed; parents should receivescientific family feeding knowledge to help children establish healthy dietary habits inorder to eliminate obesity eventually.更多还原