【作者】 王昕晔；

【导师】 张秀敏；

【作者基本信息】 吉林大学 ， 社会医学与卫生事业管理， 2014， 博士

【摘要】 儿童青少年时期是各项身体素质和身心健康发展的关键时期，学校作为儿童青少年获得健康知识和养成正确行为的重要场所，教师作为学生的教育和培养方面的重要角色，均对提高儿童的健康水平起着至关重要的作用。然而，近年来由于摄入的总能量与身体活动消耗的总能量不平衡，在学龄阶段或成年早期的超重与肥胖检出率逐年增高，年轻化问题日益严重。超重和肥胖是高血压、冠心病、脑卒中等多种慢性非传染性疾病发生的高危因素，而始于儿童期的肥胖比成人后肥胖将会导致更高的慢性病罹患率。儿童青少年超重和肥胖的发生是遗传因素，不良的饮食行为和静坐生活方式等环境因素与社会经济文化因素等共同作用的结果，其中高能量膳食、选择零食不当、不吃早餐等不合理的饮食行为是儿童青少年肥胖的主要危险因素。可见，从不健康的行为生活方式入手，控制慢性病的危险因素，即超重和肥胖在儿童青少年群体中的流行，已经成为重要的全球性公共卫生问题。【目的】本研究旨在通过针对不合理的饮食行为这一高危因素，以学校为平台，配合对教师的健康素养调查与指导，在全省范围内的中小学校积极开展以超重与肥胖控制为切入点的健康调查和干预评价研究，从而综合制定并实施有针对性的群体干预策略，促进中小学生改变不健康的行为生活方式，提高自我保健意识和能力，为探索建立“健康促进学校”模式提供科学依据。【方法】在健康现状调查阶段，采用体格测量与问卷调查相结合的方式，对吉林省17893名中小学生（8-15岁）和2085名中小学教师进行超重和肥胖的现状及影响因素调查，问卷内容包括：学生和教师的一般情况，超重和肥胖现状，膳食与运动的知识、态度、行为因素等。在群体干预与评价阶段，采用问卷调查方式对吉林省14175名中小学生进行干预前的基线调查，问卷内容包括：学生的一般情况，对三餐的能量分配、早餐、营养素、零食的认知与行为因素等，并通过实施合理膳食技能培训进行相关干预，继而拟合DID模型进行干预后的效果评价。【结果】在中小学生超重和肥胖现状及影响因素方面：吉林省中小学生总体超重率为15.0%，肥胖率为15.5%，超重和肥胖合计检出率为30.5%。男生超重和肥胖率为36.9%、女生超重和肥胖率为23.5%。8岁时的超重和肥胖发生率最高为40.1%，15岁时的超重和肥胖发生率最低为23.4%。在中小学生膳食运动的“知信行”现状及影响因素方面：在超重和肥胖人群中，仅有24.1%能够知晓控制体重的正确措施，62.9%愿意每天坚持锻炼，23.4%坚持每天运动量充足在1个半小时以上。经建立结构方程模型（SEM）得知，影响超重和肥胖的显著路径共有4条：①知识——信念——行为——超重和肥胖；②知识——行为——超重和肥胖；③信念——知识——行为——超重和肥胖；④信念——行为——超重和肥胖。在中小学生体型自我评价与BMI的一致性分析及对减肥行为的影响方面：仅有62.9%的中小学生能够正确评价自我体型，37.1%的中小学生都错误估计了自己的体型，其中低估率为31.4%、高估率为5.7%。Kappa一致性检验结果进一步表明，中小学生体型自我评价与实际体重BMI评定情况的一致性程度较弱。经中介效应检验结果可知，自我评价体型在BMI评定与中小学生减肥行为之间起到完全中介作用，即实际体重的BMI评定值是完全通过不同的体型自我评价对其减肥行为产生影响。在中小学生合理膳食技能的干预效果评价方面：干预组中在干预前仅有396人（占8.8%）能够正确回答合理膳食相关知识，并且做到相关正确行为，即具有合理膳食的综合技能，干预后具有技能人数提高到4080人（占91.2%）；对照组中在干预前具有技能人数仅为809人（占50%），干预后仍为810人（占50%）。经拟合DID模型可知，合理膳食技能的干预实施具有一定效果，在考虑到人口社会学因素对正确率的影响后，干预措施的实施使得中小学生的合理膳食技能综合正确率提高了39.5%。在中小学教师超重和肥胖现状及健康素养水平方面：吉林省中小学教师总体超重率为19.8%，肥胖率为4.6%，超重与肥胖合计检出率为24.4%，并有6.7%的人属于体重偏瘦。仅有6%能够知晓洋快餐食品的营养特点、61%愿意支持学生保证必要的运动时间、27.7%经常给学生讲运动营养知识、28%吃饭以素为主、48%运动量充足。【结论】吉林省中小学生超重和肥胖整体现状不容乐观，男生的超重与肥胖的发生率高于女生；随着年龄的增长，超重与肥胖的发生率均有下降；不同地区的超重与肥胖发生率有显著性差异。不能正确知晓控制体重措施、不能每天坚持锻炼意愿、不能做到吃肥肉次数适中与超重和肥胖的发生率呈显著正相关。中小学生体型自我评价与实际体重BMI评定情况的一致性程度较弱，女生的一致性稍优于男生，初中的一致性稍优于小学。自我评价体型在BMI评定与中小学生减肥行为之间起到完全中介作用，即实际体重的BMI评定值是完全通过不同的体型自我评价对其减肥行为产生影响。合理膳食技能的干预实施具有一定效果，使得中小学生的合理膳食技能综合正确率有所提高，其中除了“每天都吃早餐行为”正确率这一项没有显著提高，其他各项均提高显著。可见，控制儿童青少年超重和肥胖的工作已刻不容缓，应及早从低年级儿童入手，以健康饮食和运动习惯等行为生活方式为着眼点进行干预，做到早期预防，培养健康的行为生活方式，进而建立“家庭—学校”综合干预网络模式。创新点：首次对吉林省10个市（州）及长白山管委会所在地的中小学生群体超重和肥胖流行现状进行全省范围内的实证研究与综合评价；首次将有关膳食运动的“知信行”调查与中小学生超重和肥胖的现状调查进行有机结合，从而全方位阐述全省中小学生的超重和肥胖总体水平及其主要影响因素；首次采用Kappa一致性检验和中介效应检验的综合分析方法，在比较体型自我评价与实际BMI评定的同时，检验自我评价体型在BMI评定与减肥行为间的中介效应，从而综合把握中小学生群体对自身体重的自我认知情况；首次拟合DID模型对中小学生群体合理膳食技能的干预前后变化进行检验，科学评价干预措施的实施效果。更多还原

【Abstract】 The teenage period of children is crucial in the development of physicalqualities and physical and mental health. In this process, schools are importantplaces for children and adolescents to obtain the healthy knowledge and developtheir proper behaviors; teachers play a main role in the education and training ofpupils. Both of them play an important role in improving children’s healthy levels.Nevertheless, in recent years overall unbalanced energy between the total energyintake and the total energy consumption caused by physical activities has resulted inthe increased detection rate of overweight and obesity during the school age oryoung adulthood annually, younger problem is became more serious. Theoverweight and obesity are the risk factors to cause noninfectious chronic diseasessuch as hypertension, coronary heart disease, cerebral apoplexy, etc. The obesitystarting from the childhood will cause a higher prevalence of chronic diseases thanthat of obesity starting from adults. The overweight and obesity happened in theteenage period are the results of environmental factors and socio-economic andcultural factors such as genetic factors, unhealthy eating behaviors and sedentary lifestyle, of them, irrational eating behaviors. For example, high-energy diets, chosensnacks inappropriate and skipping breakfast and so on, are the main risk factors ofthe obesity in children and adolescents. Accordingly, it has become a significantglobal public health problem to control the risk factors of chronic, that is to controlits popularity of the obesity in children and adolescents, starting from the solving theunhealthy lifestyle behaviors. 【Objective】Aiming at the risk factor of irrational eating behaviors, the healthexamination survey and intervention evaluation with the overweight and obesity asthe point of penetration ranged from the schools of the Province have beenconducted positively, taking schools as the platform and combining with theteachers’ health literacy survey and guidance, sequentially the targeted groupintervention strategies can be made and carried out in order to change children andadolescents’ unhealthy lifestyle behaviors, by this, it promotes their awareness andcapabilities for self-health protection, resulting in providing scientific basis for theexploration of the establishment of “Health Promoting Schools” Mode.【Methods】In the health status survey stage, the method combining the physicalexamination with the questionnaire survey had been adopted to investigate the heathstatus and influencing factors of the overweight and obesity among17893schoolchildren (from8-15years old) and2085teachers both in elementary andsecondary schools in Jilin Province. The contents of the questionnaire survey include:the general conditions of the schoolchildren and teachers, the status of theoverweight and obesity, knowledge, attitudes, behavior factors about the diets andsports. In groups intervention and evaluation stage, the method of questionnairesurvey had been adopted to investigate the base line before intervention among14175schoolchildren in Jilin Province, the contents of the questionnaire surveyinclude: the general conditions of the pupils, their cognition and behavior factorsabout the energy distribution of three meals, breakfast, nutrients and snacks,accordingly reasonable diet skills trainings were implemented, resulting in theeffectiveness evaluation with DID Mode fitting after intervention.【Results】1. The analysis result of the overweight and obesity status andinfluencing factors among schoolchildren shows: the overall rate of overweight is15.0%, the obesity rate is15.5%，the total detection rate of the overweight andobesity is30.5%. The schoolboys’ rate of the overweight and obesity is36.9%. Theschoolgirls’ rate of the overweight and obesity is23.5%. The highest incidence of theoverweight and obesity at8years old is40.1%. The lowest incidence of the overweight and obesity at15years old is23.4%.2. The analysis result of “KAP” status about the diet movement of theschoolchildren and influencing factors shows: among fat schoolchildren, only24.1%of them know the correct measures how to control weight,62.9%of them are willingto do exercises everyday, and23.4%of them can keep exercises for more than oneand a half hours every day. It is known by the establishment of the structuralequation model (SEM) that there are four significant channels influencing theoverweight and obesity:1). Knowledge-Belief-Behavior-Overweight and obesity.2). Knowledge-Behavior-Overweight and obesity.3). Belief-Knowledge-Behavior-Overweight and obesity.4). Belief-Behavior-Overweight and obesity.3. The influencing result of the consistency analysis between the self-evaluationof schoolchildren bodies and BMI and the weight reduction behaviors shows: only62.9%among the schoolchildren can evaluate their self-body correctly,37.1%ofthem estimate their own bodies wrongly, of them, the underestimated rate is31.4%,and the overvalued rate is5.7%. The result of the consistency checking involvingKappa further shows that the consistency degree on the evaluation betweenself-evaluation of schoolchildren bodies and BMI presents relatively weak. It isknown by the mediating effect test that the self-evaluation of body presents a fullintermediation between BMI evaluation and weight reduction behaviors ofschoolchildren, which means the BMI evaluating values of actual weight has aneffect on their weight reduction behavior through different self-evaluations of body.4. The evaluation result of the intervention effects on the reasonable diet skillsof schoolchildren shows: in intervention group, there are only396persons(accounting for8.8%) who can answer the knowledge about the reasonable dietcorrectly and adopt the relatively correct behaviors, which mean that they havecomprehensive skills about the reasonable diet before intervention. The mentionednumber has increased to4080persons (accounting for91.2%) with skills afterintervention. In comparison, in the control group, the persons with skills are only809(accounting for50%) before intervention, the number is810(accounting for50%) after intervention. It is known by using DID model fitting, the interventionimplementation of the reasonable diet skill has some effect. Excluding the effect ofthe population sociology on the accuracy, the implementation of interventionmeasures has made the accuracy of the schoolchildren reasonable diet skill increasedby39.5%.5. The result of the teachers’ overweight and obesity status and health literacylevels shows: teachers’ overall prevalence of the overweight is19.8%, the obesityprevalence is4.6%. The total detection rate of the overweight and obesity is24.4%,and6.7%of them belong to weight towards to thin. Only6%of them know well thenutritional characteristics of western fast food,61%of them are willing to supporttheir pupils to have necessary movement time,27.7%of them often tell movementnutritional knowledge to their pupils,28%of them have vegetarian food mainly and48%of them do exercises enough.【Conclusions】It is not optimistic about the overall status of the schoolchildrenoverweight and obesity in Jilin Province, the schoolboys’ incidence of theoverweight and obesity is higher than that of schoolgirls; With age, the incidence ofthe overweight and obesity will fall; the incidence of the overweight and obesityhappened in different areas presents a significant difference. The incidence betweenthe overweight, obesity and those who don’t know how to control their weight,cannot keep exercise everyday and cannot maintain proper times to eating meatpresents a significant positive correlation. The consistency degree on the evaluationbetween self-evaluation of schoolchildren bodies and BMI presents relatively weak.The school girls’ concordance is relatively better than that of the schoolboys. Theconcordance found in junior high schools is relatively better than that in elementaryschools. The self-evaluation of body presents a full intermediation between BMIevaluation and weight reduction behaviors of schoolchildren, which means the BMIevaluating values of actual weight has an effect on their weight reduction behaviorthrough different self-evaluations of body. The intervention implementation of thereasonable diet skill has some effect, by which the comprehensive accuracy of schoolchildren reasonable diet skills is increased to some extent, of them, except thatthe accuracy of the behavior of “Have Breakfast Everyday” presents no greatimprovement, all other items have presented a significant improvement. It can beknown that it is time to control the overweight and obesity of schoolchildren. Theintervention of junior class children should be conducted first as early as possiblestarting from their lifestyle behaviors such as healthy diet and movement habitsaiming at the early prevention and training their healthy lifestyle behavior, and thenestablishing the comprehensive intervention network mode of “Family-School”.更多还原