Health-related parental indicators and their association with healthy weight and overweight/obese children’s physical activity

Health-related parental indicators and their association with healthy weight and overweight/obese... Background: Although it is accepted that parents play a key role in forming children’s health behaviours, differences in parent-child physical activity (PA) have not previously been analysed simultaneously in random samples of families with non-overweight and overweight to obese preschool and school-aged children. This study answers the question which of the health-related parental indicators (daily step count (SC), screen time (ST), and weight status and participation in organized leisure-time PA) help their children achieve the step count recommendations. Methods: A nationally representative sample comprising 834 families including 1564 parent-child dyads who wore the Yamax Digiwalker SW-200 pedometer for at least 8 h a day on at least four weekdays and both weekend days and completed a family log book (anthropometric parameters, SC, and ST). Logistic regression analyses were used to investigate whether parental achievement of the daily SC recommendation (10,000 SC/day), non-excessive ST (< 2 h/day), weight status, and active participation in organized PA were associated with children’sachievement of their daily SC (11,500 SC/day for pre-schoolers and 13,000/11,000 SC/day for school-aged boys/girls). Results: While living in a family with non-overweight parents helps children achieve the daily SC recommendation (mothers in the model: OR = 3.50, 95% CI = 2.29–5.34, p < 0.001; fathers in the model: OR = 2.41, 95% CI = 1.37–4.26, p < 0.01) regardless of their age category, gender, or ST, for families with overweight/obese children, only the mother’s achievement of the SC recommendations and non-excessive ST significantly (p < 0.05) increase the odds of their children reaching the daily SC recommendation. The active participation of children in organized leisure-time PA increases the odds of all children achieving the daily SC recommendations (OR = 1.80–2.85); however, for overweight/obese children this remains non-significant. The participation of parents in organized leisure-time PA does not have a significant relationship to the odds of their overweight/obese or non-overweight children achieving the daily SC recommendations. Conclusions: The mother’s health-related behaviours (PA and ST) significantly affect the level of PA of overweight/obese preschool and school-aged children. PA enhancement programmes for overweight/obese children cannot rely solely on the active participation of children in organized leisure-time PA; they also need to take other family-based PA, especially at weekends, into account. Keywords: Step counts, Organized leisure time physical activity, Preschool and school-aged children, Overweight and obesity * Correspondence: erik.sigmund@upol.cz Institute of Active Lifestyle, Faculty of Physical Culture, Palacký University Olomouc, Tr. Miru 117, 77111 Olomouc, Czech Republic Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sigmund et al. BMC Public Health (2018) 18:676 Page 2 of 11 Background among those European countries that are challenged by According to many theoretical models and theories [1–4] the trend of an increase in childhood overweight/obesity describing human behaviour, the direct influence of [40, 41], screen time behaviours [42], and reduced PA parents on the social development and behaviour of their [43]. Public health-related disciplines in these countries children is firmly established. Parents have been termed need to possess relevant information on the roles of the primary gatekeepers of their children’s health [5]. families in shaping the active lifestyle of their children. It The parent-child physical activity (PA) or screen time is because these countries tend to repeat the behavioural relationship has been studied in a wide range of social health-related patterns of children previously witnessed [6], psychological [7, 8], educational, and health-related in children and adolescents from Western high-income disciplines [9, 10], with an emphasis on healthy child countries, e.g. a decrease in PA, an increase in sedentary development [6–10]. behaviours (especially screen time activities), an increase A focus on parent-child dyad analysis in preschool and in the excessive consumption of sweetened beverages, preadolescent children is key to understanding the factors and a greater intake of fast food [44]. Such behaviours that are essential for shaping the active lifestyle of chil- consequently lead to increased rates of overweight and dren, which persists until adulthood [11, 12]. Numerous obesity [45–47]. Previous parent-child study [48] also longitudinal studies confirm the persistence of obesity pointed out that active participation of parent/children arising in preschool age to adolescence [13, 14] and adult- in organized PA as a promising “vehicle” to promote hood [15, 16]. An active lifestyle throughout childhood active lifestyle in children. However, it is not known and adolescence could thus prevent the development of whether active participation in leisure-time organized obesity in young adulthood [13]. Additionally, the rela- PA helps both healthy weight and overweight/obese tionship of parent-child overweight/obesity has already children to reach PA recommendations. The selected been proven to exist at preschool level [17–19]. Import- physical activity behaviours are more easily modifiable, antly, the risk of the transmission of obesity from child- thus influenceable through eventual intervention pro- hood to adulthood seems to be stronger when a child grams or stimuli, than socioeconomic status, structure, has one obese parent than in obese children without or place of residence, which play their role too. obese parents [16]. The study attempts to bridge the research gap of Objective parent-child PA and screen time measure- insufficient relevant information in Central European ments have been analysed globally – Western Europe nations concerning the parent-child PA/screen time [7, 20–22] and Northern Europe [23], North and relationship in a random sample of Czech families with South America [17, 24–29], Africa and South Asia preschool and school-aged children whose body weight [17], and Australia and New Zealand [30, 31]. The ranges from normal to overweight or obese with regard emphasis in such studies is placed, for instance, on active to the parents’ body weight and their participation in parental participation in organized or non-organized PA organized leisure-time PA. [24, 26, 29, 31], parental support for PA [7, 8, 32, 33]and This study aimed to estimate which of the health-related parenting styles [25, 32]. Other studies investigate role of parental indicators (daily step counts, amount of parental rules and restrictions concerning screen time screen-based entertainment time, weight status, and par- [30], parental education and family socioeconomic status ticipation in organized leisure-time PA) help their pre- [7, 17, 20, 21, 23, 30], variation in the weekday-weekend school and school-aged children achieve their step count PA and screen time relationship [7, 24, 26, 27, 29, 33], and recommendations. Furthermore, we assessed whether the level of body weight [17, 20, 22, 27, 29, 34]. However, associations differ by gender of parents, weight status and similarly valuable studies of objective parent-child PA and participation in organized PA of children. screen time measurements in the countries of Central and Eastern Europe are lacking. Methods Except for selected meta-analyses and reviews [35, 36], This research involved the use of data collected from the other parent-child PA/screen time studies are focused Czech-based Parent Child PA Care (PACPAC) Study. separately either on preschoolers [20, 22, 30, 31]or PACPAC is a three-cohort study that investigates the school-aged children and adolescents [7, 8, 17, 21, 24, parent-child PA/screen time relationship in families with 25, 27, 29, 32–34]. The parent-child PA/screen time pre-schoolers (aged 3–6.49 years) and school-aged chil- relationship in a broader age spectrum of preschool and dren (aged 6.5–12 years). This study collected data on school-aged children is seldom analysed [26, 37]. In parent-child dyads in the spring (from March until June) addition, parent-child PA/screen time relationships have and autumn (from September until November) months been analysed only rarely in the countries of Central, between 2013 and 2016. The Ethical Committee of the Southern, and Eastern Europe [38, 39]. The countries of Faculty of Physical Culture, Palacký University Olomouc Central, Southern, and Eastern Europe, however, belong approved the study design and protocol for families with Sigmund et al. BMC Public Health (2018) 18:676 Page 3 of 11 school-aged children (ref. no. 17/2013) on 25 March into a family log book. The parents received instructions 2013 and for families with preschool children (ref. no. regarding how to use a pedometer and the process of 57/2014) on 10 December 2014. recording the monitored values in the family log book. The family log book is composed of three sections – Sample and inclusion criteria the first to record the anthropometric parameters of Participants were recruited by means of two-stage strati- all the family members, the second for the PA-related fied random sampling. In the first stage, nine out of 14 data (step count, participation in organized PA), and administrative regions, three of each in the lowest, the third for recording the screen time (type and dur- middle, and highest terciles for gross domestic product ation) activities [53]. in the Czech Republic, were randomly selected. In the The parents were asked to record the demographic second stage of sampling, the selection of kindergarten and anthropometric parameters (birth date of children and primary schools respected the distribution of the and age of parents, gender, body height (with 0.5-cm urban-rural population in the Czech Republic [49]. A accuracy), and weight (with 0.5-kg accuracy)) of all the total of 296 families with preschool children and 1610 participating family members in the first section of the families with school-aged children were addressed in family log book before the start of the one-week moni- writing with an invitation to participate in the study toring of PA/screen time behaviour. The parents were before a joint meeting with the authors of the study. instructed how to measure their own body height and Participating children and their parents were predomin- weight at home, as well as the height and weight of their antly white Caucasian (> 98%), which is representative of children. The parental home measurement of the body the ethnic demographics of the Czech Republic [50]. weight and body height of their preschool [54] and The disproportion of the sample in terms of age, i.e. school-aged children and adolescents [55] are sufficiently higher number of school-aged children, was due to wider valid tools for determining the Body Mass Index (BMI) age range of school-aged children investigated compared for the subsequent identification of overweight and with pre-schoolers. Furthermore, while school attendance obesity in children [55, 56]. is compulsory, kindergarten attendance (except for the last The PA of all the participants in the three-cohort study pre-school year is optional). The objectives, procedures/ was monitored using the same type of unsealed Yamax measures, and course of the project were thoroughly Digiwalker SW-200 pedometer (Yamax Corporation, explained to the invited parents of the children and Tokyo, Japan). Participants were instructed to wear the teachers and school/kindergarten employees at a joint pedometer on their right hip for eight consecutive days meeting in each of the schools/kindergartens that partici- during waking hours except when bathing, showering, and pated. Written consent to participation in the study was dressing. Every morning after their personal hygiene, the obtained from 223 families with pre-schoolers (a response parents reset the pedometers, attached them to the right rate of 75%) and 1112 families with school-aged children hip (their children’s and their own), and recorded the time (a response rate of 69%) at the end of the joint meeting of the resetting in the family log book. In the evening, the (Table 1). The data of 38 families with preschool children parents removed the pedometers and, together with their and 463 families with school-aged children was not children, recorded the time and overall daily step count of included in the analyses because of incompleteness (miss- all the participating family members in the log book. In ing data on body weight, height, or age or an incomplete addition, parents also recorded whether they or their record of PA/screen time data in the family log book) or children actively participated in organized leisure-time PA invalidity (an absence of more than 1 day of the child from during the day into the log book. Organized leisure-time kindergarten/school or insufficient (< 8 h) time spent PA covers all kinds of structured intentional PA performed wearing the pedometer each day). In accordance with under the guidance of an educator (such as teacher, coach, the recommendations of previous studies [51, 52], the and instructor) and does not include lessons of physical final analyses included only data from parent-child education during school/kindergarten time [53]. Those pairs (mother and child n = 707 and father and child who participated at least once a week, were considered to n = 455) of participants who wore the pedometer for be participants in organized leisure-time PA. The values at least 8 h a day on at least four weekdays and both from the first day of monitoring were not included in the weekend days (Table 1). final analyses because of insufficient time spent wearing the pedometer and because of the novelty of wearing it, Procedures and measures which could have affected the level of the participants’ PA During the baseline joint meeting the invited parents and [51]. The pedometer-based monitoring of ambulatory PA kindergarten/school teachers were thoroughly acquainted is an objective, cheap, and unobtrusive method providing a with the procedures and course of the monitoring of PA reasonable assessment of a child’s day-long PA, albeit only and recording of the step count/screen time -related data when the total amount of PA, not its intensity, is of interest Sigmund et al. BMC Public Health (2018) 18:676 Page 4 of 11 Table 1 Summary sample characteristics (N, %, mean (standard deviation)) Families with preschool children Families with school-aged children Respondents addressed to participate 296 (100%) 1610 (100%) Written consent obtained (%*) 223 (75.3%) 1112 (69.1%) Initiating research (%*) 215 (72.6%) 1040 (64.6%) The final set with valid data (%*) 185 (62.5%) 649 (40.3%) 1st-3rd grade 4th–5th grade Parent-child dyads M (SD) M (SD) M (SD) Mothers N 164 289 254 Age (years) 36.19 (4.20) 38.19 (4.04) 38.94 (4.05) BMI (kg/m ) 24.02 (3.99) 23.42 (3.68) 23.91 (3.82) Overweight 24.39% 19.04% 20.87% Obese 9.76% 8.30% 7.87% Fathers N 107 187 161 Age (years) 38.91 (5.29) 40.15 (4.25) 41.38 (5.22) BMI (kg/m ) 26.04 (3.34) 26.81 (3.42) 26.64 (3.19) Overweight 50.47% 49.20% 63.31% Obese 11.21% 17.11% 14.91% Girls N 88 173 159 Age (years) 5.59 (0.74) 7.92 (0.81) 10.61 (0.74) BMI (kg/m ) 15.13 (2.41) 16.38 (2.51) 17.70 (3.00) Overweight 9.09% 15.60% 13.83% Obese 9.09% 6.94% 7.55% Boys N 97 172 145 Age (years) 5.68 (0.73) 8.00 (0.84) 10.62 (0.75) BMI (kg/m ) 15.41 (1.81) 16.65 (2.86) 17.67 (2.75) Overweight 6.18% 15.12% 17.93% Obese 9.28% 13.95% 8.28% %* – percent of the initial sample addressed % – overweight/obesity; overweight or obesity in children represents a BMI from the 85th to 97th or greater than the 97th percentile of the WHO growth charts 2 2 2 [71, 72]. Overweight and obesity in parents represents a BMI from 25 kg/m to 29.9 kg/m and greater than or equal to 30 kg/m , respectively [73] N number, M arithmetic mean, SD standard deviation, BMI Body mass index [57, 58]. Thegoodvalidityand reliabilityofthe hip-worn the amount of time their children spent watching TV Yamax Digiwalker SW-200 step count measurement sup- daily exhibits an acceptable 7-to-14-day test-retest reli- port the use of the Digiwalker for assessing free-living PA ability (ICC = 0.78, p < 0.001) [63] and shows a strong in preschool [58] and school-aged children [57–59], as well positive correlation with direct home time-lapse videos as in adults [60]. (r = 0.84, p < 0.001) [64]. The sedentary behaviour of all family members was self-reported in the family log book by the parents. Data management However, rather than all types of sedentary behaviours, The step count/screen time data was reviewed to check attention was focused on screen time activities only, for extreme values. The daily step count variable repre- since they allow more accurate discrimination of sented the mean difference between the morning (ped- health-risk behaviours than total sedentary behaviour ometer turned on) and evening (pedometer turned off) does [61, 62]. The duration and type of entertainment step count/screen time on the days of the week that screen time (sitting/lying while watching TV and sitting/ were monitored. Daily step count values below 1000 or lying in front of a PC (notebook, tablet, or smartphone) exceeding 30,000 were truncated to these recommended and not for school/work purposes) was recorded with an limit values, respectively [37, 51], and included in the accuracy of 10 min by the parents, together with their analyses. Weekly averages were calculated by adding 2/7 children, each evening. The parent-proxy assessment of of the weekend day average and 5/7 of the weekday Sigmund et al. BMC Public Health (2018) 18:676 Page 5 of 11 average. If step count and screen time were recorded on non-participants in organized leisure-time PA split by four weekdays, data for the one missing weekday based gender and the level of body weight of the children. on the participant’s personal mean scores was added. The Statistical Package for the Social Sciences (SPSS) The participants whose step count/screen time data was for Windows v.22 software (IBM Corp. Released 2013. missing for more than 1 day were excluded from the Armonk, NY, USA) was used for data management analyses. The daily step count recommendation for pre- and all statistical analyses. The alpha level of signifi- school children was set at a value of 11,500 steps/day cance was set at the minimum value of 0.05 for all [65]. For school-aged children, a value of 13,000 steps/ the statistical analyses. day was applied for boys and 11,000 steps/day for girls [53, 66], and for adults it was a value of 10,000 steps/day Results [67]. Daily screen time shorter than 10 min was not Among the children (420 girls and 414 boys), the preva- counted and if it was longer than 14 h it was shortened lence of overweight was observed in 13.6% (7.6% were to this recommended value [53]. Excessive screen time classified as obese) of the girls and 14.0% (10.9% were for preschool children was defined as more than 1 h/day classified as obese) of the boys. Of the 185 preschoolers, [68, 69] and for school-aged children [61, 62] and for the incidence of overweight was detected in 7.6% (and adults as two or more hours a day [70]. that of obesity in 9.2%) of them, while among the The BMI was calculated as the body weight (kg) school-aged children the representation of overweight divided by the square of body height (m). The chrono- amounted to 15.6% (and that of obesity to 9.3%) out of logical age of all family members was calculated from the total number of 649 school-aged children (Table 1). their date of birth until the first monitoring day. The relationship between children’s PA and parental Age-specific cut-off points [71–73] were used to define indicators of health-related behaviours is presented in the prevalence of overweight/obesity. Overweight or Table 2. Using the binary measures of achieving the obesity in children is represented by a BMI from the recommended levels of daily step count, we found strong 85th to 97th or greater than the 97th percentile of the positive associations between mothers’ and children’sstep WHO growth charts, respectively [71, 72]. Overweight count (p < 0.05), regardless of the maternal and children’s and obesity in parents is represented by a BMI from level of body weight. Fathers’ PA and level of body weight 2 2 25 kg/m to 29.9 kg/m and greater than or equal to were only significantly associated with non-overweight 30 kg/m , respectively [73]. children achieving the daily step count recommendation (Table 2). Statistical analyses While achievement of the recommended step count Descriptive characteristics for the daily step count, level by fathers significantly increased the odds of prevalence of overweight and obesity, percentages of non-overweight children achieving the daily step count participants who met the daily step count recommenda- recommendations, parental overweight/obesity status tions, percentages of participants with excessive daily significantly reduced these odds. The active participation screen time, and frequency of participation in organized of parents in organized leisure-time PA, regardless of their leisure-time PA were calculated for all family members gender, did not significantly affect the odds of their children (girls, boys, mothers, and fathers) separately. Summary achieving the daily step count recommendations, regardless sample characteristics are represented by means and of their level of body weight. Conversely, non-overweight standard deviations. The daily step count data is pre- children participating in organized leisure-time PA at least sented in the form of means and a 95% confidence inter- once weekly were more likely to meet the recommended val or percentages. Logistic regression models (Enter daily step count levels than their counterparts without or- Method) were used to identify which family-related vari- ganized leisure-time PA. ables (achievement of the recommended daily step The active participation of children in organized count, excessive screen time, parental overweight/obes- leisure-time PA (at least once a week) was positively ity, participation in organized leisure-time PA, and the associated with a significantly higher daily step count on gender of children) were associated with children of weekdays in non-overweight and overweight/obese boys normal body weight and overweight/obese children in comparison with non-participants in such activities achieving the step count recommendations separately). (Fig. 1). The significant difference in the daily step count The models were adjusted for age category and gender between boys (girls) who participated in organized of children. We used ordinary single-level regression, be- leisure-time PA and those who did not do so ranged cause initial analyses were not significantly altered by from 1764 to 2152 (1408–1471) steps on weekdays. clustering of data by school/kindergarten. An independ- Except for non-overweight boys, no significant differ- ent t-test (2-tailed) was used to compare the daily step ences in the daily step count at weekends were found in count (as presented in Fig. 1) of participants and terms of gender and body weight between participants Sigmund et al. BMC Public Health (2018) 18:676 Page 6 of 11 Fig. 1 Comparison of children’s daily step counts (mean and 95% CI) on weekdays and at weekends. Legend: CI – confidence interval; x – mean number of sessions of organized leisure-time PA per week. The statistical significance of the differences between participants in organized PA and non-participants in terms of their daily step count (independent t-test (2-tailed)) is expressed as *p < 0.05 and p < 0.001 and non-participants in organized leisure-time PA. For feature of the present study is represented by the gender- all children, regardless of gender, body weight, or partici- and age category-stratified analyses of daily step count pation in organized PA, a lower daily step count was vis- (specifically, the achievement of the daily step count ible at weekends than on school days (Fig. 1). recommendations) in all the members of families with non-overweight and overweight/obese children. Discussion In response to the specific objective of the study, it was The plethora of studies confirm the influential role of revealed that maternal achievement of PA recommendation parents on the PA of their children through a variety of (≥ 10,000 steps/day) significantly helped all children, re- mechanisms, including parents taking responsibility for gardless of their body weight, to reach the recommended PA care [33], support [8, 35, 36], encouragement [7], and daily step count. And furthermore, the active participation engagement [33]. Nonetheless, it has not yet been of children in organized leisure-time PA increased the odds explained sufficiently which of the parental health-related of all children achieving the daily step count recommenda- indicators help children achieve the recommended level of tions; however, for overweight/obese children this remained PA or how these indicators vary between non-overweight non-significant. Many studies confirmed that there is a and overweight/obese children. The results of this positive relationship between the objectively monitored PA three-cohort study extend the current knowledge in the (or proxy-reported screen time) of parents and their area of the parent-child PA relationship in a random sam- children [10, 17, 22–24, 26, 28, 37, 39, 74, 75]. However, ple of families with non-overweight and overweight/obese only a few of them focused on the analyses of the preschool and school-aged children. Another original parent-child relationship in terms of meeting the PA/screen Sigmund et al. BMC Public Health (2018) 18:676 Page 7 of 11 Table 2 Logistic regression analysis: odds ratios and 95% confidence intervals for meeting the daily step count recommendations in non-overweight and overweight/obese children, separately for the mother-child and father-child pairs included in the model Meeting daily step count recommendation 11,500 SC/day for preschoolers and 13,000/11000 SC/day for school-aged boys/girls Families with non-overweight children Families with overweight/obese children a a a a % OR 95% CI % OR 95% CI % OR 95% CI % OR 95% CI Parent Mother in the model (n = 582) Father in the model (n = 357) Mother in the model (n = 125) Father in the model (n = 98) Step counts < 10,000 38.7 Ref. 43.8 Ref. 27.6 Ref. 33.3 Ref. steps/day ≥ 10,000 67.1 3.50*** 2.29–5.34 68.0 2.41** 1.37–4.26 47.6 2.98* 1.16–7.65 57.8 1.29 0.42–3.91 steps/day Screen time < 2 h per 53.2 Ref. 59.2 Ref. 45.8 Ref. 48.1 Ref. day ≥ 2 h per 50.8 0.98 0.59–1.65 52.7 0.99 0.56–1.78 15.8 0.14** 0.03–0.59 37.5 0.38 0.10–1.34 day Weight status Normal 52.9 Ref. 65.1 Ref. 32.9 Ref. 58.1 Ref. weight Overweight/ 49.2 1.02 0.62–1.66 50.0 0.50* 0.28–0.89 35.5 1.09 0.43–2.77 37.0 0.42 0.13–1.34 obesity Organized PA No 49.7 Ref. 54.9 Ref. 35.8 Ref. 51.6 Ref. Yes (≥1× 56.0 1.10 0.71–1.71 56.1 0.62 0.34–1.12 34.1 0.53 0.17–1.62 39.3 0.46 0.13–1.65 per week) Children Gender Boys 48.2 Ref. 52.3 Ref. 29.8 Ref. 35.6 Ref. Girls 54.2 1.16 0.77–1.77 57.8 0.86 0.50–1.50 41.9 3.17* 1.22–8.26 53.1 3.82* 1.05–13.91 School grade Preschool 55.1 Ref. 61.1 Ref. 42.9 Ref. 66.7 Ref. 1st-3rd 48.4 0.80 0.46–1.41 52.7 0.60 0.29–1.24 33.8 0.23 0.05–1.16 38.3 0.31 0.06–1.68 grade 4th–5th 51.7 0.95 0.58–1.56 53.4 0.72 0.38–1.37 33.1 0.32 0.07–1.42 41.3 0.70 0.13–3.72 grade Entertainment ST Non-excessive 55.2 Ref. 58.4 Ref. 44.3 Ref. 47.7 Ref. Excessive 46.6 0.75 0.45–1.23 48.6 0.55 0.29–1.05 24.4 0.29 0.07–1.17 37.9 0.80 0.22–2.85 Organized PA No 41.8 Ref. 43.4 Ref. 27.9 Ref. 45.2 Ref. Yes (≥1× 57.6 1.80* 1.13–2.87 61.5 2.85*** 1.54–5.27 41.7 2.37 0.88–6.40 50.0 1.99 0.64–6.22 per week) Nagelkerke R 0.15*** 0.17*** 0.37*** 0.27*** The models were adjusted for age category and gender of children Organized PA – structured/organized leisure-time physical activity (e.g. sports training) does not include lessons of physical education during school/kindergarten time Entertainment ST – sitting/lying while watching TV and sitting/lying in front of a PC (notebook, tablet, or smartphone) and not for school/work purposes (Excessive – more than 1 h/day for preschool children and more than 2 h/day for school-aged children; Non-excessive – less than the excessive amount) % proportion of children (daughters, sons) who met the pedometer-based recommendation for daily step counts (a value of 11,500 steps/day for preschool children and a value of 13,000 steps/day for school-aged boys and 11,000 steps/day for school-aged girls) in the given area OR odds ratio, 95% CI confidence interval, Ref. reference group, R Nagelkerke coefficient of determination, logistic model, Enter method The statistical significance is expressed as *p < 0.05, **p < 0.01, ***p < 0.001 Sigmund et al. BMC Public Health (2018) 18:676 Page 8 of 11 time recommendations (daily hours of screen time [10, 75, recommendations being met. In the case of overweight/ 76]; pedometer-determined daily step count [39]; minutes obese children, active participation in organized leisure-time spent daily on moderate-to-vigorous accelerometer-based PA doubled the chance of their reaching the daily step PA [17]), or categorizing the level of PA/screen time count recommendation compared to those not attending (median of moderate-to-vigorous accelerometer-based PA organized leisure-time PA, but the result was not significant. [24]; median of Caltrac accelerometer counts per hour [28]; Previous studies documented the positive contribution tertile of pedometer-determined daily step count [37]). The to the all-day objectively monitored PA of active par- present study therefore adds to the body of knowledge ticipation in physical education lessons (step count, regarding the existence of a relationship between parents’ moderate-to-vigorous PA) in boys of normal weight and children’s achievement of the PA recommendations. and overweight/obese girls aged 9–11 [78, 79]. In Similarly to other studies [22, 23, 26, 34], we found addition, these studies reported a significantly higher stronger positive relationships between mother-child PA proportion of boys of normal weight and overweight/ than father-child PA in families with both non-overweight obese girls who met the recommendation of 60 min of and overweight/obese children. In addition to those moderate-to-vigorous PA per day on a day with active studies, we found that in families with overweight/obese participation in a physical education lesson than on a children the mother’s behaviour (PA and screen time) is day without a physical education lesson. Therefore, it even more closely associated with their children’sPAthan was expected that active participation in organized that of the father. On the other hand, only fathers’ body leisure-time PA would increase the chance of both weight had a negative effect on the odds of their children non-overweight and overweight/obese children achiev- meeting the step count recommendations. No such asso- ing the daily step count recommendations. However, a ciation was observed in our study regarding mothers’ body study among Finnish preschoolers did not reveal differ- weight. Perhaps overweight/obese children are more likely ences in light PA or moderate-or-vigorous PA among to adopt patterns of parental behaviour than children of participants and non-participants in organized PA or normal body weight. This idea is supported by the finding between children of normal weight and overweight/ of lower differences in the daily step count among individ- obese children [23]. Significant differences in daily PA ual members of families with overweight/obese children between participants and non-participants in organized compared to families with non-overweight children, where leisure-time PA and between children of normal weight the child’s PA exceeds the parental activity. and overweight/obese children, as well as differences in The active participation of parents in organized PA between school days and weekend days, appear to leisure-time PA did not affect the odds of overweight/obese be evident only after children start attending primary or non-overweight children achieving the daily step count school [26, 27, 53]. recommendation. In one of the rare studies on the topic, We concur with the idea that parental correlates relat- Erkelenz et al. [77] also analysed the relationship of parental ing to PA and the overweight/obesity of their children PA and the participation of their six-to-eight-year-old are related in different ways in developing versus devel- children in organized sports in addition to parent-child PA. oped countries [17], and there is still a need for more They did not observe relationship between parental and detailed disclosure of parent-child PA relationships. The children’s PA; however, children with at least one active challenge lies in determining ways to effectively motivate parent displayed more minutes of participation in organized and support parents and other caregivers of young chil- sports. The absence of a parent-child PA relationship but a dren to optimize practices related to young children’s higher level of participation of children in organized sport health-related behaviours [80]. There are several parental in the event of there being at least one more active parent correlates of the objectively measured PA of preschool indicates that parental support for children’sPAcould be and school-aged children from Central and Eastern more important than parents’ joint PA [77]. The greater Europe that should receive more attention. It is neces- significance of parental support for children’sPAthan of sary to include socioeconomic status of families and the parent-child PA is also highlighted by meta-analytical level of parental education [7, 20, 23, 30, 81], incom- studies [35, 36], which also encourage further verification pleteness of families [6, 21], PA and support from class- of the relationship between parent-child PA and various mates and siblings [7, 8], and the type of residence and types of parental support for their children’sPAand their quality of the neighbourhood [21]. children’s actual PA. The present study showed that an active participation Strengths and limitations in organized leisure-time PA (at least once a week) is the The main strength of this three-cohort parent-child only one of the anthropometric and behavioural corre- study is the involvement of all family members with pre- lates of non-overweight children that was analysed school and school-aged children in the simultaneous which significantly increased the odds of daily step count monitoring of week-long ambulatory PA and screen Sigmund et al. BMC Public Health (2018) 18:676 Page 9 of 11 time, as proxy-reported by parents. Moreover, contrary childhood puberty. Finally, the cross-sectional design of to comparable international studies [36, 80], the present this study does not allow the causality of the parent-child research used stricter inclusion criteria for the final data PA relationships to be ascertained, despite their statistical analysis. Only data from children and their parents significance. However, given the age of preschoolers and whose PA and screen time were monitored continuously school-aged children, it is more likely that parent for at least 8 h a day on at least four weekdays and both health-related behaviour affects the behaviour of children weekend days were analyses. This strictness provides a than vice versa. more valid comparison of the duration of parents’ and children’s daily step count and screen time between Conclusions weekdays and weekend days, and helps reveal the vari- Altogether, the results of this study underline the differ- ables increasing the odds of overweight/obesity among ences in the parent-child PA relationship between families four-to-12-year-old Czech children. Another strength with non-overweight and overweight/obese children and of the study is that the total amount of daily PA is highlight the effect of maternal health-related behaviour on supplemented with information about participation in their children’s PA. The mother’s achievement of PA rec- organized sport. ommendation (≥ 10,000 steps/day) significantly helps all However, the conclusions of any study need to be for- children, regardless of their body weight, to reach the rec- mulated under the spotlight of existing methodological ommended daily step count. Conversely, excessive screen limitations. Firstly, although the parental proxy-reported time (≥ 2 h per day) in the mothers of overweight/obese variables of their children’s health-related behaviour (PA children significantly reduces the odds of their achieving and screen time) are considered to be valid and reliable the recommended daily step count. Whilst the active for assessing PA and screen time levels, there is always a participation of parents in organized leisure-time PA is not possible bias caused by social desirability. However, the related to their children’s PA, the active participation of parents, kindergarten/school teachers, and children were children in organized leisure-time PA almost doubles or not told what age and gender-related step count and even multiplies the odds of their meeting the daily step screen time recommendations exist prior to the com- count recommendation in both non-overweight and mencement of the eight-day monitoring of PA or during overweight/obese children. Involving all family members in it. Moreover, the data from the first day of measurement inexpensive PA enhancement programmes (especially at was also excluded from the final data analysis because weekends) and increasing the participation of all boys and the recording of the first day was incomplete and the girls, regardless of body weight and age category, in orga- novelty of wearing the Yamax pedometer might have nized leisure-time PA could be a promising part of strat- affected the initial activity (reactivity) [51]. Second, the egies for increasing daily PA and shaping an active lifestyle. PACPAC study uses pedometers to objectively capture Abbreviations PA, but unlike accelerometers, these pendulum arm BMI: Body Mass Index; CI: Confidence interval; ICC: Intra class correlation; tools are not designed to collect information on bouts, LR: Logistic regression; OR: Odds ratio; PA: Physical activity; PC: Computer use; Ref.: Reference group; SC: Step count; SD: Standard deviation; type or, in particular, the intensity of PA. However, these SPSS: Statistical package for the social sciences; ST: Screen time; less expensive devices are recommended as an inexpen- TV: Television viewing; WHO: World Health Organization sive, small-sized, easy-to-use, and objective (valid, reli- able, and non-reactive) method that provides a summary Acknowledgements The authors would like to thank all children and parents for participation in output of daylong ambulatory PA (quantified as the step the study. Special thanks go to the school management members who count) of preschool [82, 83] and school-aged children helped facilitate the research. [84] and adults [67] for the categorization of their Funding achievement of the step count recommendations. Third, This study was supported by a research grant from the Czech Science Foundation large differences in sample size and response rate of under reg. No. 16-14620S titled “Association between physical activity behaviour families with preschool and school-aged children could in parents and their children: A three-cohort study of children aged 4-12 years”. The funders had no role in the study design, data collection and analysis, decision have a potential impact on the results of PA/screen time to publish, or preparation of the study. results. Families with preschool children were more likely to meet the inclusion criteria for weekly PA/screen Availability of data and materials The data that support the findings of this study are available on request time monitoring and provide valid anthropometric, PA/ from the corresponding author ES. The data are not publicly available due to screen time data than families with school-aged children. rules of funded projects. It may seem that attitude of families with preschool children to research is more responsible compared to Authors’ contributions DS conceived the study, obtained the funding, and led manuscript writing. families with school children; but in families with DS, ES, and PB prepared a research protocol survey and participated in data school-aged children, a lower response rate could imply collection. DS and ES undertook the data analysis and interpreted the results. more time spent on school duties and the start of ES and AMG wrote the core of the manuscript with inputs from DS and PB. Sigmund et al. BMC Public Health (2018) 18:676 Page 10 of 11 ES and AMG revised the manuscript during the review process. All authors to adult overweight and adiposity: the Fels longitudinal study. Int J Obes interpreted, read and approved the final version of manuscript. Relat Metab Disord. 2000;24:1628–35. 16. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz W. Predicting obesity Ethics approval and consent to participate in young adulthood from childhood and parental obesity. N Engl J This study was approved by the Ethics committee of the Faculty of Med. 1997;337:869–73. Physical Culture, Palacký University on 25th March 2013 for families with 17. Muthuri SK, Onywera VO, Tremblay MS, Broyles ST, Chaput JP, Fogelholm M, school-aged children (ref. no. 17/2013), and on 10th December 2014 for et al. Relationships between parental education and overweight with families with preschool children (ref. no. 57/2014). All children, teachers, childhood overweight and physical activity in 9-11 year old children: results and school management received detailed information on the design and from a 12-country study. PLoS One. 2016;11:e0147746. purpose of the survey at a meeting at each of the participating schools. 18. Parrika S, Mäki P, Levälahti E, Lehtinen-Jacks S, Martelin T, Laatikainen T. Participation of children and parents in each part of data collection was Associations between parental BMI, socioeconomic factors, family structure voluntary and without any financial incentives. Written informed consent and overweight in Finnish children: a path model approach. BMC Public was obtained from all participants. Parents consented to the inclusion of Health. 2015;15:271. their children in this study. All participating members received feedback on 19. Kitsantas P, Gaffney KF. Risk profiles for overweight/obesity among the overall school results after data processing. preschoolers. Early Hum Dev. 2010;86:563–8. 20. Hesketh KR, McMinn AM, Ekelund U, Sharp SJ, Collings PJ, Harvey NC, et al. Competing interests Objectively measured physical activity in four-year-old British children: a The authors declare that they have no competing interests. Dr. Erik Sigmund cross-sectional analysis of activity patterns segmented across the day. Int J is an Associate Editor for BMC Public Health. Behav Nutr Phys Act. 2014;11:1. 21. Pouliou T, Sera F, Griffiths L, Joshi H, Geraci M, Cortina-Borja M, et al. Environmental influences on children’s physical activity. J Epidemiol Publisher’sNote Community Health. 2015;69:77–85. Springer Nature remains neutral with regard to jurisdictional claims in 22. Sijstma A, Sauer PJJ, Corpeleijn E. 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Health-related parental indicators and their association with healthy weight and overweight/obese children’s physical activity

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Medicine & Public Health; Public Health; Medicine/Public Health, general; Epidemiology; Environmental Health; Biostatistics; Vaccine
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Abstract

Background: Although it is accepted that parents play a key role in forming children’s health behaviours, differences in parent-child physical activity (PA) have not previously been analysed simultaneously in random samples of families with non-overweight and overweight to obese preschool and school-aged children. This study answers the question which of the health-related parental indicators (daily step count (SC), screen time (ST), and weight status and participation in organized leisure-time PA) help their children achieve the step count recommendations. Methods: A nationally representative sample comprising 834 families including 1564 parent-child dyads who wore the Yamax Digiwalker SW-200 pedometer for at least 8 h a day on at least four weekdays and both weekend days and completed a family log book (anthropometric parameters, SC, and ST). Logistic regression analyses were used to investigate whether parental achievement of the daily SC recommendation (10,000 SC/day), non-excessive ST (< 2 h/day), weight status, and active participation in organized PA were associated with children’sachievement of their daily SC (11,500 SC/day for pre-schoolers and 13,000/11,000 SC/day for school-aged boys/girls). Results: While living in a family with non-overweight parents helps children achieve the daily SC recommendation (mothers in the model: OR = 3.50, 95% CI = 2.29–5.34, p < 0.001; fathers in the model: OR = 2.41, 95% CI = 1.37–4.26, p < 0.01) regardless of their age category, gender, or ST, for families with overweight/obese children, only the mother’s achievement of the SC recommendations and non-excessive ST significantly (p < 0.05) increase the odds of their children reaching the daily SC recommendation. The active participation of children in organized leisure-time PA increases the odds of all children achieving the daily SC recommendations (OR = 1.80–2.85); however, for overweight/obese children this remains non-significant. The participation of parents in organized leisure-time PA does not have a significant relationship to the odds of their overweight/obese or non-overweight children achieving the daily SC recommendations. Conclusions: The mother’s health-related behaviours (PA and ST) significantly affect the level of PA of overweight/obese preschool and school-aged children. PA enhancement programmes for overweight/obese children cannot rely solely on the active participation of children in organized leisure-time PA; they also need to take other family-based PA, especially at weekends, into account. Keywords: Step counts, Organized leisure time physical activity, Preschool and school-aged children, Overweight and obesity * Correspondence: erik.sigmund@upol.cz Institute of Active Lifestyle, Faculty of Physical Culture, Palacký University Olomouc, Tr. Miru 117, 77111 Olomouc, Czech Republic Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sigmund et al. BMC Public Health (2018) 18:676 Page 2 of 11 Background among those European countries that are challenged by According to many theoretical models and theories [1–4] the trend of an increase in childhood overweight/obesity describing human behaviour, the direct influence of [40, 41], screen time behaviours [42], and reduced PA parents on the social development and behaviour of their [43]. Public health-related disciplines in these countries children is firmly established. Parents have been termed need to possess relevant information on the roles of the primary gatekeepers of their children’s health [5]. families in shaping the active lifestyle of their children. It The parent-child physical activity (PA) or screen time is because these countries tend to repeat the behavioural relationship has been studied in a wide range of social health-related patterns of children previously witnessed [6], psychological [7, 8], educational, and health-related in children and adolescents from Western high-income disciplines [9, 10], with an emphasis on healthy child countries, e.g. a decrease in PA, an increase in sedentary development [6–10]. behaviours (especially screen time activities), an increase A focus on parent-child dyad analysis in preschool and in the excessive consumption of sweetened beverages, preadolescent children is key to understanding the factors and a greater intake of fast food [44]. Such behaviours that are essential for shaping the active lifestyle of chil- consequently lead to increased rates of overweight and dren, which persists until adulthood [11, 12]. Numerous obesity [45–47]. Previous parent-child study [48] also longitudinal studies confirm the persistence of obesity pointed out that active participation of parent/children arising in preschool age to adolescence [13, 14] and adult- in organized PA as a promising “vehicle” to promote hood [15, 16]. An active lifestyle throughout childhood active lifestyle in children. However, it is not known and adolescence could thus prevent the development of whether active participation in leisure-time organized obesity in young adulthood [13]. Additionally, the rela- PA helps both healthy weight and overweight/obese tionship of parent-child overweight/obesity has already children to reach PA recommendations. The selected been proven to exist at preschool level [17–19]. Import- physical activity behaviours are more easily modifiable, antly, the risk of the transmission of obesity from child- thus influenceable through eventual intervention pro- hood to adulthood seems to be stronger when a child grams or stimuli, than socioeconomic status, structure, has one obese parent than in obese children without or place of residence, which play their role too. obese parents [16]. The study attempts to bridge the research gap of Objective parent-child PA and screen time measure- insufficient relevant information in Central European ments have been analysed globally – Western Europe nations concerning the parent-child PA/screen time [7, 20–22] and Northern Europe [23], North and relationship in a random sample of Czech families with South America [17, 24–29], Africa and South Asia preschool and school-aged children whose body weight [17], and Australia and New Zealand [30, 31]. The ranges from normal to overweight or obese with regard emphasis in such studies is placed, for instance, on active to the parents’ body weight and their participation in parental participation in organized or non-organized PA organized leisure-time PA. [24, 26, 29, 31], parental support for PA [7, 8, 32, 33]and This study aimed to estimate which of the health-related parenting styles [25, 32]. Other studies investigate role of parental indicators (daily step counts, amount of parental rules and restrictions concerning screen time screen-based entertainment time, weight status, and par- [30], parental education and family socioeconomic status ticipation in organized leisure-time PA) help their pre- [7, 17, 20, 21, 23, 30], variation in the weekday-weekend school and school-aged children achieve their step count PA and screen time relationship [7, 24, 26, 27, 29, 33], and recommendations. Furthermore, we assessed whether the level of body weight [17, 20, 22, 27, 29, 34]. However, associations differ by gender of parents, weight status and similarly valuable studies of objective parent-child PA and participation in organized PA of children. screen time measurements in the countries of Central and Eastern Europe are lacking. Methods Except for selected meta-analyses and reviews [35, 36], This research involved the use of data collected from the other parent-child PA/screen time studies are focused Czech-based Parent Child PA Care (PACPAC) Study. separately either on preschoolers [20, 22, 30, 31]or PACPAC is a three-cohort study that investigates the school-aged children and adolescents [7, 8, 17, 21, 24, parent-child PA/screen time relationship in families with 25, 27, 29, 32–34]. The parent-child PA/screen time pre-schoolers (aged 3–6.49 years) and school-aged chil- relationship in a broader age spectrum of preschool and dren (aged 6.5–12 years). This study collected data on school-aged children is seldom analysed [26, 37]. In parent-child dyads in the spring (from March until June) addition, parent-child PA/screen time relationships have and autumn (from September until November) months been analysed only rarely in the countries of Central, between 2013 and 2016. The Ethical Committee of the Southern, and Eastern Europe [38, 39]. The countries of Faculty of Physical Culture, Palacký University Olomouc Central, Southern, and Eastern Europe, however, belong approved the study design and protocol for families with Sigmund et al. BMC Public Health (2018) 18:676 Page 3 of 11 school-aged children (ref. no. 17/2013) on 25 March into a family log book. The parents received instructions 2013 and for families with preschool children (ref. no. regarding how to use a pedometer and the process of 57/2014) on 10 December 2014. recording the monitored values in the family log book. The family log book is composed of three sections – Sample and inclusion criteria the first to record the anthropometric parameters of Participants were recruited by means of two-stage strati- all the family members, the second for the PA-related fied random sampling. In the first stage, nine out of 14 data (step count, participation in organized PA), and administrative regions, three of each in the lowest, the third for recording the screen time (type and dur- middle, and highest terciles for gross domestic product ation) activities [53]. in the Czech Republic, were randomly selected. In the The parents were asked to record the demographic second stage of sampling, the selection of kindergarten and anthropometric parameters (birth date of children and primary schools respected the distribution of the and age of parents, gender, body height (with 0.5-cm urban-rural population in the Czech Republic [49]. A accuracy), and weight (with 0.5-kg accuracy)) of all the total of 296 families with preschool children and 1610 participating family members in the first section of the families with school-aged children were addressed in family log book before the start of the one-week moni- writing with an invitation to participate in the study toring of PA/screen time behaviour. The parents were before a joint meeting with the authors of the study. instructed how to measure their own body height and Participating children and their parents were predomin- weight at home, as well as the height and weight of their antly white Caucasian (> 98%), which is representative of children. The parental home measurement of the body the ethnic demographics of the Czech Republic [50]. weight and body height of their preschool [54] and The disproportion of the sample in terms of age, i.e. school-aged children and adolescents [55] are sufficiently higher number of school-aged children, was due to wider valid tools for determining the Body Mass Index (BMI) age range of school-aged children investigated compared for the subsequent identification of overweight and with pre-schoolers. Furthermore, while school attendance obesity in children [55, 56]. is compulsory, kindergarten attendance (except for the last The PA of all the participants in the three-cohort study pre-school year is optional). The objectives, procedures/ was monitored using the same type of unsealed Yamax measures, and course of the project were thoroughly Digiwalker SW-200 pedometer (Yamax Corporation, explained to the invited parents of the children and Tokyo, Japan). Participants were instructed to wear the teachers and school/kindergarten employees at a joint pedometer on their right hip for eight consecutive days meeting in each of the schools/kindergartens that partici- during waking hours except when bathing, showering, and pated. Written consent to participation in the study was dressing. Every morning after their personal hygiene, the obtained from 223 families with pre-schoolers (a response parents reset the pedometers, attached them to the right rate of 75%) and 1112 families with school-aged children hip (their children’s and their own), and recorded the time (a response rate of 69%) at the end of the joint meeting of the resetting in the family log book. In the evening, the (Table 1). The data of 38 families with preschool children parents removed the pedometers and, together with their and 463 families with school-aged children was not children, recorded the time and overall daily step count of included in the analyses because of incompleteness (miss- all the participating family members in the log book. In ing data on body weight, height, or age or an incomplete addition, parents also recorded whether they or their record of PA/screen time data in the family log book) or children actively participated in organized leisure-time PA invalidity (an absence of more than 1 day of the child from during the day into the log book. Organized leisure-time kindergarten/school or insufficient (< 8 h) time spent PA covers all kinds of structured intentional PA performed wearing the pedometer each day). In accordance with under the guidance of an educator (such as teacher, coach, the recommendations of previous studies [51, 52], the and instructor) and does not include lessons of physical final analyses included only data from parent-child education during school/kindergarten time [53]. Those pairs (mother and child n = 707 and father and child who participated at least once a week, were considered to n = 455) of participants who wore the pedometer for be participants in organized leisure-time PA. The values at least 8 h a day on at least four weekdays and both from the first day of monitoring were not included in the weekend days (Table 1). final analyses because of insufficient time spent wearing the pedometer and because of the novelty of wearing it, Procedures and measures which could have affected the level of the participants’ PA During the baseline joint meeting the invited parents and [51]. The pedometer-based monitoring of ambulatory PA kindergarten/school teachers were thoroughly acquainted is an objective, cheap, and unobtrusive method providing a with the procedures and course of the monitoring of PA reasonable assessment of a child’s day-long PA, albeit only and recording of the step count/screen time -related data when the total amount of PA, not its intensity, is of interest Sigmund et al. BMC Public Health (2018) 18:676 Page 4 of 11 Table 1 Summary sample characteristics (N, %, mean (standard deviation)) Families with preschool children Families with school-aged children Respondents addressed to participate 296 (100%) 1610 (100%) Written consent obtained (%*) 223 (75.3%) 1112 (69.1%) Initiating research (%*) 215 (72.6%) 1040 (64.6%) The final set with valid data (%*) 185 (62.5%) 649 (40.3%) 1st-3rd grade 4th–5th grade Parent-child dyads M (SD) M (SD) M (SD) Mothers N 164 289 254 Age (years) 36.19 (4.20) 38.19 (4.04) 38.94 (4.05) BMI (kg/m ) 24.02 (3.99) 23.42 (3.68) 23.91 (3.82) Overweight 24.39% 19.04% 20.87% Obese 9.76% 8.30% 7.87% Fathers N 107 187 161 Age (years) 38.91 (5.29) 40.15 (4.25) 41.38 (5.22) BMI (kg/m ) 26.04 (3.34) 26.81 (3.42) 26.64 (3.19) Overweight 50.47% 49.20% 63.31% Obese 11.21% 17.11% 14.91% Girls N 88 173 159 Age (years) 5.59 (0.74) 7.92 (0.81) 10.61 (0.74) BMI (kg/m ) 15.13 (2.41) 16.38 (2.51) 17.70 (3.00) Overweight 9.09% 15.60% 13.83% Obese 9.09% 6.94% 7.55% Boys N 97 172 145 Age (years) 5.68 (0.73) 8.00 (0.84) 10.62 (0.75) BMI (kg/m ) 15.41 (1.81) 16.65 (2.86) 17.67 (2.75) Overweight 6.18% 15.12% 17.93% Obese 9.28% 13.95% 8.28% %* – percent of the initial sample addressed % – overweight/obesity; overweight or obesity in children represents a BMI from the 85th to 97th or greater than the 97th percentile of the WHO growth charts 2 2 2 [71, 72]. Overweight and obesity in parents represents a BMI from 25 kg/m to 29.9 kg/m and greater than or equal to 30 kg/m , respectively [73] N number, M arithmetic mean, SD standard deviation, BMI Body mass index [57, 58]. Thegoodvalidityand reliabilityofthe hip-worn the amount of time their children spent watching TV Yamax Digiwalker SW-200 step count measurement sup- daily exhibits an acceptable 7-to-14-day test-retest reli- port the use of the Digiwalker for assessing free-living PA ability (ICC = 0.78, p < 0.001) [63] and shows a strong in preschool [58] and school-aged children [57–59], as well positive correlation with direct home time-lapse videos as in adults [60]. (r = 0.84, p < 0.001) [64]. The sedentary behaviour of all family members was self-reported in the family log book by the parents. Data management However, rather than all types of sedentary behaviours, The step count/screen time data was reviewed to check attention was focused on screen time activities only, for extreme values. The daily step count variable repre- since they allow more accurate discrimination of sented the mean difference between the morning (ped- health-risk behaviours than total sedentary behaviour ometer turned on) and evening (pedometer turned off) does [61, 62]. The duration and type of entertainment step count/screen time on the days of the week that screen time (sitting/lying while watching TV and sitting/ were monitored. Daily step count values below 1000 or lying in front of a PC (notebook, tablet, or smartphone) exceeding 30,000 were truncated to these recommended and not for school/work purposes) was recorded with an limit values, respectively [37, 51], and included in the accuracy of 10 min by the parents, together with their analyses. Weekly averages were calculated by adding 2/7 children, each evening. The parent-proxy assessment of of the weekend day average and 5/7 of the weekday Sigmund et al. BMC Public Health (2018) 18:676 Page 5 of 11 average. If step count and screen time were recorded on non-participants in organized leisure-time PA split by four weekdays, data for the one missing weekday based gender and the level of body weight of the children. on the participant’s personal mean scores was added. The Statistical Package for the Social Sciences (SPSS) The participants whose step count/screen time data was for Windows v.22 software (IBM Corp. Released 2013. missing for more than 1 day were excluded from the Armonk, NY, USA) was used for data management analyses. The daily step count recommendation for pre- and all statistical analyses. The alpha level of signifi- school children was set at a value of 11,500 steps/day cance was set at the minimum value of 0.05 for all [65]. For school-aged children, a value of 13,000 steps/ the statistical analyses. day was applied for boys and 11,000 steps/day for girls [53, 66], and for adults it was a value of 10,000 steps/day Results [67]. Daily screen time shorter than 10 min was not Among the children (420 girls and 414 boys), the preva- counted and if it was longer than 14 h it was shortened lence of overweight was observed in 13.6% (7.6% were to this recommended value [53]. Excessive screen time classified as obese) of the girls and 14.0% (10.9% were for preschool children was defined as more than 1 h/day classified as obese) of the boys. Of the 185 preschoolers, [68, 69] and for school-aged children [61, 62] and for the incidence of overweight was detected in 7.6% (and adults as two or more hours a day [70]. that of obesity in 9.2%) of them, while among the The BMI was calculated as the body weight (kg) school-aged children the representation of overweight divided by the square of body height (m). The chrono- amounted to 15.6% (and that of obesity to 9.3%) out of logical age of all family members was calculated from the total number of 649 school-aged children (Table 1). their date of birth until the first monitoring day. The relationship between children’s PA and parental Age-specific cut-off points [71–73] were used to define indicators of health-related behaviours is presented in the prevalence of overweight/obesity. Overweight or Table 2. Using the binary measures of achieving the obesity in children is represented by a BMI from the recommended levels of daily step count, we found strong 85th to 97th or greater than the 97th percentile of the positive associations between mothers’ and children’sstep WHO growth charts, respectively [71, 72]. Overweight count (p < 0.05), regardless of the maternal and children’s and obesity in parents is represented by a BMI from level of body weight. Fathers’ PA and level of body weight 2 2 25 kg/m to 29.9 kg/m and greater than or equal to were only significantly associated with non-overweight 30 kg/m , respectively [73]. children achieving the daily step count recommendation (Table 2). Statistical analyses While achievement of the recommended step count Descriptive characteristics for the daily step count, level by fathers significantly increased the odds of prevalence of overweight and obesity, percentages of non-overweight children achieving the daily step count participants who met the daily step count recommenda- recommendations, parental overweight/obesity status tions, percentages of participants with excessive daily significantly reduced these odds. The active participation screen time, and frequency of participation in organized of parents in organized leisure-time PA, regardless of their leisure-time PA were calculated for all family members gender, did not significantly affect the odds of their children (girls, boys, mothers, and fathers) separately. Summary achieving the daily step count recommendations, regardless sample characteristics are represented by means and of their level of body weight. Conversely, non-overweight standard deviations. The daily step count data is pre- children participating in organized leisure-time PA at least sented in the form of means and a 95% confidence inter- once weekly were more likely to meet the recommended val or percentages. Logistic regression models (Enter daily step count levels than their counterparts without or- Method) were used to identify which family-related vari- ganized leisure-time PA. ables (achievement of the recommended daily step The active participation of children in organized count, excessive screen time, parental overweight/obes- leisure-time PA (at least once a week) was positively ity, participation in organized leisure-time PA, and the associated with a significantly higher daily step count on gender of children) were associated with children of weekdays in non-overweight and overweight/obese boys normal body weight and overweight/obese children in comparison with non-participants in such activities achieving the step count recommendations separately). (Fig. 1). The significant difference in the daily step count The models were adjusted for age category and gender between boys (girls) who participated in organized of children. We used ordinary single-level regression, be- leisure-time PA and those who did not do so ranged cause initial analyses were not significantly altered by from 1764 to 2152 (1408–1471) steps on weekdays. clustering of data by school/kindergarten. An independ- Except for non-overweight boys, no significant differ- ent t-test (2-tailed) was used to compare the daily step ences in the daily step count at weekends were found in count (as presented in Fig. 1) of participants and terms of gender and body weight between participants Sigmund et al. BMC Public Health (2018) 18:676 Page 6 of 11 Fig. 1 Comparison of children’s daily step counts (mean and 95% CI) on weekdays and at weekends. Legend: CI – confidence interval; x – mean number of sessions of organized leisure-time PA per week. The statistical significance of the differences between participants in organized PA and non-participants in terms of their daily step count (independent t-test (2-tailed)) is expressed as *p < 0.05 and p < 0.001 and non-participants in organized leisure-time PA. For feature of the present study is represented by the gender- all children, regardless of gender, body weight, or partici- and age category-stratified analyses of daily step count pation in organized PA, a lower daily step count was vis- (specifically, the achievement of the daily step count ible at weekends than on school days (Fig. 1). recommendations) in all the members of families with non-overweight and overweight/obese children. Discussion In response to the specific objective of the study, it was The plethora of studies confirm the influential role of revealed that maternal achievement of PA recommendation parents on the PA of their children through a variety of (≥ 10,000 steps/day) significantly helped all children, re- mechanisms, including parents taking responsibility for gardless of their body weight, to reach the recommended PA care [33], support [8, 35, 36], encouragement [7], and daily step count. And furthermore, the active participation engagement [33]. Nonetheless, it has not yet been of children in organized leisure-time PA increased the odds explained sufficiently which of the parental health-related of all children achieving the daily step count recommenda- indicators help children achieve the recommended level of tions; however, for overweight/obese children this remained PA or how these indicators vary between non-overweight non-significant. Many studies confirmed that there is a and overweight/obese children. The results of this positive relationship between the objectively monitored PA three-cohort study extend the current knowledge in the (or proxy-reported screen time) of parents and their area of the parent-child PA relationship in a random sam- children [10, 17, 22–24, 26, 28, 37, 39, 74, 75]. However, ple of families with non-overweight and overweight/obese only a few of them focused on the analyses of the preschool and school-aged children. Another original parent-child relationship in terms of meeting the PA/screen Sigmund et al. BMC Public Health (2018) 18:676 Page 7 of 11 Table 2 Logistic regression analysis: odds ratios and 95% confidence intervals for meeting the daily step count recommendations in non-overweight and overweight/obese children, separately for the mother-child and father-child pairs included in the model Meeting daily step count recommendation 11,500 SC/day for preschoolers and 13,000/11000 SC/day for school-aged boys/girls Families with non-overweight children Families with overweight/obese children a a a a % OR 95% CI % OR 95% CI % OR 95% CI % OR 95% CI Parent Mother in the model (n = 582) Father in the model (n = 357) Mother in the model (n = 125) Father in the model (n = 98) Step counts < 10,000 38.7 Ref. 43.8 Ref. 27.6 Ref. 33.3 Ref. steps/day ≥ 10,000 67.1 3.50*** 2.29–5.34 68.0 2.41** 1.37–4.26 47.6 2.98* 1.16–7.65 57.8 1.29 0.42–3.91 steps/day Screen time < 2 h per 53.2 Ref. 59.2 Ref. 45.8 Ref. 48.1 Ref. day ≥ 2 h per 50.8 0.98 0.59–1.65 52.7 0.99 0.56–1.78 15.8 0.14** 0.03–0.59 37.5 0.38 0.10–1.34 day Weight status Normal 52.9 Ref. 65.1 Ref. 32.9 Ref. 58.1 Ref. weight Overweight/ 49.2 1.02 0.62–1.66 50.0 0.50* 0.28–0.89 35.5 1.09 0.43–2.77 37.0 0.42 0.13–1.34 obesity Organized PA No 49.7 Ref. 54.9 Ref. 35.8 Ref. 51.6 Ref. Yes (≥1× 56.0 1.10 0.71–1.71 56.1 0.62 0.34–1.12 34.1 0.53 0.17–1.62 39.3 0.46 0.13–1.65 per week) Children Gender Boys 48.2 Ref. 52.3 Ref. 29.8 Ref. 35.6 Ref. Girls 54.2 1.16 0.77–1.77 57.8 0.86 0.50–1.50 41.9 3.17* 1.22–8.26 53.1 3.82* 1.05–13.91 School grade Preschool 55.1 Ref. 61.1 Ref. 42.9 Ref. 66.7 Ref. 1st-3rd 48.4 0.80 0.46–1.41 52.7 0.60 0.29–1.24 33.8 0.23 0.05–1.16 38.3 0.31 0.06–1.68 grade 4th–5th 51.7 0.95 0.58–1.56 53.4 0.72 0.38–1.37 33.1 0.32 0.07–1.42 41.3 0.70 0.13–3.72 grade Entertainment ST Non-excessive 55.2 Ref. 58.4 Ref. 44.3 Ref. 47.7 Ref. Excessive 46.6 0.75 0.45–1.23 48.6 0.55 0.29–1.05 24.4 0.29 0.07–1.17 37.9 0.80 0.22–2.85 Organized PA No 41.8 Ref. 43.4 Ref. 27.9 Ref. 45.2 Ref. Yes (≥1× 57.6 1.80* 1.13–2.87 61.5 2.85*** 1.54–5.27 41.7 2.37 0.88–6.40 50.0 1.99 0.64–6.22 per week) Nagelkerke R 0.15*** 0.17*** 0.37*** 0.27*** The models were adjusted for age category and gender of children Organized PA – structured/organized leisure-time physical activity (e.g. sports training) does not include lessons of physical education during school/kindergarten time Entertainment ST – sitting/lying while watching TV and sitting/lying in front of a PC (notebook, tablet, or smartphone) and not for school/work purposes (Excessive – more than 1 h/day for preschool children and more than 2 h/day for school-aged children; Non-excessive – less than the excessive amount) % proportion of children (daughters, sons) who met the pedometer-based recommendation for daily step counts (a value of 11,500 steps/day for preschool children and a value of 13,000 steps/day for school-aged boys and 11,000 steps/day for school-aged girls) in the given area OR odds ratio, 95% CI confidence interval, Ref. reference group, R Nagelkerke coefficient of determination, logistic model, Enter method The statistical significance is expressed as *p < 0.05, **p < 0.01, ***p < 0.001 Sigmund et al. BMC Public Health (2018) 18:676 Page 8 of 11 time recommendations (daily hours of screen time [10, 75, recommendations being met. In the case of overweight/ 76]; pedometer-determined daily step count [39]; minutes obese children, active participation in organized leisure-time spent daily on moderate-to-vigorous accelerometer-based PA doubled the chance of their reaching the daily step PA [17]), or categorizing the level of PA/screen time count recommendation compared to those not attending (median of moderate-to-vigorous accelerometer-based PA organized leisure-time PA, but the result was not significant. [24]; median of Caltrac accelerometer counts per hour [28]; Previous studies documented the positive contribution tertile of pedometer-determined daily step count [37]). The to the all-day objectively monitored PA of active par- present study therefore adds to the body of knowledge ticipation in physical education lessons (step count, regarding the existence of a relationship between parents’ moderate-to-vigorous PA) in boys of normal weight and children’s achievement of the PA recommendations. and overweight/obese girls aged 9–11 [78, 79]. In Similarly to other studies [22, 23, 26, 34], we found addition, these studies reported a significantly higher stronger positive relationships between mother-child PA proportion of boys of normal weight and overweight/ than father-child PA in families with both non-overweight obese girls who met the recommendation of 60 min of and overweight/obese children. In addition to those moderate-to-vigorous PA per day on a day with active studies, we found that in families with overweight/obese participation in a physical education lesson than on a children the mother’s behaviour (PA and screen time) is day without a physical education lesson. Therefore, it even more closely associated with their children’sPAthan was expected that active participation in organized that of the father. On the other hand, only fathers’ body leisure-time PA would increase the chance of both weight had a negative effect on the odds of their children non-overweight and overweight/obese children achiev- meeting the step count recommendations. No such asso- ing the daily step count recommendations. However, a ciation was observed in our study regarding mothers’ body study among Finnish preschoolers did not reveal differ- weight. Perhaps overweight/obese children are more likely ences in light PA or moderate-or-vigorous PA among to adopt patterns of parental behaviour than children of participants and non-participants in organized PA or normal body weight. This idea is supported by the finding between children of normal weight and overweight/ of lower differences in the daily step count among individ- obese children [23]. Significant differences in daily PA ual members of families with overweight/obese children between participants and non-participants in organized compared to families with non-overweight children, where leisure-time PA and between children of normal weight the child’s PA exceeds the parental activity. and overweight/obese children, as well as differences in The active participation of parents in organized PA between school days and weekend days, appear to leisure-time PA did not affect the odds of overweight/obese be evident only after children start attending primary or non-overweight children achieving the daily step count school [26, 27, 53]. recommendation. In one of the rare studies on the topic, We concur with the idea that parental correlates relat- Erkelenz et al. [77] also analysed the relationship of parental ing to PA and the overweight/obesity of their children PA and the participation of their six-to-eight-year-old are related in different ways in developing versus devel- children in organized sports in addition to parent-child PA. oped countries [17], and there is still a need for more They did not observe relationship between parental and detailed disclosure of parent-child PA relationships. The children’s PA; however, children with at least one active challenge lies in determining ways to effectively motivate parent displayed more minutes of participation in organized and support parents and other caregivers of young chil- sports. The absence of a parent-child PA relationship but a dren to optimize practices related to young children’s higher level of participation of children in organized sport health-related behaviours [80]. There are several parental in the event of there being at least one more active parent correlates of the objectively measured PA of preschool indicates that parental support for children’sPAcould be and school-aged children from Central and Eastern more important than parents’ joint PA [77]. The greater Europe that should receive more attention. It is neces- significance of parental support for children’sPAthan of sary to include socioeconomic status of families and the parent-child PA is also highlighted by meta-analytical level of parental education [7, 20, 23, 30, 81], incom- studies [35, 36], which also encourage further verification pleteness of families [6, 21], PA and support from class- of the relationship between parent-child PA and various mates and siblings [7, 8], and the type of residence and types of parental support for their children’sPAand their quality of the neighbourhood [21]. children’s actual PA. The present study showed that an active participation Strengths and limitations in organized leisure-time PA (at least once a week) is the The main strength of this three-cohort parent-child only one of the anthropometric and behavioural corre- study is the involvement of all family members with pre- lates of non-overweight children that was analysed school and school-aged children in the simultaneous which significantly increased the odds of daily step count monitoring of week-long ambulatory PA and screen Sigmund et al. BMC Public Health (2018) 18:676 Page 9 of 11 time, as proxy-reported by parents. Moreover, contrary childhood puberty. Finally, the cross-sectional design of to comparable international studies [36, 80], the present this study does not allow the causality of the parent-child research used stricter inclusion criteria for the final data PA relationships to be ascertained, despite their statistical analysis. Only data from children and their parents significance. However, given the age of preschoolers and whose PA and screen time were monitored continuously school-aged children, it is more likely that parent for at least 8 h a day on at least four weekdays and both health-related behaviour affects the behaviour of children weekend days were analyses. This strictness provides a than vice versa. more valid comparison of the duration of parents’ and children’s daily step count and screen time between Conclusions weekdays and weekend days, and helps reveal the vari- Altogether, the results of this study underline the differ- ables increasing the odds of overweight/obesity among ences in the parent-child PA relationship between families four-to-12-year-old Czech children. Another strength with non-overweight and overweight/obese children and of the study is that the total amount of daily PA is highlight the effect of maternal health-related behaviour on supplemented with information about participation in their children’s PA. The mother’s achievement of PA rec- organized sport. ommendation (≥ 10,000 steps/day) significantly helps all However, the conclusions of any study need to be for- children, regardless of their body weight, to reach the rec- mulated under the spotlight of existing methodological ommended daily step count. Conversely, excessive screen limitations. Firstly, although the parental proxy-reported time (≥ 2 h per day) in the mothers of overweight/obese variables of their children’s health-related behaviour (PA children significantly reduces the odds of their achieving and screen time) are considered to be valid and reliable the recommended daily step count. Whilst the active for assessing PA and screen time levels, there is always a participation of parents in organized leisure-time PA is not possible bias caused by social desirability. However, the related to their children’s PA, the active participation of parents, kindergarten/school teachers, and children were children in organized leisure-time PA almost doubles or not told what age and gender-related step count and even multiplies the odds of their meeting the daily step screen time recommendations exist prior to the com- count recommendation in both non-overweight and mencement of the eight-day monitoring of PA or during overweight/obese children. Involving all family members in it. Moreover, the data from the first day of measurement inexpensive PA enhancement programmes (especially at was also excluded from the final data analysis because weekends) and increasing the participation of all boys and the recording of the first day was incomplete and the girls, regardless of body weight and age category, in orga- novelty of wearing the Yamax pedometer might have nized leisure-time PA could be a promising part of strat- affected the initial activity (reactivity) [51]. Second, the egies for increasing daily PA and shaping an active lifestyle. PACPAC study uses pedometers to objectively capture Abbreviations PA, but unlike accelerometers, these pendulum arm BMI: Body Mass Index; CI: Confidence interval; ICC: Intra class correlation; tools are not designed to collect information on bouts, LR: Logistic regression; OR: Odds ratio; PA: Physical activity; PC: Computer use; Ref.: Reference group; SC: Step count; SD: Standard deviation; type or, in particular, the intensity of PA. However, these SPSS: Statistical package for the social sciences; ST: Screen time; less expensive devices are recommended as an inexpen- TV: Television viewing; WHO: World Health Organization sive, small-sized, easy-to-use, and objective (valid, reli- able, and non-reactive) method that provides a summary Acknowledgements The authors would like to thank all children and parents for participation in output of daylong ambulatory PA (quantified as the step the study. Special thanks go to the school management members who count) of preschool [82, 83] and school-aged children helped facilitate the research. [84] and adults [67] for the categorization of their Funding achievement of the step count recommendations. Third, This study was supported by a research grant from the Czech Science Foundation large differences in sample size and response rate of under reg. No. 16-14620S titled “Association between physical activity behaviour families with preschool and school-aged children could in parents and their children: A three-cohort study of children aged 4-12 years”. The funders had no role in the study design, data collection and analysis, decision have a potential impact on the results of PA/screen time to publish, or preparation of the study. results. Families with preschool children were more likely to meet the inclusion criteria for weekly PA/screen Availability of data and materials The data that support the findings of this study are available on request time monitoring and provide valid anthropometric, PA/ from the corresponding author ES. The data are not publicly available due to screen time data than families with school-aged children. rules of funded projects. It may seem that attitude of families with preschool children to research is more responsible compared to Authors’ contributions DS conceived the study, obtained the funding, and led manuscript writing. families with school children; but in families with DS, ES, and PB prepared a research protocol survey and participated in data school-aged children, a lower response rate could imply collection. DS and ES undertook the data analysis and interpreted the results. more time spent on school duties and the start of ES and AMG wrote the core of the manuscript with inputs from DS and PB. Sigmund et al. BMC Public Health (2018) 18:676 Page 10 of 11 ES and AMG revised the manuscript during the review process. All authors to adult overweight and adiposity: the Fels longitudinal study. Int J Obes interpreted, read and approved the final version of manuscript. Relat Metab Disord. 2000;24:1628–35. 16. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz W. Predicting obesity Ethics approval and consent to participate in young adulthood from childhood and parental obesity. N Engl J This study was approved by the Ethics committee of the Faculty of Med. 1997;337:869–73. Physical Culture, Palacký University on 25th March 2013 for families with 17. Muthuri SK, Onywera VO, Tremblay MS, Broyles ST, Chaput JP, Fogelholm M, school-aged children (ref. no. 17/2013), and on 10th December 2014 for et al. Relationships between parental education and overweight with families with preschool children (ref. no. 57/2014). All children, teachers, childhood overweight and physical activity in 9-11 year old children: results and school management received detailed information on the design and from a 12-country study. PLoS One. 2016;11:e0147746. purpose of the survey at a meeting at each of the participating schools. 18. Parrika S, Mäki P, Levälahti E, Lehtinen-Jacks S, Martelin T, Laatikainen T. Participation of children and parents in each part of data collection was Associations between parental BMI, socioeconomic factors, family structure voluntary and without any financial incentives. Written informed consent and overweight in Finnish children: a path model approach. BMC Public was obtained from all participants. Parents consented to the inclusion of Health. 2015;15:271. their children in this study. All participating members received feedback on 19. Kitsantas P, Gaffney KF. Risk profiles for overweight/obesity among the overall school results after data processing. preschoolers. Early Hum Dev. 2010;86:563–8. 20. Hesketh KR, McMinn AM, Ekelund U, Sharp SJ, Collings PJ, Harvey NC, et al. Competing interests Objectively measured physical activity in four-year-old British children: a The authors declare that they have no competing interests. Dr. Erik Sigmund cross-sectional analysis of activity patterns segmented across the day. Int J is an Associate Editor for BMC Public Health. Behav Nutr Phys Act. 2014;11:1. 21. Pouliou T, Sera F, Griffiths L, Joshi H, Geraci M, Cortina-Borja M, et al. Environmental influences on children’s physical activity. J Epidemiol Publisher’sNote Community Health. 2015;69:77–85. Springer Nature remains neutral with regard to jurisdictional claims in 22. Sijstma A, Sauer PJJ, Corpeleijn E. 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