Application value of neck circumference in screening for overweight and obesity among children and adolescents
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摘要:
目的 探讨颈围用于筛查儿童青少年超重肥胖的应用价值,为筛查儿童青少年超重肥胖提供理论依据和新思路。 方法 于2023年5—7月,采取整群随机抽样法抽取郑州市3所学校的3~16岁儿童青少年共2 493名,收集一般资料及颈围、体质量指数(BMI)、腰高比等信息。采用Mann-Whitney秩和检验、Spearman相关分析、受试者工作特征曲线对数据进行统计分析。 结果 3~16岁儿童青少年超重肥胖率为33.05%,腹型肥胖率为28.33%。男女童超重肥胖组颈围在学龄前期、学龄期、青春期与正常体重组相比差异均有统计学意义(Z=-16.69~-4.54,P值均 < 0.05)。不同性别各年龄分期儿童青少年颈围与BMI均呈正相关(r=0.50~0.79,P值均<0.01)。ROC曲线分析显示男女童颈围在学龄前期、学龄期、青春期时协助筛查超重肥胖发生准确性较好[男童AUC值(95%CI)分别为0.80(0.71~0.89),0.89(0.86~0.91),0.84(0.81~0.87);女童分别为0.76(0.67~0.86),0.81(0.74~0.88),0.73(0.68~0.77),P值均<0.01],男童最佳颈围界值分别为26.95,28.95,33.55 cm,女童分别为25.05,26.55,28.35 cm。男女童在学龄期、青春期颈围与腰高比均呈正相关(r=0.41~0.70,P值均<0.01)。ROC曲线显示男女童颈围在学龄期、青春期时协助筛查腹型肥胖发生准确性较好[男童AUC值(95%CI)分别为0.89(0.86~0.92),0.82(0.78~0.85);女童分别为0.84(0.75~0.93),0.87(0.75~0.93)],男童最佳界值分别为28.95,32.75 cm;女童最佳界值分别为26.45,31.85 cm。 结论 颈围可应用于儿童青少年超重肥胖和腹型肥胖筛查,为儿童青少年超重肥胖防控工作提供了新思路。 Abstract:Objective To discuss the clinical value of neck circumference in screening for overweight and obesity in children and adolescents, so as to provide a theoretical basis and new ideas for overweight and obesity screening. Methods From May to July 2023, a total of 2 493 children and adolescents aged 3 to 16 were sampled from three schools by the cluster random sampling method. General data, neck circumference, body mass index (BMI), waist-to-height ratio, and other information were collected. Mann-Whitney rank-sum test, Spearman correlation analysis, and receiver operating characteristic (ROC) curve analysis were used to statistically analyze the data. Results The prevalence of overweight and obesity in children and adolescents aged 3 to 16 was 33.05%, and the prevalence of abdominal obesity was 28.33%.The neck circumferences of boys and girls in the overweight and obese group showed statistically significant differences from the normal weight group during the pre-school, school-age, and adolescence periods (Z=-16.69-4.54, P < 0.05). The neck circumferences of children of different genders were moderately positively correlated with BMI (r=0.50-0.79, P < 0.01). ROC curve analysis showed that neck circumference had good accuracy in assisting the screening for the occurrence of overweight and obesity in boys and girls during the pre-school, school-age, and adolescence periods [the AUC for boys: 0.80(0.71-0.89), 0.89(0.86-0.91), 0.84(0.81-0.87); the AUC for girls: 0.76(0.67-0.86), 0.81(0.74-0.88), 0.73(0.68-0.77), P < 0.01], the optimal neck circumference cut-off values for boys were 26.95, 28.95, 33.55 cm, and for girls were 25.05, 26.55, 28.35 cm respectively. The neck circumferences of boys and girls were moderately positively correlated with the waist-to-height ratio during the school-age and adolescence periods (r=0.41-0.70, P < 0.01). ROC curves showed that neck circumferences had good accuracy in assisting the screening for the occurrence of abdominal obesity in boys and girls during the school-age and adolescence periods [the AUC for boys: 0.89(0.86-0.92), 0.82(0.78-0.85); the AUC for girls: 0.84(0.75-0.93), 0.87(0.75-0.93)], the optimal cut-off values for boys were 28.95, 32.75 cm; for girls were 26.45, 31.85 cm respectively. Conclusion The neck circumference can be applied to screen for overweight and abdominal obesity in children and adolescents, and can provide new ideas for the prevention and control of overweight and obesity in children and adolescents. -
Key words:
- Neck /
- Overweight /
- Obesity /
- ROC curve /
- Child /
- Adolescent
1) 利益冲突声明 所有作者声明无利益冲突。 -
肥胖是导致生理和代谢改变的慢性病,可使儿童青少年面临如心血管疾病、血脂异常、不健康心理和情绪不良等健康风险[1-4]。儿童青少年肥胖相关的并发症出现早且严重,多数会延续到成年,对儿童青少年及成人后健康构成巨大威胁[5-8]。儿童肥胖以惊人的速度上升,据Wang等[9]预测,到2030年预计中国学龄前儿童超重肥胖率将达15.6%,学龄儿童将达31.8%。故儿童青少年时期应采用简单、可靠的筛查方法识别超重肥胖,并实施有效的干预措施。
体质量指数(body mass index, BMI)、腰围、腰高比等人体测量指标因方法相对廉价且为非侵入性,目前是识别超重肥胖的最常用方法[10-11]。腰高比(waist-to-height ratio, WHtR)是近年来备受推荐的中心性肥胖、心血管代谢异常、代谢综合征的评估筛查指标[12]。然而,上述测量指标在测量时受到测量时间、进餐、呼吸、配合度等多种因素影响。研究显示[13-15],颈围是上身皮下脂肪的代表,与体重、BMI、腰围高度相关,且简单实用、容易测量,适用于筛选超重肥胖。目前关于颈围在儿童青少年超重肥胖筛查中的应用尚未达成共识,且缺乏不同儿童期的最佳界值[16]。本研究旨在探讨不同性别、年龄分期儿童颈围与BMI、腰高比的相关性,以及儿童青少年筛查超重肥胖时颈围的最佳界值,为儿童青少年超重肥胖的筛查提供理论依据和新思路。
1. 对象与方法
1.1 对象
采用整群随机抽样方法,于2023年5—7月采用直接抽选法从河南省郑州市抽取幼儿园、小学和初中学校各1所,每所学校的所有学生均作为研究对象,共2 754名3~16岁儿童青少年参与调查。剔除信息、体检数据填写存在明显错误及不完整的261名儿童青少年,最终纳入2 493名儿童青少年,有效率为90.52%。其中学龄前期儿童280名,学龄期儿童958名,青春期儿童1 255名;男童1 512名,女童981名。平均年龄(10.22±3.21)岁,纳入标准:(1)年龄3~16岁;(2)能够配合完成人体指标测量。排除标准:(1)颈部外伤、颈部畸形、淋巴结肿大、腮腺炎、甲状腺疾病儿童;(2)性早熟儿童;(3)病理性肥胖儿童。本研究经研究对象及学生家长知情同意并签署知情同意书,研究经河南省儿童医院郑州儿童医院医学伦理委员会批准(伦理号:2021-H-K31)。
1.2 调查方法
1.2.1 基本信息
制定统一的基本信息收集表,收集儿童青少年姓名、性别、出生日期、实际年龄。信息由各班班主任填写,家长核对。计算调查日期距出生日期之间的精确天数,实际年龄=相应精确天数/365,保留小数点后1位。儿童期分期为学龄前期(年龄≥3周岁到小学入学前)、学龄期(小学入学至青春期前)、青春期(第二性征出现)[17]。
1.2.2 体格检查
身高、体重、腰围测量标准:操作参照《学生健康检查技术规范》执行[18]。检查前对医务人员进行统一培训,测量仪器统一并经过严格校准,采用符合国家标准的身高体重秤及不易伸缩纤维软尺。身高、腰围精确至0.1 cm、体重精确到0.1 kg。颈围测量标准[19]:参与的儿童青少年两眼平视前方,自然均匀呼吸,两臂自然下垂,双足并拢,口微张以减少颈部肌肉的紧张,以颈后第7颈椎上缘和前面于喉结下缘水平或颈部中点绕颈部1周测量。测量结果精确到0.1 cm。性发育分期标准[20-21]:由经过专业培训的内分泌专科医生根据Tanner分期法,采用视诊结合触诊评估儿童第二性征的发育情况,结合女童乳房和阴毛、男童睾丸和阴毛发育,将女童乳房发育TannerⅡ期、男童外生殖器发育TannerⅡ期或男童睾丸容积达到4 mL作为青春期启动的标志。
1.2.3 肥胖超重、腹型肥胖判断标准
腹型肥胖依据腰高比进行判断[WHtR=腰围(cm)/身高(cm)]。依据《学龄儿童青少年超重与肥胖筛查》(WS/T 586—2018)[22]、《7岁以下儿童生长标准》[23]判定超重/肥胖,凡BMI大于等于相应性别、年龄组“超重”“肥胖”界值点者为超重/肥胖,BMI=体重(kg)/[身高(m)]2。采用刘浩东等[24-25]制定的儿童青少年腹型肥胖筛查标准:6~16岁男童和6~9岁女童腰高比>0.48,10~16岁女童>0.46。
1.3 质量控制
成立项目组和质量控制组,统一制定实施方案,对参与医务人员、各班班主任进行集中培训,培训合格后方可参与现场工作,并且统一调配。现场实施开始前,确保场地适宜。仪器设备准确齐全,且保证前后测量仪器设备的一致性。认真收录和梳理数据,实行双录入原则,并且核实具体内容,确保数据的真实准确性。
1.4 统计学分析
采用SPSS 24.0软件进行统计分析,非正态分布资料以M(P25,P75)表示,组间比较采用Mann-Whitney秩和检验。非正态分布采用Spear-man秩相关进行变量间相关分析,其中r≥0.6为强相关,0.4≤r<0.6中度相关,r<0.4弱相关。采用受试者工作特征曲线(ROC)评估不同性别、不同年龄分期儿童青少年颈围作为人体测量指标在协助筛查超重肥胖、腹型肥胖发生中的准确性。以P < 0.05为差异有统计学意义。
2. 结果
2.1 一般情况
2 493名儿童青少年超重肥胖率为33.05%(824名);男童超重肥胖率为34.65%(524名),女童为30.58%(300名)。6~16岁儿童青少年共2 252名,腹型肥胖率为24.33%(548名),男童腹型肥胖率为28.64%(397名),女童为17.44%(151名)。不同性别超重肥胖组儿童青少年颈围在学龄前期、学龄期、青春期与正常体重组相比差异均有统计学意义(P值均 < 0.05)。见表 1。
表 1 不同性别各年龄分期儿童青少年超重肥胖组与正常体重组颈围比较[M(P25,P75), cm]Table 1. Comparison of neck circumference between overweight and obese group and normal weight group in different gender and stages of children and adolescents[M(P25, P75), cm]性别 分期 超重肥胖组 正常体重组 Z值 P值 人数 颈围 人数 颈围 男 学龄前期 31 27.00(26.00,28.00) 117 25.00(24.00,26.00) -5.17 <0.01 学龄期 239 30.60(29.00,32.50) 429 27.00(26.00,28.50) -16.69 <0.01 青春期 254 34.90(32.93,37.00) 442 30.50(28.05,33.00) -14.80 <0.01 女 学龄前期 33 25.50(24.45,36.35) 99 24.40(23.70,25.00) -4.54 <0.01 学龄期 39 27.20(26.00,28.40) 251 25.50(24.50,26.50) -6.17 <0.01 青春期 228 31.00(29.50,32.80) 331 29.50(28.00,30.50) -9.16 <0.01 2.2 不同性别各年龄分期儿童青少年颈围与BMI、腰高比的相关性
Spearman相关分析显示,在学龄前期、学龄期、青春期时男女童颈围与BMI均呈正相关(r值分别为0.50,0.79,0.78;0.54,0.55,0.75);除学龄前期男童外,男女童颈围与腰高比均呈正相关(r值分别为0.64,0.65;0.20,0.41,0.49)(P值均 < 0.01)。
2.3 不同性别各年龄分期儿童青少年颈围判断超重肥胖的ROC曲线分析
结果显示,男女童颈围在学龄前期、学龄期、青春期时协助筛查超重肥胖发生的曲线下面积(AUC值)为0.73~0.89,最佳颈围界值为25.05~33.55 cm。见表 2。
表 2 不同性别各年龄分期儿童青少年颈围判断超重肥胖的ROC曲线分析Table 2. ROC curve analysis of neck circumference to identify overweight and obese children and adolescents in different genders and stages性别 分期 人数 AUC值(95%CI) P值 截断值 敏感度/% 特异度/% 男 学龄前期 148 0.80(0.71~0.89) < 0.01 26.95 61.3 85.5 学龄期 668 0.89(0.86~0.91) < 0.01 28.95 82.4 80.2 青春期 696 0.84(0.81~0.87) < 0.01 33.55 65.7 83.9 女 学龄前期 132 0.76(0.67~0.86) < 0.01 25.05 57.6 82.8 学龄期 290 0.81(0.74~0.88) < 0.01 26.55 66.7 80.1 青春期 559 0.73(0.68~0.77) < 0.01 28.35 70.0 66.1 2.4 不同性别学龄期、青春期儿童青少年应用颈围判断腹型肥胖的ROC曲线分析
以腹型肥胖为状态变量,以学龄期、青春期儿童青少年颈围为检验变量。绘制ROC曲线显示男女童颈围在学龄期、青春期时协助筛查腹型肥胖发生的曲线下面积(AUC值)范围为0.82~0.89,最佳颈围界值范围为26.45~32.75 cm。见表 3。
表 3 不同性别儿童青少年在学龄期、青春期颈围判断腹型肥胖的ROC曲线分析Table 3. ROC curve of neck circumference to identify abdominal obesity in school-aged and pubertal children and adolescents with different genders性别 分期 人数 AUC值(95%CI) P值 截断值 敏感度/% 特异度/% 男 学龄期 668 0.89(0.86~0.92) < 0.01 28.95 86.7 78.3 青春期 696 0.82(0.78~0.85) < 0.01 32.75 78.3 68.2 女 学龄期 290 0.84(0.75~0.93) < 0.01 26.45 86.7 71.6 青春期 559 0.87(0.88~0.91) < 0.01 31.85 70.9 88.2 3. 讨论
本研究结果显示,男女童在学龄前期、学龄期、青春期超重肥胖组颈围与正常体重组差异均有统计学意义,且颈围与BMI均呈正相关。该结果与国内外多项研究结果相一致[14, 19, 26]。提示颈围作为儿童青少年超重肥胖筛查指标具有可行性。
颈围对儿童超重肥胖筛查诊断截断值的研究尚无统一结论。本研究ROC曲线分析发现颈围在不同性别、不同年龄分期儿童中判断超重肥胖发生准确性较好,AUC值为0.73~0.89。男童学龄前期、学龄期、青春期判断超重肥胖发生的最佳颈围界值分别为26.95,28.95,33.55 cm,女童分别为25.05,26.55,28.35 cm。Turkay等[14]界定6~10岁男女童判断超重、肥胖颈围最佳界值为27.9,26.9 cm。一项纳入465名12~14岁墨西哥青春期儿童研究[13]显示,颈围判断男女童肥胖、超重发生的最佳界值为12岁30.0,29.3 cm,13岁31.9,30.4 cm;14岁33.5,30.7 cm。巴基斯坦学者研究[19]显示,男童超重和肥胖的颈围最佳界点为25.00~30.35 cm,女童为24.00~31.62 cm。
BMI可评估超重肥胖,但不能区分肌肉和脂肪积累。腹部肥胖与心脑血管疾病、糖尿病肾病和糖尿病视网膜病变相关[27-28]。腰围、腰高比是目前评估腹型肥胖最常用的指标[1, 15]。本研究显示男女童在学龄期、青春期颈围与腰高比呈中强度正相关,而学龄前期男女童颈围与腰高比呈弱正相关。可能与儿童生长发育和体型变化特点有关,5~7岁后BMI急剧上升、脂肪明显积聚[29]。ROC曲线分析显示颈围协助学龄期、青春期男女童筛查腹型肥胖AUC值为0.82~0.89。学龄期、青春期男童颈围筛查腹型肥胖的最佳界值分别为28.95,32.75 cm;女童为26.45,31.85 cm。师亚楠等[30]对6~16岁南京地区各年龄段儿童青少年研究发现,男童、女童颈围评估腹型肥胖AUC值分别≥0.830,≥0.796,男童颈围截断值为27.15~37.05 cm,女童为26.25~30.50 cm。Valencia-Sosa等[27]对墨西哥1 802名儿童研究发现,颈围与腰围呈高度相关,可被用于评估腹型肥胖。综合国内外研究提示,颈围对筛查学龄期、青春期男女童腹型肥胖准确度较好。
本研究对颈围在儿童超重肥胖、腹型肥胖筛查中的应用价值进行了探讨,但仍存在局限性。(1)颈围在成人研究中不仅应用于肥胖筛查,还用于预测疾病风险、治疗效果评价;颈围与高血压、高甘油三酯血症、空腹血糖受损、阻塞性睡眠呼吸暂停等疾病发生呈正相关[31]。有关儿童青少年颈围与其他疾病相关性尚需进一步探讨。(2)颈围与人体体脂分布、身体成分等相关性需后续进一步收集资料加以完善。(3)使用单一指标虽然方便临床实践工作开展,但存在局限性,可结合多个指标提高诊断的准确性。(4)低龄儿童对触觉敏感度高,痒感控制差,接受度一般,测量时不易配合,会影响测量精度。(5)超重肥胖儿童颈部周围脂肪组织堆积、易颈椎后纵韧带骨化,进而引起颈椎生理弯曲改变,使颈椎的解剖结构在体表上精准定位存在困难[32]。
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表 1 不同性别各年龄分期儿童青少年超重肥胖组与正常体重组颈围比较[M(P25,P75), cm]
Table 1. Comparison of neck circumference between overweight and obese group and normal weight group in different gender and stages of children and adolescents[M(P25, P75), cm]
性别 分期 超重肥胖组 正常体重组 Z值 P值 人数 颈围 人数 颈围 男 学龄前期 31 27.00(26.00,28.00) 117 25.00(24.00,26.00) -5.17 <0.01 学龄期 239 30.60(29.00,32.50) 429 27.00(26.00,28.50) -16.69 <0.01 青春期 254 34.90(32.93,37.00) 442 30.50(28.05,33.00) -14.80 <0.01 女 学龄前期 33 25.50(24.45,36.35) 99 24.40(23.70,25.00) -4.54 <0.01 学龄期 39 27.20(26.00,28.40) 251 25.50(24.50,26.50) -6.17 <0.01 青春期 228 31.00(29.50,32.80) 331 29.50(28.00,30.50) -9.16 <0.01 表 2 不同性别各年龄分期儿童青少年颈围判断超重肥胖的ROC曲线分析
Table 2. ROC curve analysis of neck circumference to identify overweight and obese children and adolescents in different genders and stages
性别 分期 人数 AUC值(95%CI) P值 截断值 敏感度/% 特异度/% 男 学龄前期 148 0.80(0.71~0.89) < 0.01 26.95 61.3 85.5 学龄期 668 0.89(0.86~0.91) < 0.01 28.95 82.4 80.2 青春期 696 0.84(0.81~0.87) < 0.01 33.55 65.7 83.9 女 学龄前期 132 0.76(0.67~0.86) < 0.01 25.05 57.6 82.8 学龄期 290 0.81(0.74~0.88) < 0.01 26.55 66.7 80.1 青春期 559 0.73(0.68~0.77) < 0.01 28.35 70.0 66.1 表 3 不同性别儿童青少年在学龄期、青春期颈围判断腹型肥胖的ROC曲线分析
Table 3. ROC curve of neck circumference to identify abdominal obesity in school-aged and pubertal children and adolescents with different genders
性别 分期 人数 AUC值(95%CI) P值 截断值 敏感度/% 特异度/% 男 学龄期 668 0.89(0.86~0.92) < 0.01 28.95 86.7 78.3 青春期 696 0.82(0.78~0.85) < 0.01 32.75 78.3 68.2 女 学龄期 290 0.84(0.75~0.93) < 0.01 26.45 86.7 71.6 青春期 559 0.87(0.88~0.91) < 0.01 31.85 70.9 88.2 -
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