Kenneth Lo

Waist-to-height ratio, body mass index and waist circumference for screening paediatric cardio-metabolic risk factors: a meta-analysis

Waist‐to‐height ratio (WHtR) is superior to body mass index and waist circumference for measuring adult cardio‐metabolic risk factors. However, there is no meta‐analysis to evaluate its discriminatory power in children and adolescents. A meta‐analysis was conducted using multiple databases, including Embase and Medline. Studies were included that utilized receiver‐operating characteristics curve analysis and published area under the receiver‐operating characteristics curves (AUC) for adiposity indicators with hyperglycaemia, elevated blood pressure, dyslipidemia, metabolic syndrome and other cardio‐metabolic outcomes. Thirty‐four studies met the inclusion criteria. AUC values were extracted and pooled using a random‐effects model and were weighted using the inverse variance method. The mean AUC values for each index were greater than 0.6 for most outcomes including hypertension. The values were the highest when screening for metabolic syndrome (AUC > 0.8). WHtR did not have significantly better screening power than other two indexes in most outcomes, except for elevated triglycerides when compared with body mass index and high metabolic risk score when compared with waist circumference. Although not being superior in discriminatory power, WHtR is convenient in terms of measurement and interpretation, which is advantageous in practice and allows for the quick identification of children with cardio‐metabolic risk factors at an early age.

Associations between Parental Feeding Styles and Childhood Eating Habits: A Survey of Hong Kong Pre-School Children

Childhood obesity is a global public health issue, including in the Chinese setting, and its prevalence has increased dramatically throughout the last decade. Since the origins of childhood obesity may lie in the pre-school period, factors relating to very young children’s food consumption should be investigated. Parental influence, including feeding style, is the major determinant of childhood dietary behaviour through altering food provision and social environment. However, the applicability of previous research on parental feeding styles was limited by small sample size. To evaluate the influence of parental feeding styles on childrens dietary patterns, a cross-sectional study was conducted among 4553 pre-schoolers in Hong Kong. Information was obtained about dietary intake and how regularly they had breakfast, using previous health surveillance surveys taken among primary school students. Parental feeding styles were assessed by a validated Parental Feeding Style Questionnaire and categorized into ‘instrumental feeding’, ‘emotional feeding’, ‘prompting and encouragement to eat’ and ‘control over eating’. Multivariable analysis was performed, adjusted for demographic information. Instrumental and/or emotional feeding was found to relate to inadequate consumption of fruit, vegetables and breakfast, and positively correlated with intake of high-energy-density food. Encouragement on eating was associated with more frequent consumption of fruits, vegetables, dairy products and breakfast. Control over eating correlated with more frequent consumption of fruits, vegetables and breakfast, and less consumption of dairy products and high-energy-density food. The present study has provided evidence on the associations between parental feeding styles and dietary patterns of Hong Kong pre-school children from a reasonably large population. Parents should avoid instrumental and emotional feeding, and implement control and encouragement to promote healthy food intake. Longitudinal studies and interventions on parental feeding style are required to confirm the research findings.

Endorsement of PRISMA statement and quality of systematic reviews and meta-analyses published in nursing journals: a cross-sectional study

Objective Systematic reviews (SRs) often poorly report key information, thereby diminishing their usefulness. Previous studies evaluated published SRs and determined that they failed to meet explicit criteria or characteristics. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was recommended as a reporting guideline for SR and meta-analysis (MA), but previous studies showed that adherence to the statement was not high for SRs published in different medical fields. Thus, the aims of this study are twofold: (1) to investigate the number of nursing journals that have required or recommended the use of the PRISMA statement for reporting SR, and (2) to examine the adherence of SRs and/or meta-analyses to the PRISMA statement published in nursing journals. Design A cross-sectional study. Methods Nursing journals listed in the ISI journal citation report were divided into 2 groups based on the recommendation of PRISMA statement in their ‘Instruction for Authors’. SRs and meta-analyses published in 2014 were searched in 3 databases. 37 SRs and meta-analyses were randomly selected in each group. The adherence of each item to the PRISMA was examined and summarised using descriptive statistics. The quality of the SRs was assessed by Assessing the Methodological Quality of Systematic Reviews. The differences between the 2 groups were compared using the Mann-Whitney U test. Results Out of 107 nursing journals, 30 (28.0%) recommended or required authors to follow the PRISMA statement when they submit SRs or meta-analyses. The median rates of adherence to the PRISMA statement for reviews published in journals with and without PRISMA endorsement were 64.9% (IQR: 17.6–92.3%) and 73.0% (IQR: 59.5–94.6%), respectively. No significant difference was observed in any of the items between the 2 groups. Conclusions The median adherence of SRs and meta-analyses in nursing journals to PRISMA is low at 64.9% and 73.0%, respectively. Nonetheless, the adherence level of nursing journals to the PRISMA statement does not significantly vary whether they endorse or recommend such a guideline.

Chinese translation and validation of a parental feeding style questionnaire for parents of Hong Kong preschoolers

BackgroundChildhood obesity is a major public health issue in many countries, including China. The importance of parenting relative to the healthy development of children requires the development of instruments for assessing parental influence on child dietary pattern. This study aimed to confirm the internal reliability and validity of a self-report measure on parental feeding styles, including emotional feeding, instrumental feeding, prompting or encouragement to eat, and control over eating.MethodsA 27-item parental feeding style questionnaire (PFSQ) was translated into Chinese and then translated back into English to verify consistency. The questionnaire was then used to conduct a cross-sectional survey on the parents of Hong Kong preschoolers. The internal reliability and validity of the questionnaire were examined by Cronbach’s alpha and exploratory factor analysis, respectively.Results4,553 completed questionnaires were received. Cronbach’s alpha of subscales ranged from 0.63 to 0.81, and the overall reliability was good (alpha = 0.75). The factor structure of this questionnaire was similar to that of the original and Turkish versions. One-factor structure was identified for emotional feeding, instrumental feeding (four items), and prompting or encouragement to eat, whereas a two-factor structure was revealed for control over eating.ConclusionThe Chinese version of the PFSQ has good reliability and validity in assessing parental feeding styles in Hong Kong. Researchers can use this instrument to improve their understanding on how parental feeding styles may affect the dietary patterns and ultimately the weight statuses of children among Chinese-speaking populations across different countries.

The effect of music during bronchoscopy: A meta-analysis

Bronchoscopy is considered a stressful procedure performed on patients. Hence, the use of music to ease the anxiety of patients has been examined in various studies, but the results have been inconclusive. The aim of this review is to synthesize the findings of previous studies on the effects of music therapy on the physiological outcomes of patients undergoing bronchoscopy. An electronic database search was performed to identify the literature. Random-effects model was used to combine the results, and meta-regression was used to explore the heterogeneity. Seven studies with 829 subjects were included. Results showed that the combined mean differences (95% confidence interval) for systolic and diastolic blood pressure were -11.99 (-15.82, -6.57) and -4.84 (-7.78, -1.90) mm Hg, respectively, whereas that for heart rate was -10.57 (-16.63, -4.51) beats per minute. In conclusion, listening to music reduced blood pressure and heart rate among patients undergoing bronchoscopy.

Subjective sleep quality, blood pressure, and hypertension: a meta-analysis

Sleep quality is an important aspect of sleep, but no meta‐analysis has elucidated its relationship with blood pressure (BP) and hypertension. A meta‐analysis was conducted in October 2016 using multiple databases, including Embase and Medline. Studies that assessed subjective sleep quality and BP or hypertension were included. Upon full‐text evaluation, 29 articles from 45 041 patients were selected, of which 22 articles were included in the meta‐analysis and seven were presented narratively. Poor sleep quality was significantly associated with a greater likelihood of hypertension (odds ratio, 1.48; P value = .01). Poor sleepers had higher average systolic BP (mean difference = 4.37, P value = .09) and diastolic BP (mean difference = 1.25, P value = .32) than normal sleepers without statistical significance. Patients with hypertension had significantly worse sleep quality scores (mean difference = 1.51, P value < .01), while BP dippers had significantly better scores (mean difference = −1.67, P value < .01). The findings highlight the relationship between sleep quality and hypertension.

Citation classics in the nutrition and dietetics literature: 50 frequently cited articles

Aim: To identify the most cited articles under the category of ‘Nutrition and Dietetics’ and the reasons behind high citation rates; and to investigate reasons for journals having high impact factors (IFs). Methods: The 50 most cited articles were selected in August 2013 after sourcing all journals published from 1956 to 2013 under the category ‘Nutrition and Dietetics’ in the Institute for Scientific Information Journal Citation Reports: Science Edition 2012 database. Journals were categorised by country, number of top cited papers published in particular journal, language, year of publication of the first volume and IF. Articles were classified based on country location of the study design, research area, first author’s institution and organisation. Relationship between country of origin and high IF was determined. Results: Twenty-seven of 76 journals originated from USA, and the American Journal of Clinical Nutrition published 17 of the 50 most cited articles. The most common study designs of the most cited articles ranged from ‘basic science’ and ‘development and validation of tools’ (1960–1979) to ‘literature and systematic reviews’ (after 2000). The most frequently studied fields shifted from ‘nutritional status, dietary intake, and body composition’ and ‘obesity and eating disorder’ (1960–1979) to ‘vitamins, minerals, and phytochemicals’ (after 2000). Conclusions: The majority of top cited articles and journals originate from the USA. The common study designs and research topics in ‘Nutrition and Dietetics’ have changed over the years. An evolution from basic science to translational research and changing awareness from nutrition deficiency to disease prevention were observed.

Studying Impact of Nutrition on Growth (SING): a prospective cohort for comparing the health outcomes of young children with the dietary quality score

Introduction This study aims to explore the prospective association between the dietary quality (DQ) of preschoolers and their health status in Hong Kong, with the body mass index as the main outcome variable. Methods and analysis This prospective cohort study has recruited 3539 children aged between 2 and 4 years old, with a follow-up period of 4 years. Their diet was reported by their parents by a 3-day food diary, and their body weight and height were measured yearly with standardised instruments. Questionnaires were administered to parents to acquire information of the children’s prenatal development and dietary intake before their age of 2 years and of their baseline lifestyle and family backgrounds. The DQ was measured by the Healthy Eating Index as a continuous scale, while the exposure was defined as having a higher dietary quality score. Data were analysed using SPSS V.24. Linear and logistic regressions were used to examine the association of those predictive factors to the outcomes. Generalised estimating equations will be used to examine the longitudinal changes of the outcomes. A pilot study has been conducted, the preliminary results from which are presented in this cohort profile. Ethics and dissemination This study has been approved by the Joint Chinese University of Hong Kong and New Territory East Cluster Clinical Research Ethics Committee (CREC Ref No: 2013–632). Written informed consent was obtained from all subjects. The results will be published in due course.

Reply to comment on: waist-to-height ratio, body mass index and waist circumference for screening pediatric cardio-metabolic risk factors: a meta-analysis.

Dear Editor, We appreciate the interest of Dr Tian on our paper and the effort in evaluating our review. Dr Tian has raised concern on the methodological validity of pooling area under the curve (AUC) in our previous review.(1) We have pooled the AUC values because of two reasons. First of all, this method is consistent with another review conducted among adults so that the findings are more comparable.(2) Secondly, area under the ROC curve is useful in the early stages of diagnosis, especially for tests that do not require subjective interpretation.(3,4) That suits the scope of our review, which assesses the cardio-metabolic outcomes. We did consider using other methods to summarize our results, but too few studies have provided adequate information. For example, the numbers of the true/false positive and true/false negative are needed for combining the data by the hierarchical summary receiver operator characteristics (HSROC) method. However, among all outcomes in our review, only 3 out of the 10 studies on metabolic syndrome(5–7) and 3 out of the 11 studies on hypertension (8–10) have adequate information to compute those 4 values based on the reported sensitivity, specificity and prevalence of outcome. HSROC models were fitted for the two outcomes using the R-function “HSROC” developed by Schiller et al.(11) The pooled sensitivity and specificity of WHtR to screen for metabolic syndrome are 75.6% (95% C.I. = 37.8%–100%) and 93.9% (95% C.I. = 56.3%– 100%), respectively, while that for hypertension are 35.6% (95% C.I. = 15.2%–73.0%) and 94.4% (95% C.I. = 47.1%–100%), respectively. (Fig. 1)WHtR is sensitive to screen for metabolic syndrome and specific to screen for both outcomes. It is notable that only three studies were included in the analysis of each outcome, and the 95% confidence intervals were quite wide. When compared with sensitivity and specificity, AUC value is more easily accessible. That facilitates a more comprehensive evaluation on the current evidence. There is a trade-off between comprehensiveness of the analysis and the usage of a more sophisticated method. After careful consideration, we have opted for chosen the former advantage, with no major loss in the validity when screening for cardiometabolic outcomes.

Associated Demographic Factors of Instrumental and Emotional Feeding in Parents of Hong Kong Children

BACKGROUND Instrumental and emotional feeding have been associated with obesogenic dietary behaviors and obesity in children. Therefore, identifying parents who are more likely to use detrimental feeding styles may be helpful for tailoring interventions. OBJECTIVE This study examines the demographic variation of instrumental and emotional feeding by using a sample of the Hong Kong population. DESIGN A cross-sectional research is presented. Instrumental and emotional feeding styles were assessed. PARTICIPANTS A total of 3,742 Hong Kong parents from 27 kindergartens, with children aged 2 to 7 years old, were enrolled in this study. MAIN OUTCOME MEASURES Instrumental and emotional feeding styles were assessed by a validated Parental Feeding Style Questionnaire. STATISTICAL ANALYSIS Differences among the demographic characteristics in parental feeding styles were compared by independent t test or analysis of variance. Multiple linear regressions were performed to determine the associated demographic factors. RESULTS A greater tendency to adopt instrumental feeding was associated with younger children (β=-.07), feeding a daughter (β=.05), and a mother having a full-time job (β=.10). By contrast, a greater tendency to adopt emotional feeding was associated with younger children (β=-.07), feeding a daughter (β=.06), a mother having a full-time job (β=.16), or a lower parental education level (β=-.11). CONCLUSIONS Parents with full-time jobs, lower education levels, or who were nurturing a younger child may be more likely to use unhealthy feeding styles. Researchers should consider developing intervention strategies that focus on decreasing emotional and instrumental feeding styles for full-time employed or less-educated parents of younger children, particularly daughters.