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doi:10.1111/jpc.12442

ORIGINAL ARTICLE

Obesity and physical activity patterns in children and adolescents María Laguna,1 Jonatan R Ruiz,2,5 Cristian Gallardo,6 Teresa García-Pastor,3 María-Teresa Lara4 and Susana Aznar1 1 PAFS-UCLM Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Toledo, 2Department of Physical Education and Sport, School of Sport Sciences, University of Granada, Granada, 3Faculty of Physical Activity and Sports Science, University of Camilo José Cela, 4Sport Medical Center, Madrid, Spain, 5 Department of Biosciences and Nutrition at NOVUM, Unit for Preventive Nutrition, Karolinska Institutet, Huddinge, Sweden and 6School of Education, University of Santo Tomás, Osorno, Chile

Aim: The aim of this study is to measure objectively and accurately the physical activity (PA) patterns in Spanish children and adolescents according to their obesity status, gender and age groups. Methods: A sample of 487 children and 274 adolescents from the European Youth Heart Study participated in the study. The variables measured were anthropometric characteristics (height, weight and body mass index), and PA was measured during 6 consecutive days using the GT1M accelerometer. Results: Three-way analysis of variance (age × gender × obesity status) showed significant differences in the interaction effect in age, gender and obesity status (normal-weight and overweight/obesity) for mean of moderate-to-vigorous PA (MVPA) (P = 0.02) and vigorous PA (VPA) (P = 0.014) within the sample. Nine-year-old normal-weight children achieved significantly (P < 0.05) more MVPA on weekdays than 9-year-old overweight/obesity children. During weekend days, all sample achieved significant more MVPA (P < 0.01) and significant more VPA (P < 0.05) than during weekdays. Few children (37.5% of 9-year-old normal-weight and 34.0% of 9-year-old overweight/obese) and adolescents (16.4% and 27.3% normal-weight and overweight/obese, respectively) met the current health-related recommendations of 60 min of MVPA daily. Conclusions: It is clear that activity levels are insufficient for all children, in particular overweight/obese children and adolescents, although the precise nature of the relationship appears to differ between boys and girls. Key words:

adolescent; child; guidelines; obesity; patterns; physical activity.

What is already known on this topic

What this paper adds

1 Obese children achieve less physical activity (PA) than nonobese children. 2 An important strategy in order to achieve healthier body composition is to encourage a lifetime PA participation in overweight and obese children. 3 Assessing PA patterns is especially important because increasing PA in childhood might be essential to develop a lifetime PA lifestyle.

1 This study supports that whereas in 9-year-old group, gender and obesity status were associated with MVPA, in 15-year-old group, only gender had an association with MVPA. 2 This study report that there is a need to focus the efforts in 9-year-old overweight/obese children and in all 15-year-old adolescents (with or without overweight/obese) outside school time (afternoon–evening time). 3 Future recommendations should develop effective links between schools and students with community PA programmes.

The prevalence of overweight and obesity in youth has substantially increased across Europe1 and all over the world.2–4 This increase has both important immediate and long-term health implications.5–8 Similarly, physical inactivity during the early years of life is currently considered a major contributor to increasing levels of Correspondence: Dr Susana Aznar, PAFS-UCLM Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III, s/n., 45071 Toledo, Spain. Fax: +34 925 268 846; email: [email protected] Conflict of interest: No conflict of interests. Accepted for publication 21 May 2013.

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obesity and other serious medical conditions being seen in children and adolescents in Europe and elsewhere.1,9 Therefore, physical activity (PA) seems to be an ideal focus of intervention, because it has many other benefits in addition to body weight regulation.10 Current health-related PA recommendations for children and adolescents have been established in at least 60 min of moderate-to-vigorous PA (MVPA), 5 days a week,11,12 and they have been updated recently by the World Health Organization,13 which has also incorporated vigorous intensity activities. To help achieve current PA guidelines, the American Heart Association included specific school PA guidelines (30 min of MVPA) that should be achieved within the school hours.14

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An important strategy in order to achieve healthier body composition is to encourage a lifetime PA participation in overweight and obese children.15 Therefore, assessing PA patterns is especially important because increasing PA in childhood might be essential to develop a lifetime physically active lifestyle,16 and it is of interest to improve our understanding of the variation in PA behaviour in Spanish children. Consequently, more efficient intervention programmes could be developed. Several studies have addressed the daily patterns of PA in youth population according to age and gender, describing differences between days (during weekdays and weekend days),17 by day of the week,18,19 defined time blocks within days20 and by hours.17,21 But little is known if there are substantial differences in the pattern of PA according to normal-weight versus overweight/ obesity. The aim of this study was to measure objectively and accurately the PA patterns in Spanish children and adolescents according to their obesity status, gender and age groups.

Material and Methods Sample A total of 1395 children and adolescents from a representative sample of private and state schools in the community of Madrid, Spain, participated in the study. The European Youth Heart Study is a school-based, cross-sectional study designed to examine the interactions between personal, environmental and lifestyle influences on the risk factor for future cardiovascular diseases in several European countries. Study design, selection criteria and sample calculations have been reported elsewhere.22 Ethical approval was obtained by the Health Institute Carlos III in Madrid, Spain, and parental informed consent was obtained for each subject prior to data collection.

Obesity and physical activity patterns

detected as a combined function of the frequency and intensity of the movement, while an electronic filter rejects motion outside the range of normal human movement. Validation studies examining this accelerometer suggest that it is a valid and reliable measurement of children’s PA with highly significant correlation (r = 0.86) with energy expenditure assessed by indirect calorimetry, as well as a high degree of inter-instrument reliability.24–26 For data to be considered valid, two criteria were established: a minimum of data for a period of 4 consecutive days including 1 weekend day and a minimum of 10 registered h of data per day.27 Activity counts were summed for each hour that the accelerometer was worn between 7:00 h and 24:00 h to provide a representative picture of daily activity. Minute-byminute activity counts were summed for each epoch hour of measurement. For this study, epoch duration or sampling period was set at 15 s and the output was expressed as counts per minute (counts/min). For each measurement period, the total counts were divided by the number of registered hours to adjust for unequal monitoring times, and then converted to counts/ min, in accordance with other studies. Count ranges for the various activity intensities were 0–499 for sedentary, 500–1999 for light, 2000–2999 for moderate, 3000–4499 for vigorous and 4500–32 767 for very vigorous activities according to Andersen et al.28 To analyse the accelerometer data, Kinesoft software (Eslinger Consulting, Clifton Royal, New Brunswick, Canada), developed specifically for the Actical and Actigraph accelerometers, was used. The outcome variables were expressed in time (min/day) spent at different PA-intensity categories. Therefore, we calculated how many minutes of moderate, vigorous and very vigorous activity children achieved during the week, on weekdays and weekend days, and calculate their daily PA pattern. The number of days children achieved a minimum of 60 MVPA per day was calculated to report PA guidelines achievement. We excluded from the analysis bouts of 20 continuous min of activity with intensity counts of 0, considering these periods to be nonwearing time.29

Measurement Anthropometric characteristics Height was measured using a Holtain stadiometer without shoes and recorded in meters to the nearest millimeter. Weight was measured to the nearest 0.1 kg with a calibrated beam balance scale in light clothing. The body mass index (BMI) was calculated from the ratio weight/height2 (kg/m2) and organised using age and sex adjusted cut-off points described by International Obesity Task Force.23 Two BMI groups were established (overweight/obesity vs. normal-weight).

PA measurement PA was measured during 6 consecutive days (Thursday to Tuesday or Friday to Wednesday) using the GT1M accelerometer (Actigraph LLC, Pensacola, FL, USA). All children wore the accelerometer in an elastic waistband on the right hip during the daytime, except while bathing or during other aquatic activities. Verbal and written instructions for care and placement of the monitor were given to both children and their parents. GT1M is a lightweight (27 g) and small (4.5 × 3.5 × 1.0 cm), single plane (vertical) accelerometer. Movement in a vertical plane is

Statistics All analyses were performed by using the SPSS (version 19.0, SPSS, Inc., Chicago, IL, USA). Normality tests, symmetry and kurtosis were conducted. Mean ± standard deviation was used to describe the physical characteristics and all PA variables. Independent t-tests were used to examine gender differences for continuous variables and the chi-square test for nominal variables. The associations of gender and obesity status with MVPA and vigorous PA (VPA) were tested in each age group, by threeway (age × gender × obesity status) analysis of variance (ANOVA). Independent t-tests were used to analyse differences in PA patterns among groups of age, gender and obesity status (overweight/obesity vs. normal-weight), within the sample, and paired samples t-tests were used to analyse differences between weekdays and weekend days. The level of significance was set at P < 0.05.

Results A total of 914 children agreed to wear an accelerometer. Of the children who agreed to participate, 761 children and

Journal of Paediatrics and Child Health 49 (2013) 942–949 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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Table 1 Descriptive characteristics and levels of PA in study sample Children

n Weight (kg) Height (cm) BMI (Kg/m2) Overweight (%) Obesity (%) Overweight + obesity (%) Moderate PA (min/day) Vigorous PA (min/day) Moderate-to-vigorous PA (min/day)

Adolescents

Boys

Girls

Boys

Girls

233 35.4 (7.8) 138.6 (6.0) 18.3 (3.1) 25.3 7.3 32.6 32.2 (9.9) 35.9 (20.1) 68.9 (30.6)

254 36.4 (7.9) 140.1 (6.6)* 18.4 (3.1) 25.2 8.7 33.9 25.6 (8.9)† 25.7 (16.2)† 52.3 (26.1)†

141 62.7 (9.7) 171.5 (7.0) 21.3 (2.7) 21.3 2.1 23.4 19.3 (7.2) 29.2 (16.5) 50.2 (21.5)

133 56.3 (12.3)† 161.7 (6.5)† 21.5 (4.1) 15.0 1.5 16.5 18.4 (7.1) 22.8 (12.8)† 41.7 (16.6)†

Mean (SD) unless otherwise specified. *Significant differences between gender to same age group at P < 0.01. †Significant differences between gender to same age group at P < 0.001. BMI, body mass index; SD, standard deviation; PA, physical activity.

adolescents (487 9-year-olds (233 boys, 254 girls) and 274 15-year-olds (141 boys and 133 girls) returned the accelerometer that satisfied the validity criteria. Subjects who provided valid accelerometer recordings did not differ significantly in the study variables from children who did not provide valid recording. Characteristics of the study sample are shown in Table 1. Three-way ANOVA (age × gender × obesity status) showed significant differences in the interaction effect in age, gender and obesity status (normal-weight and overweight/obesity) for mean of MVPA (P = 0.02) and VPA (P = 0.014) within the sample. When the sample was divided according to age group, there were significant differences in the interaction effect gender × obesity status in 9-year-old group for MVPA (P < 0.001) and VPA (P < 0.001). However, we only observed significant differences (P < 0.01) in the interaction effect gender for the same variables in the 15-year-old group (P = 0.004). Nine–year-old children met significantly (P < 0.001) more MVPA than 15-year-old adolescents during all week (weekdays and weekend days). All girls achieved significantly (P < 0.001) less MVPA than boys, independently of obesity status (normalweight and overweight/obesity). No significant differences were found in MVPA minutes in all samples (9- and 15-year-old children) between normal-weight versus overweight/obese. All 9-year-old normal-weight children (boys and girls) achieved significantly (P < 0.05) more MVPA on weekdays than 9-year-old overweight/obesity children (boys and girls). Nine-year-old normal-weight boys achieved significantly (P < 0.05) more MVPA on weekdays and on weekend days (P < 0.01) and significantly more VPA on weekdays (P < 0.01) and on weekend days (P < 0.05) than their overweight/obese counterparts. Contrary, 9-year-old overweight/obese girls achieved significantly (P < 0.05) more both MVPA and VPA than normalweight/obese girls during weekdays. No significant differences were found in 15-years-old girls group (Table 2). During weekend days, all sample were significantly (P < 0.01) more active (more MVPA), and they achieved significantly (P < 944

0.05) more VPA than during weekdays. When the sample was divided according to age group, we compared weekdays versus weekend days, and significant (P < 0.01) differences were found only in 9-year-old group, whereas there were no significant differences in 15-years-old group.

Achievement of the health-PA guidelines A percentage of 40.9 of 9-year-old normal-weight children and 35.2% of 9-year-old overweight/obese children achieved PA recommendations. The achievement of PA guidelines for the 15-year-olds was 11.9% and 20.0% normal-weight and overweight/obese children, respectively. A percentage of 13.8 of 9-year-old normal-weight children and 9.3% 9-year-old overweight/obese children achieved PA recommendations within school (30 min of MVPA). Moreover, 0.9% 15-year-old normal-weight adolescents and 0.0% 15–year-old overweight/obese adolescents realised at least 30 min of MVPA within school hours.

Daily (7:00–24:00 h) MVPA patterns Figure 1 presents weekday daily MVPA pattern for 9-year-old and 15-year-old boys and girls separately. During weekdays, significant (P < 0.05) differences between normal-weight and overweight/obese 9-year-old boys were found in the following hours: 9:00, 12:00 and 14:00 h. Moreover, in the 9-year-old girl group, significant (P < 0.01) differences were found at 8:00 h, when overweight/obese 9-year-old girls achieved more MVPA than normal-weight 9-year-old girls. In 9-year-old group, PA bigger blocks were found between 11:00 and 14:00 h (which coincided with school recess, physical education and active transportation to home) and from 17:00 to 20:00 h (period when most of the organised PA activities and sport clubs take place). No significant differences in MVPA were found in 15-year-old group adolescents according to their obesity status during weekdays. During weekend days, in the 9-year-old boys group, significant differences between normal-weight and overweight/obese 9-year-old boys were found in the following hours: 14:00,

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Table 2

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PA levels of the sample’s subjects according to age and obesity status Children

All week (min) Moderate-to-vigorous PA Vigorous PA Weekdays (min) Moderate-to-vigorous PA Vigorous PA Weekend days (min) Moderate-to-vigorous PA Vigorous PA

Adolescents

Normal-weight (n = 325)

Overweight/obesity (n = 162)

Normal-weight (n = 219)

Overweight/obesity (n = 55)

61.0 (31.0) 31.6 (19.9)

58.6 (26.4) 28.7 (16.5)

45.3 (19.4) 25.3 (14.6)

49.3 (20.6) 29.2 (16.9)

57.2 (30.1)‡§ 30.1 (18.9)‡§

57.4 (27.0) 28.5 (16.6)

45.2 (18.5) 25.8 (14.4)

49.61 (20.1) 29.62 (17.1)

69,10 (43.16)*‡ 34,61 (27.52)*‡

61.1 (34.9)† 29.0 (21.4)

45.3 (32.4) 24.4 (22.4)

49.62 (34.8) 28.76 (25.1)

Mean (SD). *Significant differences at the same age group, between normal-weight and overweight/obesity at P < 0.05. †Significant differences at the same obesity status by age groups at P < 0.05. ‡Significant differences at the same obesity status by age groups at P < 0.01. §Significant difference between weekdays and weekend days P < 0.001. SD, standard deviation; PA, physical activity.

18:00, 19:00 and 20:00 h (at the level of P < 0.01) and 13:00, 16:00 h (at the level of P < 0.05) (Fig. 2). In all these hours, 9-year-old normal-weight boys achieved more MVPA than their overweight/obese counterparts. No significant differences in patterns of MVPA were found in 15-year-old group adolescents between normal-weight and overweight/obese adolescents during weekdays and weekend days. We analysed peaks in the daily MVPA pattern by age groups and obesity status, and we observed that 9-year-old group achieved significantly (P < 0.001) more minutes of MVPA during morning period (school time) than afternoon and evening period (extracurricular time) (Table 3). However, during weekend days, 9-year-old normal-weight (P < 0.001) and 9-year-old overweight/obese (P < 0.05) achieved significantly more MVPA during afternoon–evening period than in the morning. In adolescents only were observed significant differences (P < 0.001) in normal-weight subjects, who attained more MVPA during afternoon–evening than morning.

Discussion This study examined the daily PA patterns of a sample of children and adolescents according to age, gender and obesity status. The main result of this study suggests that whereas in 9-year-old group, gender and obesity status were associated with MVPA, in 15-year-old group, only gender had an association with MVPA. There is paucity of research in the achievement of PA recommendations (measured objectively) according to obesity levels in Spanish childhood and adolescence.17,21 To our knowledge, no previous research has reported between-day and within-day differences according to BMI, using accelerometer to measure the PA patterns of 9- and 15-year-old children in Spain. These data are necessary to understand the PA behaviour in childhood and adolescence and to provide efficient intervention programmes. The PA variables used here (MVPA and VPA) are similar to those which were reported previously30 because there are evi-

dences that prevention of excess fatness in growing youths is primarily dependent on adequate volumes of MVPA30–36 and VPA.34,37,38 The mean time spent in MVPA in this study was 61 min/day for children (boys: 69 min/day; girls: 52 min/day) and 46 min/ day for adolescents (boys: 50 min/day; girls: 42 min/day). These results are lower than those presented for European children,18,39 and in other Spanish regions.18 Riddoch et al.29 reported 192 min/day for boys and 160 min/day for girls in 9-year-old European children. Martinez-Gomez et al.40 showed higher levels of MVPA in Spanish adolescents. These two studies used the same cut-off points of accelerometer counts to define MVPA and VPA. Higher levels of PA in non-overweight than overweight/obese children have been demonstrated,30,41–44 and our results confirm previous findings in young people.45,46 Our results reflect that children have more free time to be active on weekends than during weekdays, contrary to other studies where weekdays were described as a critical period of interventions to promote PA.47–49 Similar to our study results were found by Dishman et al.50 in Australian 10-year-old children. Also, Trost et al.51 found that compared with weekdays, children exhibited significantly higher levels of MVPA on weekends. Both normal-weight and overweight/obese children and adolescents followed similar daily activity patterns. In children, the hour 8:00 seems to be a time when normal-weight boys are substantially more active than overweight/obese children on weekdays. The MVPA weekday pattern reflected Spanish school timetable. Both normal-weight children and overweight/obese children showed three peaks of MVPA, which coincided with travelling to school (8:00–9:00 h) and 11:00 to 14:00 period within school (although 15-year-old adolescents showed a peak at 11:00 and other at 14:00 h) and extracurricular activities (17:00 to 20:00 h). During weekdays, these periods were the key times when children were most active. At the weekend, activity patterns were less apparent, although the period 18:00– 20:00 h seemed to be a time when normal-weight boys were

Journal of Paediatrics and Child Health 49 (2013) 942–949 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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9-year-old girls

9-year-old boys

25

30

MVPA mean (min)

MVPA mean (min)

20

15

10

20

10 5

0

0

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h) 15-year-old girls

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h) 15-year-old boys

25

30

MVPA mean (min)

MVPA mean (min)

20 20

10

15

10

5

0

Fig. 1

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h)

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h)

MVPA weekday pattern for normal-weight (■) and overweight/obese (□) children and adolescents by gender.

substantially more active than overweight/obese boys on weekend days. All children and adolescents achieved significantly (P < 0.001) more MVPA within school than afternoon–evening period from 17:00 until 20:00 h, when organised PA are placed. Previous studies in children45 have shown both overweight/obese and normal-weight children have generally higher levels of activity during school hours compared with evenings, suggesting that the home environment is closely associated with reduced levels of PA. This supports the use of family-based interventions to increase PA in obese children.52–54 A particular strength of our study lies in the objective measure of PA by accelerometer. However, several limitations should be taken into consideration in this study. The observations of the present study are limited by the cross-sectional 946

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design nature, that is, direction of causality cannot be determined. Another limitation of the study is that BMI is indirect method to assess body fat. In addition, some limitations must be assumed when the current PA outcomes are compared with those of other studies because several factors such as type of monitor, length of the epoch and cut-off points selected.55 In summary, our study suggested that gender and obesity status was associated with MVPA and VPA in 9-year-old group, while in 15-year-old group, only gender was associated with MVPA and VPA. Nine–year-old normal-weight children tend to be more active than overweight/obese children, while in 15-year-old adolescents, there were no differences according to obesity status. All children and adolescents tend to be more active during school periods, and they were more active during weekend days than weekdays. However, all sample achieved a

Journal of Paediatrics and Child Health 49 (2013) 942–949 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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9-year-old girls

9-year-old boys 20

12

MVPA mean (min)

MVPA mean (min)

10 8 6

15

10

4 5 2 0

0

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h) 15-year-old girls

12

10

10

8 MVPA mean (min)

MVPA mean (min)

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h) 15-year-old boys

8

6

6

4

4 2

2

0

0

Fig. 2

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h)

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hours a day (h)

MVPA weekend day pattern for normal-weight (■) and overweight/obese (□) children and adolescents by gender.

Table 3

MVPA of children and adolescents in morning period (11:00–14:00 h) versus afternoon-evening period (17:00–20:00 h) Weekdays

Children normal-weight Children overweight + obesity Adolescents normal-weight Adolescents overweight + obesity

Weekend days

Moderate-to-vigorous PA morning (11:00–14:00 h)

Moderate-to-vigorous PA afternoon (17:00–20:00 h)

Moderate-to-vigorous PA morning (11:00–14:00 h)

Moderate-to-vigorous PA afternoon (17:00–20:00 h)

66,09 (37,18)† 61,46 (37,76)† 30,89 (22,89)† 30,02 (20,39)†

13,44 (10,54) 12,87 (8,58) 10,10 (7,93) 11,03 (9,36)

20,82 (17,50) 16,55 (13,71) 10,03 (12,63) 12,56 (17,97)

24,14 (18,50)† 19,81 (14,92)* 16,34 (16,39)† 16,04 (16,40)

Mean (SD). *Significant differences between morning period versus afternoon-evening period within age group at P < 0.05. †Significant differences between morning period versus afternoon-evening period within age group at P < 0.001. MVPA, moderate-to-vigorous physical activity; SD, standard deviation.

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low amount of MVPA. Our investigation also showed the need to focus these efforts in 9-year-old overweight/obese children and in all 15-year-old adolescents (with or without overweight/ obese) outside school time (afternoon–evening time). Therefore, to improve and enhance PA opportunities outside school seems to be an adequate aim. Longitudinal and/or intervention studies are needed to contrast and confirm these results.

Acknowledgements We would like to thank the ‘Viceconsejería de Deportes’ through the Sports Medicine Center in the Community of Madrid in Spain for providing funding for this study. We would also like to acknowledge all EYHS group leaders who assisted us in implementing the study. Finally, to all participating schools, which made this study possible.

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Obesity and physical activity patterns in children and adolescents.

The aim of this study is to measure objectively and accurately the physical activity (PA) patterns in Spanish children and adolescents according to th...
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