5.7 Methodological considerations
5.7.4 Statistical considerations
It is possible that the small sample sizes across all three studies is not big enough to detect small differences in the outcomes, especially in study I. In study II and III, as in many longitudinal studies, there are large dropout numbers. Even though the used statistical method, LMM, has advantages in dealing with missing values, there have been indications that larger values of missing data could introduce potential bias in the analyses (288).
Moreover, the power calculations performed in the beginning of Early STOPP were performed on prevalence of obesity. All though we have analyzed the data using this outcome, it has not been the only outcome of interest, and power calculations for BMISDS, PA, sleep, or dietary habits were not performed. Since the inclusion of participants was not successful, we could not meet the originally planned numbers. A renewed power estimate was calculated; however, it is possible that the new power could not handle the amount of dropout.
6 CONCLUSIONS
PA among the children in Early STOPP increased continuously with age and form three years of age the children were more active on weekdays than on weekend days. However, these patterns were not equal between the least and most active children. This together with the finding that higher time in preschool-care suggests that PA interventions could be effective in the preschool setting targeting the lowest active children. Maternal PA was a correlate of importance for child PA. If an increased maternal PA can lead to an incerase in child PA should be further investigated.
Early STOPP, a targeted obesity prevention intervention with a long-term and
multicomponent design was not effective in preventing obesity among children at high risk for the disease. It was also ineffective in the secondary aim, promoting and increasing PA.
Overall, child PA was not affecting weight development nor were children with overweight/obesity less active than their normal weight peers. Results from this thesis indicates that obesity during early childhood is not affected by PA.
7 FUTURE PERSPECTIVE
The knowledge of PA during early childhood is constantly increasing and objective measures to capture PA as well as SB and sleep in the youngest children are more reliable now than previously. Future research should study the 24-hour movement patterns to further increase the understanding of how PA, SB and sleep co-varies and what factors that may affect a young child’s everyday movement. Also, this thesis studied several potential correlates to PA but mostly within the “Demographic/Biological” domain. Future research should continue studying potential correlates in other domains as well as study the potential genetical impact on PA. Also, characterizing the lowest active children should be prioritized since these children are not only the least active but also distinguishes them from the other children in PA patterns.
Obesity is a worldwide epidemic that needs to be tackled by society, both by searching for effective treatment options and by preventing the disease in our children. Up until now prevention interventions have been ineffective. The future needs to seek new alternatives, widen the interventions and not solely try to prevent this complex disease by promoting PA and dietary habits.
8 ACKNOWLEDGEMENTS
I would like to express my deepest appreciation to all of you that has made this journey possible. It has been a privilege to be able to learn about science and to get deep into the knowledge about childhood obesity and child physical activity. I thank you all for supporting and believing in me.
I would like to thank all the participating families in Early STOPP, especially “my” coaching-families. You let me be a small part of your life, inviting me to get to know you and your children. You helped me understand the struggles of parenthood, meanwhile allowing me, a young newly grad, to guide you – for this I am humble and forever grateful. Without
participants, clinical research would not be possible, it is because of your commitment that we can increase our knowledge!
Maria Hagströmer, the superwoman in human form. As my main supervisor you have not only guided me as a PhD-student, but you have also been supportive in all aspects of life.
Your never-ending encouragement during these years has been invaluable and it is amazing how quick you always answer big and small questions. Your feedback on my work has helped me become a better writer, reader, speaker, and researcher. For this and everything else I am truly grateful, thank you.
Claude Marcus, it has now been ten years and a couple of -moved- offices since you first let me become a part of your research team. I am so thankful for the opportunities you have provided me. You are a man with big visions and your enthusiasm and great knowledge on childhood obesity research has inspired me. Our discussions on obesity and physical activity have challenged me and made me think outside the box, leading me to become a better researcher. Thank you!
Emilia Hagman, thank you for being an awesome co-supervisor. You have always been available around the corner, or lately, just a zoom-click away. You have taken the time to answer my questions, both the good and the bad, and your thoughtful feedback has helped me grow as a researcher. I really appreciate you.
Pernilla Danielsson-Liljeqvist, it has been a true joy to work with you and your passion for children with obesity is contagious. I have really enjoyed managing the childhood obesity course together and I hope to continue with great collaborations.
Julia Xiu, having you as a doctoral study buddy has been a blessing. Your knowledge on accelerometry and child health is inspiring and the fact that you never hesitate to explain and share that knowledge is greatly appreciated. I hope to see you soon!
Elin Vidlund, all I know about accelerometry I initially learned from you. Thank you for accepting to supervise my master thesis and for great collaboration on study I. You are always helpful and kind.
Michaela Forssén, you were the one that suggested to Claude that I should become a part of the research team. For this I am forever grateful. Working with you was always fun and you were one of the sincerest people I have ever met. You left this world to soon and I miss you.
Karin Nordin, I will always think of the time, when we collected the six-year data in Early STOPP, as the most fun part of this process. The early mornings and the large amount of coffee we shared was amazing. You are a fantastic nurse and a great colleague and friend.
To the former co-workers in Early STOPP, Anna Ek, Kerstin Ekbom, Mirjam Ekstedt, Paulina Nowicka and Viktoria Svensson, what a journey it has been. Thank you for all the interesting discussions over the years, for sharing your knowledge and insights on childhood obesity and for making Early STOPP possible and joyful.
To my current and former doctoral friends, Resthie Putri, thank you for your time and for statistical discussions and help, it was invaluable. Markus Brissman, Linnea Johansson, Louise Lindberg and Veroniqa Lundbäck, what would this have been without you? Not as fun, not as inspiring, and not as educative. Thanks for all the discussions, high and low and for all the laughs.
Thank you, former colleagues, at B6A, Anna E Ek, Mahnoush Etminan Malek, Monika Grzeskowiak, Pernilla Hedvall Kallerman and Jonna Nyman, and thank you current and former administrative staff for invaluable support, Anette Johansson, Nina Risti, Agneta Wittlock, Carol Melton and Lisbeth Sjödin.
Thank you, Björn Fischler, head of the pediatric unit, for your help and support during these years, it has been appreciated!
To the members of the Hagströmer research group, Ing-Mari Dohrn, Linda Ekenros, Cecilia Fridén, Patrik Karlsson, Kristina Larsson, Andrea Porserud, Philip von Rosen, Jenny Rossen, Simon Torikka and Susanna Aufwerber, you have contributed to new insights, new knowledge, and fun memories over the past years, thank you!
Thank you Henrike Häbel, Ulf Hammar, and Matteo Bottai for statistical discussions and consultation.
Simon Körösi, my mentor, thank you for your support, for always being a phone call away and for being a dear friend!
To ALL my beloved friends, especially Anna Roa and Andrea Frölin, thank you for supporting me during these years. For always and alldays having my back and for patiently waiting for my returning text messages. Let’s drink some wine soon!
My inner circle, my team B. Tack för att ni alla alltid funnits där för mig och för att ni accepterar mig för den jag är. Mamma, tack för att du alltid stöttat mig och visat att allt är möjligt och att inga hinder är stora nog för att inte kunna ta sig över. Du inspirerar mig!
Pappa, tack för att du alltid tror på mig och för att du visat mig att godhet, hjälpsamhet och humor är ett vinnande koncept. Magnus, tack för att du alltid, alltid ställer upp! Lisa, Hannes, Julia och Tobias, det är få förunnat att ha så fina syskon som dessutom också är dom bästa av vänner. Tack för alla livliga diskussioner om högt och lågt genom livet. Tack för att ni är ni och framför allt tack för stödet under denna doktorandresa. Ni imponerar mig!
Tack till Anders, Nathalie, Willy och Alexandra för att ni kompletterar team B på bästa tänkbara sätt. Det är en ynnest att få kalla er för familj!
To the in-laws, Helene, Stefan, Johan och Annica, tack för att ni från första stund omfamnat mig och gjort mig till en del av er familj. Tack för att ni låter oss invadera era hem och
spendera ljuvliga somrar i Småland. Framför allt tack för er support den gångna sommaren när jag var tvungen att låsa in mig! Våffelfamiljen, Anton och Sandira, tack för all
uppbackning med barnen, för fotosessionerna och alla kvällar i uterummet. Jag uppskattar och är så tacksam för vår fina relation! Di gamle, förmodligen mina största supporters. Tack för alla nyfikna frågor och hejarop, det har betytt mycket för mig!
Till alla ljuvliga ungar jag har förmånen att ha i min närhet, Ruben, Hjalmar, Algot, Hilding, Gustaf, Wilmer, Leo, Lorentz, Arvid, Noa, Blanca, Elvis, Inez, Sigge, Penny och Bosse, tack för att ni förgyller tillvaron!
Petter, inget av det här hade varit möjligt utan dig, din oändliga support och positivism. Tack för att du hela tiden påminner mig om vad som egentligen är viktigt och spelar roll. Tack för att du lyfter upp mig när jag är nere och plockar ner mig igen när jag svävat i väg. Du är min klippa och min lugna vrå, tack för att du är du, vi är vi och för att jag får vara jag.
Jag älskar dig!
Einar och Bille, ni är allt jag någonsin önskat. Varje dag med er är ett äventyr som jag älskar att få vara en del av. Era skratt och era bus gör mig varm inombords och nu har mamma äntligen mer tid till att hoppa i kuddhögar med er! Jag älskar er, mest av allt!
This thesis was primarily funded by the generous grants from the Stockholm Free Masons’
Foundation for Children's Welfare, the Swedish Council for Working Life and Social Research, Vinnova (Sweden’s Innovation Agency), the Medical Research Council, the Swedish Heart and Lung Foundation, Stiftelsen Sven Jerrings Fond, HRH crown princess Lovisa’s foundation for pediatric care, and Anna-Lisa and Arne Gustafsson’s foundation. My sincerest Thank you!
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