Do preventive child examinations in general practice reduce the risk of overweight and obesity?

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Signe Heuckendorff, Rene Brund, Charlotte Eggertsen, Janus Thomsen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4240167/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2022 Read the published version in European Journal of Public Health → Version 1 posted You are reading this latest preprint version Abstract Objective : This study aims to investigate the association between attendance at routine preventive child health examinations in general practice and the risk of overweight and obesity in Danish children at age six, with a specific focus on children of parents with psychosocial risk factors. Methods : Utilizing nationwide Danish registers, a population-based birth cohort of 725 926 children born between 2000-2012 was analyzed. Information on preventive health examination attendance and BMI data were obtained. Statistical analyses, including modified Poisson regression, were conducted to assess the relationship between examination attendance and overweight/obesity risk. Results : The study found no significant association between attending these examinations and a reduced risk of overweight at age six in the overall population. In the subgroup of children of parents having 10 years of education of less, non-attendance was associated with a slightly increased risk of overweight, ranging from eight to nine percent. Regarding obesity risk, a dose-response correlation was observed, indicating that missing examinations increased the risk of obesity. Children of parents with psychosocial risk factors, particularly those with parents of low educational attainment, faced increased obesity risks, with the highest risk observed in children of parents with 10 years of education or less who missed all examinations, showing a four- to five-fold increase compared to children of parents with 14 years of the education or more attending all or missing only one exam (reference). Conclusion : Although routine preventive child health examinations may not directly reduce the risk of overweight, they could potentially mitigate obesity risk, especially in vulnerable populations. Further research is warranted to understand the underlying mechanisms and to develop targeted interventions to address health disparities in childhood obesity. Health sciences/Health care/Paediatrics Health sciences/Medical research/Epidemiology Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Childhood obesity has emerged as a global epidemic, presenting a significant public health challenge( 1 ). Even in Denmark, a country with a comparatively low prevalence, the rates remain concerning, with over 10% of children aged 6–7 classified as overweight and 3% as obese( 2 ). Alarmingly, obesity rates are projected to escalate by 2030( 1 ). Moreover, there is a pronounced social inequality in distribution of overweight and obesity among children( 3 , 4 ), underscoring the urgency for effective preventive and early detection interventions. In Denmark, a tax-based healthcare system ensures that health services, including routine preventive child health examinations, are free of charge( 5 ). General practitioners play a pivotal role in the identification and management of childhood overweight and obesity( 6 , 7 ). The Danish Health Authority guideline specifies the assessment of overweight and obesity as a key aspect of the routine examinations conducted by general practitioners. Notably, all children aged 0–5 years in Denmark are offered seven routine preventive child health appointments in general practice, ensuring comprehensive monitoring of their physical, mental and social well-being( 6 ). This unique opportunity places general practice in an ideal position to identify and address overweight and obesity at an early stage. Early identification and intervention are paramount, given the association between persistent childhood obesity and an elevated risk of developing adult type 2 diabetes and cardiovascular disease( 8 , 9 ). Children attending preventive health examinations in general practice may benefit from timely recognition and intervention, potentially averting the progression of overweight or obesity( 10 ). Furthermore, children of parents with psychosocial risk factors, including those with parents of low educational levels( 11 ) or mental health conditions may particularly gain from these examinations, which encompass preventive healthcare, early detection and counselling tailored to the specific needs of both parents and children. Despite the conceptualization of these examinations as interventions to address health inequality( 12 , 13 ), their actual impact on child health remains poorly studied and largely unexplored. To bridge this gap, our study aims to investigate the association between attending preventive child health examinations and the risk of overweight and obesity at the age of six. We will explore this association within the broader pediatric population and specifically assess its implications for children of parents with psychosocial risk factors, including short length of education and mental health conditions. This research seeks to contribute to valuable insight to inform targeted interventions and policies aimed at reducing childhood obesity and health disparities. Methods Study design We conducted a population-based birth cohort using nationwide Danish registers. Setting All children in Denmark are offered seven examinations in general practice during their first five years of life. The first three examinations are during the first year, followed by one examination annually at the ages of two, three, four, and five. Participants We included all Danish children born between 2000 and 2012. Children were included at the age of six, as health examinations at school ages are conducted by school health nurses. Most children undergo their five-year examination during their sixth year and before they turn six years old, thus providing a suitable follow-up period from the children’s sixth to seventh birthday. Exposure was measured five years prior to baseline, from the child’s first to sixth birthday. Children were excluded if information on parents’ identification number was missing, blocking linkage to the parents, or if the children or parents were not residing in Denmark at baseline or during the exposure period. Variables The outcome of interest was body mass index (BMI) at school age, defined as the first registration of BMI by the school health nurse at the age of six or later. Overweight and obesity were defined based on The International Obesity Taskforce (IOTF) criteria,( 14 ) using age- and gender-specific BMI centile corresponding to BMI at age 18, with a BMI ≥ 25 at age 18 defining overweight and a BMI ≥ 30 at age 18 defining obesity. The exposure variable was attendance at preventive child health examinations, including the four examinations at ages two, three, four, and five, respectively, categorized as: attending all or missing one (reference), missing two or three, and missing all four examinations. Parental psychosocial risk factors were short length of education and mental health conditions, categorized as maternal and paternal risk factors, respectively. Parental e ducation was categorized based on the International Standard Classification of Education (2011)( 15 ) and grouped into three categories according to the parent’s highest educational attainment: level 0–2 (10 years of mandatory education or below), level 3–4 (10–14 years of education, such as high school), and level 5–8 (more than 14 years of education, such as a bachelor’s degree). Mental health conditions were categorized based on the level of mental healthcare received within five years prior to baseline and categorized in three mutually exclusive groups. Parents with minor mental health conditions had been treated solely at primary healthcare settings. Moderate mental health conditions required a higher level of mental healthcare. The most severe mental health conditions, such as schizophrenia and bipolar disorders, constituted a separate category. More detailed definitions of the mental health conditions are further described elsewhere( 16 ). We included following covariates: Parent’s age at the time of the child’s birth, parental cohabitation (living with a partner or not), parity (firstborn or not), country of origin (Nordic, Western European, and other), and calendar year. To account for geographic variation in access to healthcare services, municipality was categorized into four categories: outer, rural, intermediate, and city. We adjusted for parent’s age and calendar year using restricted cubic splines with three knots( 17 ). All covariates were extracted at baseline. Data sources Data linkages were achieved using the personal identity number assigned to all Danish residents at birth or to individuals when they become residents. Register keepers at Statistics Denmark carried out data collection and register linkage. All data were deidentified before the researchers gained access. Information on child participation in preventive health examinations at general practice and mental health-related contacts to primary healthcare were retrieved from the Danish Health Service Register.( 18 ) Data on height and weight were obtained from the National Children’s Database.( 19 ) Information on parents’ highest completed education was provided by the Population Education Register.( 20 ). The National Patient Register provided information about psychiatric diagnoses and hospital contacts( 21 ) while the Danish National Prescription Registry provided data on reimbursed prescriptions on psychopharmaceuticals.( 22 ) Information on the age of the child and parents, parental cohabitation status, country of origin, and municipality were retrieved from the Danish Civil Registration System.( 23 ) Statistics Descriptive statistics, including numbers and percentages, were calculated for groups of children of parents with psychosocial risk factors by categories of preventive child health examination attendance. Modified Poisson regression analyses were conducted to produce adjusted risk ratios (RRs) for overweight and obesity. RRs for overweight and obesity were calculated for the overall population and within subgroups of vulnerable children for maternal and paternal risk factors, respectively. The reference group comprised children with the expected lowest risk of overweight or obesity, namely those attending all or missing one examination, and for example, having mothers with the longest attained education. To account for sibling correlation, a generalized estimating equation with an exchangeable correlation structure was used to fit a generalized linear model with log-link function, assuming a Poisson distribution and employing robust variance estimation. Results We included 725 926 children in the analyses. This followed the exclusion of 25 826 (2.8%) children due to missing parental identification number, 79 351 (8.7%) due to non-residency of the child and/or the parents in Denmark at baseline or during the exposure period. Additionally, 78 962 (8.7%) were excluded due to missing information on BMI status at school age (Fig. 1). Baseline sociodemographic characteristics by attendance at preventive child health examination are presented in Table 1 . Overall, more than two-thirds (69%) of the children attended all four exams or missed only one. The proportion of children of parents with psychosocial risk factors was higher in groups missing two or three examinations and those missing all four examinations than the group of children attending all or missing one examination. For instance, 11% of the children attending all or missing one exam had mothers with 10 years of education or less; this percentage was 23% and 33% for children attending two or three examinations and those missing all four examinations, respectively. Table 1 Baseline sociodemografic characteristics. Numbers and percentages of the overall population and percentages of children by covariate and category of preventive child health examination attendance Attending all/missing one Attending two or three exams Missing all exams Number of children (%) 498877 (68.7) 194367 (26.8) 32682 (4.5) Parity First born 45.4 36.6 23.5 Not first born 50.7 57.0 65.0 Missing variable 3.9 6.4 11.5 Country of origin Nordic 94.7 84.9 82.9 Western Europe 0.3 0.5 0.8 Other 5.0 14.5 16.3 Missing 0.0 0.0 Municipality Outer 8.0 7.2 8.7 Rural 28.9 25.5 27.0 Intermediate 17.3 16.5 16.2 City 45.7 50.5 46.7 Missing variable 0.1 0.2 1.4 MATERNAL COVARIATES Age 32 38.8 38.1 39.9 Missing 0.0 0.0 0.1 Educational level 14 years 50.8 37.9 27.8 Missing 0.5 1.5 2.7 Mental health condition None 74.1 68.3 66.2 Minor 18.4 19.7 19.5 Moderate 6.7 10.4 12.1 Severe 0.9 1.6 2.2 Cohabitation status Living with partner 88.3 79.3 71.9 Not living with partner 11.7 20.4 26.7 Missing variable 0.1 0.2 1.4 PATERNAL COVARIATES Age 32 56.1 55.5 57.1 Missing 0.0 0.1 0.3 Educational level 14 years 39.1 31.6 24.5 Missing 0.9 2.1 3.1 Mental health condition None 84.1 78.5 75.8 Minor 10.7 12.8 13.3 Moderate 4.4 7.3 9.1 Severe 0.8 1.4 1.8 Cohabitation status Living with partner 88.5 79.7 72.5 Not living with partner 11.3 19.9 25.9 Missing variable 0.1 0.4 1.5 Figure 2 illustrates the risk of overweight and obesity in the overall population. Attendance at preventive child health examinations, compared to non-attendance, was not associated with a reduced risk of overweight at age six in the overall population (RR 1.02, 95% CI 1.01–1.02, Fig. 2). In the subgroup of children of parents with 10 years of education of less, a slightly increased risk of overweight of eight to nine percent was associated with non-attendance (Fig. 3). An increased risk of overweight was not seen in the other subgroups. Overall, a dose-response correlation was observed, with higher risks of obesity associated with the number of missed examinations. In the overall population, the children with four missed examinations had a 31% increased risk of obesity compared to the children attending all or missing only one examination (Fig. 2). Among the examined risk groups, the highest risk was observed for children of parents with 10 years of education or less missing all exams, with a four- to five-fold increased risk of obesity compared to children of parents with more than 14 years of education attending all or missing one exam (Fig. 3). Discussion This study aimed to investigate the association between attending preventive child health examinations in general practice and the risk of overweight and obesity in Danish children at the age of six. We also aimed to assess the implications of these examinations for subgroups of children of parents with psychosocial risk factors being short length of education and mental health conditions. Our findings suggest that attending preventive child health examinations is not associated with a reduced risk of overweight at the age of six, except a slightly increased risk of overweight for children of parents with 10 years of education or less. However, there is a dose-response correlation between the number of missed examinations and the risk of obesity, with higher risks observed in children who missed more examinations. The lack of association between attending preventive child health examinations and the risk of overweight is surprising, given the potential for early identification and intervention. It is possible that the examinations themselves are not effective in addressing the complex factors contributing to overweight and obesity in children. A report found lack of focus on overweight and knowledge of cross-sectional collaborators in general practitioners( 24 ). While the examinations may provide an opportunity for healthcare professionals to identify and counsel parents and children, it may not be sufficient to address the social and environmental factors that contribute to overweight and obesity. Future research should explore the specific component of these examinations and their effectiveness in addressing overweight and obesity. Interestingly, our study found that the risk of obesity was higher in children who missed more preventive child health examinations. This may indicate that attending these examinations could potentially offer a protective influence against obesity. This is supported by a UK study by Mason et al.( 10 ) finding that cuts to spending on government-funded facilities aimed at providing a range of support services to families with young children, including early education, healthcare, and parenting support, were associated with increased childhood obesity( 10 ). However, it is important to note that our finding of this association does not imply causation. There may be other factors that contribute to both attending these examinations and a lower risk of obesity. For example, parents who are more engaged in their child’s health may also be more likely to engage in healthy behaviors that reduce the risk of obesity. Future research should explore the mechanisms through which attending these examinations may reduce the risk of obesity. In addition, our study examined the implications of attending preventive child health examinations for vulnerable subgroups. We found that children with parents of low educational levels or mental health conditions, as well as those born to young parents, had a higher risk of obesity. This highlights the importance of targeted interventions and support for these vulnerable populations. Preventive child health examinations may provide an opportunity to identify and address the specific needs of these children and their parents( 25 ). A report by the Danish Health Authority highlights that a short maternal level of education is an important indicator of the necessity of extra support and concludes that a stronger focus on outreach and retention effort for families with low education and social vulnerability could reduce health inequality( 26 ). However, evidence on effective strategies for supporting these populations and reducing the risk of obesity are lacking. It is worth noting that our study has some limitations. Firstly, our study relied on data from national registers, which may be subject to errors and missing information. Especially, missing data of the outcome variable in nine percent of the population may lead to selection bias. Secondly, we cannot rule out confounding. Attending child health examinations might be associated with healthier lifestyle and higher level of health literacy. However, we did handle covariates known to be associated with not attending preventive child health examinations, such as maternal depression,( 27 ) young and single parents,( 28 ) and older siblings( 28 ) by controlling. Finally, our study focused on the Danish context, and the findings may not be generalizable to other countries with different healthcare systems and social contexts. In conclusion, regarding overweight, our study found only found an association of eight to nine percent between attending preventive child health examinations in general practice and the risk of overweight at the age of six in children of parents with 10 years of education or less. However, there was a dose-response correlation between the number of missed examinations and the risk of obesity. These findings suggest that while these examinations may not be effective in reducing the risk of overweight, they may have a protective effect against obesity. Further research is needed to understand specific components of these examinations and their effectiveness in addressing overweight and obesity. Additionally, targeted interventions and support should be developed for vulnerable populations to reduce the risk of obesity. Declarations Competing interests Nothing to declare Author Contributions SH, RBKB, CNE, JLT and KF contributed to the planning, design, analysis and interpretation of the data. SH performed the statistical analyses and drafted the manuscript. SH, RBKB, CNE, JLT and KF revised the manuscript critically. SH, RBKB, CNE, JLT and KF have all read and approved the final manuscript. Data availability Statement The data that support the findings of this study is available from the Statistics Denmark but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. 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Attendance of routine childcare visits in primary care for children of mothers with depression: a nationwide population-based cohort study. British Journal of General Practice. 2018;68(667):e97–104. Søndergaard G, Biering-Sørensen S, Michelsen SI, Schnor O, Andersen AMN. Non-participation in preventive child health examinations at the general practitioner in Denmark: A register-based study. Scand J Prim Health Care. 2008;26(1):5–11. Additional Declarations There is NO conflict of interest to disclose Cite Share Download PDF Status: Published Journal Publication published 01 Oct, 2022 Read the published version in European Journal of Public Health → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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4","display":"","copyAsset":false,"role":"figure","size":293580,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"figure4RRforobesityinsubgroups.png","url":"https://assets-eu.researchsquare.com/files/rs-4240167/v1/44ce32eb1074915b916ac5d4.png"},{"id":54915238,"identity":"b1ca59ac-6cf3-4c73-8fb5-19eb93c2cbb4","added_by":"auto","created_at":"2024-04-18 14:02:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1124800,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4240167/v1/71d3ceff-6565-4d94-ba19-ee4b9a7a1acf.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose","formattedTitle":"Do preventive child examinations in general practice reduce the risk of overweight and obesity?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildhood obesity has emerged as a global epidemic, presenting a significant public health challenge(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Even in Denmark, a country with a comparatively low prevalence, the rates remain concerning, with over 10% of children aged 6\u0026ndash;7 classified as overweight and 3% as obese(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Alarmingly, obesity rates are projected to escalate by 2030(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Moreover, there is a pronounced social inequality in distribution of overweight and obesity among children(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), underscoring the urgency for effective preventive and early detection interventions.\u003c/p\u003e \u003cp\u003eIn Denmark, a tax-based healthcare system ensures that health services, including routine preventive child health examinations, are free of charge(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). General practitioners play a pivotal role in the identification and management of childhood overweight and obesity(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The Danish Health Authority guideline specifies the assessment of overweight and obesity as a key aspect of the routine examinations conducted by general practitioners. Notably, all children aged 0\u0026ndash;5 years in Denmark are offered seven routine preventive child health appointments in general practice, ensuring comprehensive monitoring of their physical, mental and social well-being(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This unique opportunity places general practice in an ideal position to identify and address overweight and obesity at an early stage.\u003c/p\u003e \u003cp\u003eEarly identification and intervention are paramount, given the association between persistent childhood obesity and an elevated risk of developing adult type 2 diabetes and cardiovascular disease(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Children attending preventive health examinations in general practice may benefit from timely recognition and intervention, potentially averting the progression of overweight or obesity(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Furthermore, children of parents with psychosocial risk factors, including those with parents of low educational levels(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) or mental health conditions may particularly gain from these examinations, which encompass preventive healthcare, early detection and counselling tailored to the specific needs of both parents and children.\u003c/p\u003e \u003cp\u003eDespite the conceptualization of these examinations as interventions to address health inequality(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), their actual impact on child health remains poorly studied and largely unexplored. To bridge this gap, our study aims to investigate the association between attending preventive child health examinations and the risk of overweight and obesity at the age of six. We will explore this association within the broader pediatric population and specifically assess its implications for children of parents with psychosocial risk factors, including short length of education and mental health conditions. This research seeks to contribute to valuable insight to inform targeted interventions and policies aimed at reducing childhood obesity and health disparities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eWe conducted a population-based birth cohort using nationwide Danish registers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eAll children in Denmark are offered seven examinations in general practice during their first five years of life. The first three examinations are during the first year, followed by one examination annually at the ages of two, three, four, and five.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe included all Danish children born between 2000 and 2012. Children were included at the age of six, as health examinations at school ages are conducted by school health nurses. Most children undergo their five-year examination during their sixth year and before they turn six years old, thus providing a suitable follow-up period from the children\u0026rsquo;s sixth to seventh birthday.\u003c/p\u003e \u003cp\u003eExposure was measured five years prior to baseline, from the child\u0026rsquo;s first to sixth birthday. Children were excluded if information on parents\u0026rsquo; identification number was missing, blocking linkage to the parents, or if the children or parents were not residing in Denmark at baseline or during the exposure period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eVariables\u003c/h2\u003e \u003cp\u003eThe outcome of interest was body mass index (BMI) at school age, defined as the first registration of BMI by the school health nurse at the age of six or later. Overweight and obesity were defined based on The International Obesity Taskforce (IOTF) criteria,(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) using age- and gender-specific BMI centile corresponding to BMI at age 18, with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 at age 18 defining overweight and a BMI\u0026thinsp;\u0026ge;\u0026thinsp;30 at age 18 defining obesity.\u003c/p\u003e \u003cp\u003eThe exposure variable was attendance at preventive child health examinations, including the four examinations at ages two, three, four, and five, respectively, categorized as: attending all or missing one (reference), missing two or three, and missing all four examinations.\u003c/p\u003e \u003cp\u003eParental psychosocial risk factors were short length of education and mental health conditions, categorized as maternal and paternal risk factors, respectively. \u003cem\u003eParental\u003c/em\u003e e\u003cem\u003education\u003c/em\u003e was categorized based on the International Standard Classification of Education (2011)(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and grouped into three categories according to the parent\u0026rsquo;s highest educational attainment: level 0\u0026ndash;2 (10 years of mandatory education or below), level 3\u0026ndash;4 (10\u0026ndash;14 years of education, such as high school), and level 5\u0026ndash;8 (more than 14 years of education, such as a bachelor\u0026rsquo;s degree). \u003cem\u003eMental health conditions\u003c/em\u003e were categorized based on the level of mental healthcare received within five years prior to baseline and categorized in three mutually exclusive groups. Parents with minor mental health conditions had been treated solely at primary healthcare settings. Moderate mental health conditions required a higher level of mental healthcare. The most severe mental health conditions, such as schizophrenia and bipolar disorders, constituted a separate category. More detailed definitions of the mental health conditions are further described elsewhere(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe included following covariates: Parent\u0026rsquo;s age at the time of the child\u0026rsquo;s birth, parental cohabitation (living with a partner or not), parity (firstborn or not), country of origin (Nordic, Western European, and other), and calendar year. To account for geographic variation in access to healthcare services, municipality was categorized into four categories: outer, rural, intermediate, and city. We adjusted for parent\u0026rsquo;s age and calendar year using restricted cubic splines with three knots(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). All covariates were extracted at baseline.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData sources\u003c/h2\u003e \u003cp\u003eData linkages were achieved using the personal identity number assigned to all Danish residents at birth or to individuals when they become residents. Register keepers at Statistics Denmark carried out data collection and register linkage. All data were deidentified before the researchers gained access.\u003c/p\u003e \u003cp\u003eInformation on child participation in preventive health examinations at general practice and mental health-related contacts to primary healthcare were retrieved from the Danish Health Service Register.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) Data on height and weight were obtained from the National Children\u0026rsquo;s Database.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Information on parents\u0026rsquo; highest completed education was provided by the Population Education Register.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The National Patient Register provided information about psychiatric diagnoses and hospital contacts(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) while the Danish National Prescription Registry provided data on reimbursed prescriptions on psychopharmaceuticals.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Information on the age of the child and parents, parental cohabitation status, country of origin, and municipality were retrieved from the Danish Civil Registration System.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eDescriptive statistics, including numbers and percentages, were calculated for groups of children of parents with psychosocial risk factors by categories of preventive child health examination attendance. Modified Poisson regression analyses were conducted to produce adjusted risk ratios (RRs) for overweight and obesity. RRs for overweight and obesity were calculated for the overall population and within subgroups of vulnerable children for maternal and paternal risk factors, respectively. The reference group comprised children with the expected lowest risk of overweight or obesity, namely those attending all or missing one examination, and for example, having mothers with the longest attained education. To account for sibling correlation, a generalized estimating equation with an exchangeable correlation structure was used to fit a generalized linear model with log-link function, assuming a Poisson distribution and employing robust variance estimation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe included 725 926 children in the analyses. This followed the exclusion of 25 826 (2.8%) children due to missing parental identification number, 79 351 (8.7%) due to non-residency of the child and/or the parents in Denmark at baseline or during the exposure period. Additionally, 78 962 (8.7%) were excluded due to missing information on BMI status at school age (Fig.\u0026nbsp;1). Baseline sociodemographic characteristics by attendance at preventive child health examination are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Overall, more than two-thirds (69%) of the children attended all four exams or missed only one. The proportion of children of parents with psychosocial risk factors was higher in groups missing two or three examinations and those missing all four examinations than the group of children attending all or missing one examination. For instance, 11% of the children attending all or missing one exam had mothers with 10 years of education or less; this percentage was 23% and 33% for children attending two or three examinations and those missing all four examinations, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline sociodemografic characteristics. Numbers and percentages of the overall population and percentages of children by covariate and category of preventive child health examination attendance\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttending all/missing one\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttending two or three exams\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMissing all exams\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e498877 (68.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e194367 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32682 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot first born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCountry of origin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNordic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern Europe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMunicipality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOuter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMATERNAL COVARIATES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental health condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCohabitation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot living with partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePATERNAL COVARIATES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental health condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCohabitation status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e88.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot living with partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing variable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure 2 illustrates the risk of overweight and obesity in the overall population. Attendance at preventive child health examinations, compared to non-attendance, was not associated with a reduced risk of overweight at age six in the overall population (RR 1.02, 95% CI 1.01\u0026ndash;1.02, Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eIn the subgroup of children of parents with 10 years of education of less, a slightly increased risk of overweight of eight to nine percent was associated with non-attendance (Fig.\u0026nbsp;3). An increased risk of overweight was not seen in the other subgroups.\u003c/p\u003e \u003cp\u003eOverall, a dose-response correlation was observed, with higher risks of obesity associated with the number of missed examinations. In the overall population, the children with four missed examinations had a 31% increased risk of obesity compared to the children attending all or missing only one examination (Fig.\u0026nbsp;2). Among the examined risk groups, the highest risk was observed for children of parents with 10 years of education or less missing all exams, with a four- to five-fold increased risk of obesity compared to children of parents with more than 14 years of education attending all or missing one exam (Fig.\u0026nbsp;3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to investigate the association between attending preventive child health examinations in general practice and the risk of overweight and obesity in Danish children at the age of six. We also aimed to assess the implications of these examinations for subgroups of children of parents with psychosocial risk factors being short length of education and mental health conditions. Our findings suggest that attending preventive child health examinations is not associated with a reduced risk of overweight at the age of six, except a slightly increased risk of overweight for children of parents with 10 years of education or less. However, there is a dose-response correlation between the number of missed examinations and the risk of obesity, with higher risks observed in children who missed more examinations.\u003c/p\u003e \u003cp\u003eThe lack of association between attending preventive child health examinations and the risk of overweight is surprising, given the potential for early identification and intervention. It is possible that the examinations themselves are not effective in addressing the complex factors contributing to overweight and obesity in children. A report found lack of focus on overweight and knowledge of cross-sectional collaborators in general practitioners(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). While the examinations may provide an opportunity for healthcare professionals to identify and counsel parents and children, it may not be sufficient to address the social and environmental factors that contribute to overweight and obesity. Future research should explore the specific component of these examinations and their effectiveness in addressing overweight and obesity.\u003c/p\u003e \u003cp\u003eInterestingly, our study found that the risk of obesity was higher in children who missed more preventive child health examinations. This may indicate that attending these examinations could potentially offer a protective influence against obesity. This is supported by a UK study by Mason et al.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) finding that cuts to spending on government-funded facilities aimed at providing a range of support services to families with young children, including early education, healthcare, and parenting support, were associated with increased childhood obesity(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, it is important to note that our finding of this association does not imply causation. There may be other factors that contribute to both attending these examinations and a lower risk of obesity. For example, parents who are more engaged in their child\u0026rsquo;s health may also be more likely to engage in healthy behaviors that reduce the risk of obesity. Future research should explore the mechanisms through which attending these examinations may reduce the risk of obesity.\u003c/p\u003e \u003cp\u003eIn addition, our study examined the implications of attending preventive child health examinations for vulnerable subgroups. We found that children with parents of low educational levels or mental health conditions, as well as those born to young parents, had a higher risk of obesity. This highlights the importance of targeted interventions and support for these vulnerable populations. Preventive child health examinations may provide an opportunity to identify and address the specific needs of these children and their parents(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). A report by the Danish Health Authority highlights that a short maternal level of education is an important indicator of the necessity of extra support and concludes that a stronger focus on outreach and retention effort for families with low education and social vulnerability could reduce health inequality(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, evidence on effective strategies for supporting these populations and reducing the risk of obesity are lacking.\u003c/p\u003e \u003cp\u003eIt is worth noting that our study has some limitations. Firstly, our study relied on data from national registers, which may be subject to errors and missing information. Especially, missing data of the outcome variable in nine percent of the population may lead to selection bias. Secondly, we cannot rule out confounding. Attending child health examinations might be associated with healthier lifestyle and higher level of health literacy. However, we did handle covariates known to be associated with not attending preventive child health examinations, such as maternal depression,(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) young and single parents,(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and older siblings(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) by controlling. Finally, our study focused on the Danish context, and the findings may not be generalizable to other countries with different healthcare systems and social contexts.\u003c/p\u003e \u003cp\u003eIn conclusion, regarding overweight, our study found only found an association of eight to nine percent between attending preventive child health examinations in general practice and the risk of overweight at the age of six in children of parents with 10 years of education or less. However, there was a dose-response correlation between the number of missed examinations and the risk of obesity. These findings suggest that while these examinations may not be effective in reducing the risk of overweight, they may have a protective effect against obesity. Further research is needed to understand specific components of these examinations and their effectiveness in addressing overweight and obesity. Additionally, targeted interventions and support should be developed for vulnerable populations to reduce the risk of obesity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eNothing to declare\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contributions\u003c/h2\u003e \u003cp\u003eSH, RBKB, CNE, JLT and KF contributed to the planning, design, analysis and interpretation of the data. SH performed the statistical analyses and drafted the manuscript. SH, RBKB, CNE, JLT and KF revised the manuscript critically. SH, RBKB, CNE, JLT and KF have all read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData availability Statement\u003c/h2\u003e \u003cp\u003eThe data that support the findings of this study is available from the Statistics Denmark but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Questions or requests concerning this data is directed to the corresponding author Signe Heuckendorff.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Obesity Federation. World Obesity Atlas 2023 [Internet]. 2023 [cited 2024 Mar 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.worldobesity.org/publications/?cat=19\u003c/span\u003e\u003cspan address=\"https://data.worldobesity.org/publications/?cat=19\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndersen MB, Thorsted A, Jezek AH, Due P, S\u0026oslash;rensen TIA, Thygesen LC. Overv\u0026aelig;gt og sv\u0026aelig;r overv\u0026aelig;gt blandt danske b\u0026oslash;rn og unge - Forekomst og sociodemografisk fordeling [Overweight and obesity among Danish children and adolescents - Prevalence and sociodemographic distribution]. Copenhagen; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiltoft-Jensen A, Fagt S, M\u0026oslash;ller F. Ulighed i b\u0026oslash;rneoverv\u0026aelig;gt i Danmark [Internet]. DST Analyse. 2021. 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Parental mental health conditions and use of healthcare services in children the first year of life\u0026ndash; a register-based, nationwide study. BMC Public Health. 2021;21(1):557.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesquilbet L, Mariotti F. Dose-response analyses using restricted cubic spline functions in public health research. Stat Med. 2010;29(9):\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003en/a-n/a\u003c/span\u003e\u003cspan address=\"http://n/a-n/a\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSahl Andersen J, De Fine Olivarius N, Krasnik A. The Danish National Health Service Register. 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Attendance of routine childcare visits in primary care for children of mothers with depression: a nationwide population-based cohort study. British Journal of General Practice. 2018;68(667):e97\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;ndergaard G, Biering-S\u0026oslash;rensen S, Michelsen SI, Schnor O, Andersen AMN. Non-participation in preventive child health examinations at the general practitioner in Denmark: A register-based study. Scand J Prim Health Care. 2008;26(1):5\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4240167/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4240167/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: This study aims to investigate the association between attendance at routine preventive child health examinations in general practice and the risk of overweight and obesity in Danish children at age six, with a specific focus on children of parents with psychosocial risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Utilizing nationwide Danish registers, a population-based birth cohort of 725 926 children born between 2000-2012 was analyzed. Information on preventive health examination attendance and BMI data were obtained. Statistical analyses, including modified Poisson regression, were conducted to assess the relationship between examination attendance and overweight/obesity risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study found no significant association between attending these examinations and a reduced risk of overweight at age six in the overall population. In the subgroup of children of parents having 10 years of education of less, non-attendance was associated with a slightly increased risk of overweight, ranging from eight to nine percent. Regarding obesity risk, a dose-response correlation was observed, indicating that missing examinations increased the risk of obesity. Children of parents with psychosocial risk factors, particularly those with parents of low educational attainment, faced increased obesity risks, with the highest risk observed in children of parents with 10 years of education or less who missed all examinations, showing a four- to five-fold increase compared to children of parents with 14 years of the education or more attending all or missing only one exam (reference).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Although routine preventive child health examinations may not directly reduce the risk of overweight, they could potentially mitigate obesity risk, especially in vulnerable populations. Further research is warranted to understand the underlying mechanisms and to develop targeted interventions to address health disparities in childhood obesity.\u003c/p\u003e","manuscriptTitle":"Do preventive child examinations in general practice reduce the risk of overweight and obesity?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-18 13:54:17","doi":"10.21203/rs.3.rs-4240167/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5a70c588-9866-497f-be03-219a3f8aaaed","owner":[],"postedDate":"April 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":30545125,"name":"Health sciences/Health care/Paediatrics"},{"id":30545126,"name":"Health sciences/Medical research/Epidemiology"}],"tags":[],"updatedAt":"2024-04-18T13:54:51+00:00","versionOfRecord":{"articleIdentity":"rs-4240167","link":"https://doi.org/10.1093/eurpub/ckac129.050","journal":{"identity":"european-journal-of-public-health","isVorOnly":true,"title":"European Journal of Public Health"},"publishedOn":"2022-10-01 13:54:51","publishedOnDateReadable":"October 1st, 2022"},"versionCreatedAt":"2024-04-18 13:54:17","video":"","vorDoi":"10.1093/eurpub/ckac129.050","vorDoiUrl":"https://doi.org/10.1093/eurpub/ckac129.050","workflowStages":[]},"version":"v1","identity":"rs-4240167","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4240167","identity":"rs-4240167","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}