[Skip to Content]

Claim CME

Obesity

COVID-19–Related Life Experiences, Outdoor Play, and Long-term Adiposity Changes Among Preschool- and School-Aged Children in Singapore 1 Year After Lockdown

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Pediatrics

Published Online: January 24, 2022

Original Investigation

Article Information and Disclosures

Ka Kei Sum, MSc¹;

Shirong Cai, PhD¹;

Evelyn Law, MD, PhD^1,2;

Bobby Cheon, PhD^1,3;

Geoffrey Tan, MBBS, PhD⁴;

Evelyn Loo, PhD^1,2;

Yung Seng Lee, MBBS, PhD²;

Fabian Yap, MBBS⁵;

Jerry Kok Yen Chan, MBChB, PhD⁵;

Mary Daniel, MBBS, EdM⁵;

Yap Seng Chong, MBBS, MD^1,6;

Michael Meaney, PhD¹;

Johan Eriksson, MD, DMSc^1,6;

Jonathan Huang, PhD¹

Author Affiliations

¹Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
²Department of Paediatrics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
³School of Social Sciences, Nanyang Technological University, Singapore
⁴Institute of Mental Health, Singapore
⁵KK Women’s and Children’s Hospital, Singapore
⁶Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University Singapore, Singapore

Read article on JAMA Network

Read Article Claim CME

Key Points

Question What are typical lifestyle changes experienced by children after COVID-19–related lockdowns, and what are potential long-term outcomes?

Findings In this cohort study of 604 children, one-third of parents and school-aged children reported elimination of outdoor play or exercise, and those with lower family income before and after lockdown were more likely to report elimination of outdoor play. Elimination of play was associated with increased adiposity 1 year after lockdown in school-aged children but not preschool-aged children.

Meaning Outdoor play is an important part of children’s well-being, and efforts to mitigate avoidable negative outcomes of COVID-19 pandemic–related lockdowns should be considered.

Abstract

Importance Despite the potential for COVID-19 infection control–related events to have an effect on child well-being, comprehensive assessments of postlockdown changes and persistent outcomes are lacking.

Objective To survey the extent of COVID-19 lockdown–related lifestyle changes, their differences by child age and family socioeconomic status, and the potential association with child adiposity 1 year after lockdown.

Design, Setting, and Participants A self-administered, electronic survey was introduced to 2 ongoing child cohorts (the Singapore Preconception Study of Long-term Maternal and Child Outcomes [S-PRESTO] cohort of preschool children aged 1-4.5 years and the Growing Up in Singapore Towards Healthy Outcomes [GUSTO] cohort of primary school children aged 9-10.7 years) from July 8, 2020, to September 5, 2020, which was 1 to 3 months after the end of strict universal movement restrictions (duration of 73 days ending on June 19, 2020). All active participants from S-PRESTO and GUSTO, 2 population-based, longitudinal, parent-offspring cohorts in Singapore, were invited to participate and monitored through June 15, 2021.

Exposures Exposures included family income before and after the COVID-19 lockdown, changes in child outdoor play or exercise, and COVID-19–related life events; all data were self-reported by parents and school-aged children 1 to 3 months after the lockdown.

Main Outcomes and Measures Primary outcomes were self-reported COVID-19–related life events and changes in child online socialization, outdoor play or exercise, and intrafamily relationships. Study staff measured children’s weight, height, and skinfold thickness before and up to 1 year after lockdown. Body mass indices (calculated as weight in kilograms divided by height in meters squared) and World Health Organization–standardized scores were computed. Differences before and after lockdown were compared using baseline-adjusted linear regression.

Results A total of 604 parents (53% of active cohort participants) and 356 school-aged children completed the survey and were similar to source cohorts. This represents 373 of 761 eligible children in the GUSTO cohort (mean [SD] age, 9.9 [0.4] years; 197 girls [52.8%]) and 231 of 370 eligible children in the S-PRESTO cohort (mean [SD] age, 2.6 [0.8] years; 121 boys [52.6%]). The COVID-19–related life changes were prevalent and varied (eg, 414 of 600 children [69.0%] reported changes in social activities). More than one-third of primary school–aged children (122 of 356 [34.3%]) and one-quarter of preschool-aged children (56 of 229 [24.5%]) eliminated any outdoor play after the lockdown. Lower family income before the lockdown was associated with increased odds of elimination of outdoor play (adjusted odds ratio per 1000 Singapore dollars [$730 US dollars] decrease, 1.09; 95% CI, 1.01-1.19). Complete elimination of outdoor activity (vs continued outdoor activity) was associated with an increase in body mass index of 0.48 (95% CI, 0.03-0.94) and a body mass index z score of 0.18 units (95% CI, 0-0.37) in school-aged children approximately 1 year after lockdown.

Conclusions and Relevance Results of this cohort study suggest that 1 to 3 months after a brief, strict lockdown, a large proportion of parents and school-aged children reported elimination of outdoor play, which was more prevalent in lower-income families. Future research to better understand clinical implications and ways to mitigate lockdown outcomes is essential.

Claim CME

Sign in to take quiz and track your certificates

Buy This Activity

Article Information

Accepted for Publication: October 20, 2021.

Published Online: January 24, 2022. doi:10.1001/jamapediatrics.2021.5585

Corresponding Author: Jonathan Huang, PhD, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, 30 Medical Dr, Singapore, 117609 (jonathan_huang@sics.a-star.edu.sg).

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Sum KK et al. JAMA Pediatrics.

Author Contributions: Ms Sum and Dr Huang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Huang, Cheon, Eriksson, Law, Lee, Meaney, Sum, Tan, Chong.

Acquisition, analysis, or interpretation of data: Huang, Cai, Chan, Cheon, Daniel, Loo, Meaney, Sum, Yap.

Drafting of the manuscript: Huang, Cai, Sum, Tan.

Critical revision of the manuscript for important intellectual content: Huang, Cai, Chan, Cheon, Daniel, Eriksson, Law, Lee, Loo, Meaney, Sum, Tan, Yap, Chong.

Statistical analysis: Huang, Sum.

Obtained funding: Lee, Meaney, Chong.

Administrative, technical, or material support: Cai, Eriksson, Loo, Meaney, Yap, Chong.

Supervision: Huang, Chan, Law, Chong.

Conflict of Interest Disclosures: Dr Chong reported being a part of an academic consortium that has received research funding from companies selling nutritional products. No other disclosures were reported.

Funding/Support: This research was supported in part by grants NMRC/TCR/004-NUS/2008 and NMRC/TCR/012-NUHS/2014 from the Singapore National Research Foundation under the Translational and Clinical Research Flagship (Dr Chong) and grant OFLCG/MOH-000504 from the Open Fund Large Collaborative Grant Programmes and administered by the Singapore Ministry of Health’s National Medical Research Council, Singapore (Dr Chong). Additional funding was provided by the Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore (Dr Eriksson).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the GUSTO and S-PRESTO study group investigators and coordinators.

References

Rundle AG , Park Y , Herbstman JB , Kinsey EW , Wang YC . COVID-19-related school closings and risk of weight gain among children. Obesity (Silver Spring). 2020;28(6):1008-1009. doi:10.1002/oby.22813 PubMed Google Scholar Crossref

Fegert JM , Vitiello B , Plener PL , Clemens V . Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child Adolesc Psychiatry Ment Health. 2020;14(1):20. doi:10.1186/s13034-020-00329-3 PubMed Google Scholar Crossref

Caputo EL , Reichert FF . Studies of physical activity and COVID-19 during the pandemic: a scoping review. J Phys Act Health. 2020;17(12):1275-1284. doi:10.1123/jpah.2020-0406 PubMed Google Scholar Crossref

Rajmil L , Hjern A , Boran P , Gunnlaugsson G , Kraus de Camargo O , Raman S ; International Society for Social Pediatrics & Child Health (ISSOP) and International Network for Research on Inequalities in Child Health (INRICH) COVID-19 Working Group. Impact of lockdown and school closure on children’s health and well-being during the first wave of COVID-19: a narrative review. BMJ Paediatr Open. 2021;5(1):e001043. doi:10.1136/bmjpo-2021-001043 PubMed Google Scholar

Yomoda K , Kurita S . Influence of social distancing during the COVID-19 pandemic on physical activity in children: a scoping review of the literature. J Exerc Sci Fit. 2021;19(3):195-203. doi:10.1016/j.jesf.2021.04.002 PubMed Google Scholar Crossref

Sunda M , Gilic B , Peric I , Jurcev Savicevic A , Sekulic D . Evidencing the influence of the COVID-19 pandemic and imposed lockdown measures on fitness status in adolescents: a preliminary report. Healthcare (Basel). 2021;9(6):681. doi:10.3390/healthcare9060681 PubMed Google Scholar Crossref

López-Bueno R , López-Sánchez GF , Casajús JA , et al. Health-related behaviors among school-aged children and adolescents during the Spanish COVID-19 confinement. Front Pediatr. 2020;8:573. doi:10.3389/fped.2020.00573 PubMed Google Scholar Crossref

Pietrobelli A , Pecoraro L , Ferruzzi A , et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity (Silver Spring). 2020;28(8):1382-1385. doi:10.1002/oby.22861 PubMed Google Scholar Crossref

Alves JM , Yunker AG , DeFendis A , Xiang AH , Page KA . BMI status and associations between affect, physical activity, and anxiety among U.S. children during COVID-19. Pediatr Obes. 2021;16(9):e12786. doi:10.1111/ijpo.12786 PubMed Google Scholar

Ten Velde G , Lubrecht J , Arayess L , et al. Physical activity behaviour and screen time in Dutch children during the COVID-19 pandemic: pre-, during- and post-school closures. Pediatr Obes. 2021;16(9):e12779. doi:10.1111/ijpo.12779 PubMed Google Scholar

Xiang M , Zhang Z , Kuwahara K . Impact of COVID-19 pandemic on children and adolescents’ lifestyle behavior larger than expected. Prog Cardiovasc Dis. 2020;63(4):531-532. doi:10.1016/j.pcad.2020.04.013 PubMed Google Scholar Crossref

Medrano M , Cadenas-Sanchez C , Oses M , Arenaza L , Amasene M , Labayen I . Changes in lifestyle behaviours during the COVID-19 confinement in Spanish children: a longitudinal analysis from the MUGI project. Pediatr Obes. 2021;16(4):e12731. doi:10.1111/ijpo.12731 PubMed Google Scholar

Tulchin-Francis K , Stevens W Jr , Gu X , et al. The impact of the coronavirus disease 2019 pandemic on physical activity in U.S. children. J Sport Health Sci. 2021;10(3):323-332. doi:10.1016/j.jshs.2021.02.005 PubMed Google Scholar Crossref

Dunton GF , Do B , Wang SD . Early effects of the COVID-19 pandemic on physical activity and sedentary behavior in children living in the U.S. BMC Public Health. 2020;20(1):1351. doi:10.1186/s12889-020-09429-3 PubMed Google Scholar Crossref

Schmidt SCE , Anedda B , Burchartz A , et al. Physical activity and screen time of children and adolescents before and during the COVID-19 lockdown in Germany: a natural experiment. Sci Rep. 2020;10(1):21780. doi:10.1038/s41598-020-78438-4 PubMed Google Scholar Crossref

Moore SA , Faulkner G , Rhodes RE , et al. Impact of the COVID-19 virus outbreak on movement and play behaviours of Canadian children and youth: a national survey. Int J Behav Nutr Phys Act. 2020;17(1):85. doi:10.1186/s12966-020-00987-8 PubMed Google Scholar Crossref

Jia P , Zhang L , Yu W , et al. Impact of COVID-19 lockdown on activity patterns and weight status among youths in China: the COVID-19 Impact on Lifestyle Change Survey (COINLICS). Int J Obes (Lond). 2021;45(3):695-699. doi:10.1038/s41366-020-00710-4 PubMed Google Scholar Crossref

Konstantinou C , Andrianou XD , Constantinou A , et al. Exposome changes in primary school children following the wide population non-pharmacological interventions implemented due to COVID-19 in Cyprus: a national survey. EClinicalMedicine. 2021;32:100721. doi:10.1016/j.eclinm.2021.100721 PubMed Google Scholar

Jenssen BP , Kelly MK , Powell M , Bouchelle Z , Mayne SL , Fiks AG . COVID-19 and changes in child obesity. Pediatrics. 2021;147(5):e2021050123. doi:10.1542/peds.2021-050123 PubMed Google Scholar

Patterson RR , Sornalingam S , Cooper M . Consequences of COVID-19 on the childhood obesity epidemic. BMJ. 2021;373(n953):n953. doi:10.1136/bmj.n953 PubMed Google Scholar

Mulugeta W , Hoque L . Impact of the COVID-19 lockdown on weight status and associated factors for obesity among children in Massachusetts. Obes Med. 2021;22(6):100325. doi:10.1016/j.obmed.2021.100325 Google Scholar

Vinker-Shuster M , Grossman ES , Yeshayahu Y . Increased weight gain of children during the COVID-19 lockdown. Isr Med Assoc J. 2021;23(4):219-222.PubMed Google Scholar

Loo EXL , Soh SE , Loy SL , et al; S-PRESTO Study Group. Cohort profile: Singapore Preconception Study of Long-term Maternal and Child Outcomes (S-PRESTO). Eur J Epidemiol. 2021;36(1):129-142. doi:10.1007/s10654-020-00697-2 PubMed Google Scholar Crossref

Soh SE , Tint MT , Gluckman PD , et al; GUSTO Study Group. Cohort profile: Growing Up in Singapore Towards Healthy Outcomes (GUSTO) birth cohort study. Int J Epidemiol. 2014;43(5):1401-1409. doi:10.1093/ije/dyt125 PubMed Google Scholar Crossref

Sarason IG , Johnson JH , Siegel JM . Assessing the impact of life changes: development of the Life Experiences Survey. J Consult Clin Psychol. 1978;46(5):932-946. doi:10.1037/0022-006X.46.5.932 PubMed Google Scholar Crossref

Loo BKG , Lim MCM , Gao JSM , Zainuddin MA . Impact of Singapore’s COVID-19 control measures on home-based physical activity in children. Ann Acad Med Singap. 2021;50(6):481-484. doi:10.47102/annals-acadmedsg.202138 PubMed Google Scholar Crossref

Aris IM , Chen L-W , Tint MT , et al. Body mass index trajectories in the first two years and subsequent childhood cardio-metabolic outcomes: a prospective multi-ethnic Asian cohort study. Sci Rep. 2017;7(1):8424. doi:10.1038/s41598-017-09046-y PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.