Do clinicians want recommendations? A multi-center study comparing evidence summaries with and without GRADE recommendations

Neumann I, Alonso-Coello P, Vandvik PO, Agoritsas T, Mas G, Akl EA, et al.
Journal of Clinical Epidemiology , Article in press.



Evidence-based clinical practice guidelines provide recommendations to assist clinicians in decision-making and to reduce the gap between best current research evidence and clinical practice. However, some argue that providing pre-appraised evidence summaries alone, rather than recommendations, is more appropriate.


To evaluate clinicians’ preferences, understanding of the evidence and intended course of action in response to evidence summaries with and without recommendations.


We included practicing clinicians attending educational sessions across 10 countries. Clinicians were randomized to receive relevant clinical scenarios supported by research evidence of low or very-low certainty, and accompanied by either strong or weak recommendations developed with the GRADE system. Within each group, participants were further randomized to receive the recommendation plus the corresponding evidence summary or the evidence summary alone. We evaluated participants’ preferences and understanding for the presentation strategy as well as their intended course of action.


189/219 (86%) and 201/248 (81%) participants preferred having recommendations accompanying evidence summaries for both strong and weak recommendations, respectively. Across all scenarios less than half of participants correctly interpreted information provided in the evidences summaries (e.g. estimates of effect, certainty in the research evidence). Presence of a recommendation resulted in a more appropriate intended course of action for two scenarios involving strong recommendations.


Evidence summaries alone are not enough to impact clinicians’ course of action. Clinicians clearly prefer having recommendations accompanying evidence summaries in the context of low or very-low certainty of evidence (Trial registration NCT02006017).


Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management.

Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC STEERING GROUP.

OBJECTIVES: To update clinical practice guidelines to assist primary care (PC)
clinicians in the management of adolescent depression. This part of the updated
guidelines is used to address practice preparation, identification, assessment,
and initial management of adolescent depression in PC settings.
METHODS: By using a combination of evidence- and consensus-based methodologies,
guidelines were developed by an expert steering committee in 2 phases as informed
by (1) current scientific evidence (published and unpublished) and (2) draft
revision and iteration among the steering committee, which included experts,
clinicians, and youth and families with lived experience.
RESULTS: Guidelines were updated for youth aged 10 to 21 years and correspond to 
initial phases of adolescent depression management in PC, including the
identification of at-risk youth, assessment and diagnosis, and initial
management. The strength of each recommendation and its evidence base are
summarized. The practice preparation, identification, assessment, and initial
management section of the guidelines include recommendations for (1) the
preparation of the PC practice for improved care of adolescents with depression; 
(2) annual universal screening of youth 12 and over at health maintenance visits;
(3) the identification of depression in youth who are at high risk; (4)
systematic assessment procedures by using reliable depression scales, patient and
caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, 
Fifth Edition criteria; (5) patient and family psychoeducation; (6) the
establishment of relevant links in the community, and (7) the establishment of a 
safety plan.
CONCLUSIONS: This part of the guidelines is intended to assist PC clinicians in
the identification and initial management of adolescents with depression in an
era of great clinical need and shortage of mental health specialists, but they
cannot replace clinical judgment; these guidelines are not meant to be the sole
source of guidance for depression management in adolescents. Additional research 
that addresses the identification and initial management of youth with depression
in PC is needed, including empirical testing of these guidelines.


Vision screening for correctable visual acuity deficits in school-age children and adolescents.

Evans JR, Morjaria P, Powell C.
Cochrane Database Syst Rev. 2018 Feb 15;2:CD005023.

BACKGROUND: Although the benefits of vision screening seem intuitive, the value
of such programmes in junior and senior schools has been questioned. In addition 
there exists a lack of clarity regarding the optimum age for screening and
frequency at which to carry out screening.
OBJECTIVES: To evaluate the effectiveness of vision screening programmes carried 
out in schools to reduce the prevalence of correctable visual acuity deficits due
to refractive error in school-age children.
SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials
(CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017,
Issue 4); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and 
the ICTRP. The date of the search was 3 May 2017.
SELECTION CRITERIA: We included randomised controlled trials (RCTs), including
cluster-randomised trials, that compared vision screening with no vision
screening, or compared interventions to improve uptake of spectacles or
efficiency of vision screening.
DATA COLLECTION AND ANALYSIS: Two review authors independently screened search
results and extracted data. Our pre-specified primary outcome was uncorrected, or
suboptimally corrected, visual acuity deficit due to refractive error six months 
after screening. Pre-specified secondary outcomes included visual acuity deficit 
due to refractive error more than six months after screening, visual acuity
deficit due to causes other than refractive error, spectacle wearing, quality of 
life, costs, and adverse effects. We graded the certainty of the evidence using
MAIN RESULTS: We identified seven relevant studies. Five of these studies were
conducted in China with one study in India and one in Tanzania. A total of 9858
children aged between 10 and 18 years were randomised in these studies, 8240 of
whom (84%) were followed up between one and eight months after screening. Overall
we judged the studies to be at low risk of bias. None of these studies compared
vision screening for correctable visual acuity deficits with not screening.Two
studies compared vision screening with the provision of free spectacles versus
vision screening with no provision of free spectacles (prescription only). These 
studies provide high-certainty evidence that vision screening with provision of
free spectacles results in a higher proportion of children wearing spectacles
than if vision screening is accompanied by provision of a prescription only (risk
ratio (RR) 1.60, 95% confidence interval (CI) 1.34 to 1.90; 1092 participants).
The studies suggest that if approximately 250 per 1000 children given vision
screening plus prescription only are wearing spectacles at follow-up (three to
six months) then 400 per 1000 (335 to 475) children would be wearing spectacles
after vision screening and provision of free spectacles. Low-certainty evidence
suggested better educational attainment in children in the free spectacles group 
(adjusted difference 0.11 in standardised mathematics score, 95% CI 0.01 to 0.21,
1 study, 2289 participants). Costs were reported in one study in Tanzania in 2008
and indicated a relatively low cost of screening and spectacle provision
(low-certainty evidence). There was no evidence of any important effect of
provision of free spectacles on uncorrected visual acuity (mean difference -0.02 
logMAR (95% CI adjusted for clustering -0.04 to 0.01) between the groups at
follow-up (moderate-certainty evidence). Other pre-specified outcomes of this
review were not reported.Two studies explored the effect of an educational
intervention in addition to vision screening on spectacle wear. There was
moderate-certainty evidence of little apparent effect of the education
interventions investigated in these studies in addition to vision screening,
compared to vision screening alone for spectacle wearing (RR 1.11, 95% CI 0.95 to
1.31, 1 study, 3177 participants) or related outcome spectacle purchase (odds
ratio (OR) 0.84, 95% CI 0.55 to 1.31, 1 study, 4448 participants). Other
pre-specified outcomes of this review were not reported.Three studies compared
vision screening with ready-made spectacles versus vision screening with
custom-made spectacles. These studies provide moderate-certainty evidence of no
clinically meaningful differences between the two types of spectacles. In one
study, mean logMAR acuity in better and worse eye was similar between groups:
mean difference (MD) better eye 0.03 logMAR, 95% CI 0.01 to 0.05; 414
participants; MD worse eye 0.06 logMAR, 95% CI 0.04 to 0.08; 414 participants).
There was high-certainty evidence of no important difference in spectacle wearing
(RR 0.98, 95% CI 0.91 to 1.05; 1203 participants) between the two groups and
moderate-certainty evidence of no important difference in quality of life between
the two groups (the mean quality-of-life score measured using the National Eye
Institute Refractive Error Quality of Life scale 42 was 1.42 better (1.04 worse
to 3.90 better) in children with ready-made spectacles (1 study of 188
participants). Although none of the studies reported on costs directly,
ready-made spectacles are cheaper and may represent considerable cost-savings for
vision screening programmes in lower income settings. There was low-certainty
evidence of no important difference in adverse effects between the two groups.
Adverse effects were reported in one study and were similar between groups. These
included blurred vision, distorted vision, headache, disorientation, dizziness,
eyestrain and nausea.
AUTHORS' CONCLUSIONS: Vision screening plus provision of free spectacles improves
the number of children who have and wear the spectacles they need compared with
providing a prescription only. This may lead to better educational outcomes.
Health education interventions, as currently devised and tested, do not appear to
improve spectacle wearing in children. In lower-income settings, ready-made
spectacles may provide a useful alternative to expensive custom-made spectacles.

Interventions to reduce accidents in childhood: a systematic review.

Barcelos RS, Del-Ponte B, Santos IS.
J Pediatr (Rio J). 2017 Dec 30. pii: S0021-7557(17)30798-2.
OBJECTIVE: To review the literature on interventions planned to prevent the
incidence of injuries in childhood.
SOURCE OF DATA: The PubMed, Web of Science, and Bireme databases were searched by
two independent reviewers, employing the single terms accidents, accident,
injuries, injury, clinical trial, intervention, educational intervention, and
multiple interventions, and their combinations, present in the article title or
abstract, with no limits except period of publication (2006-2016) and studies in 
human subjects.
SYNTHESIS OF DATA: Initially, 11,097 titles were located. Fifteen articles were
selected for the review. Eleven were randomized trials (four carried out at the
children's households, five in pediatric healthcare services, and two at
schools), and four were non-randomized trials carried out at the children's
households. Four of the randomized trials were analyzed by intention-to-treat and
a protective effect of the intervention was observed: decrease in the number of
risk factors, decrease in the number of medical consultations due to injuries,
decrease in the prevalence of risk behaviors, and increase of the parents'
knowledge regarding injury prevention in childhood.
CONCLUSION: Traumatic injuries in childhood are amenable to primary prevention
through strategies that consider the child's age and level of development, as
well as structural aspects of the environment.

A systematic review of the effects of supervised toothbrushing on caries incidence in children and adolescents.

Dos Santos APP, de Oliveira BH, Nadanovsky P.
Int J Paediatr Dent. 2018 Jan;28(1):3-11. doi: 10.1111/ipd.12334. Epub 2017 Sep21.
BACKGROUND: The anticaries effect of supervised toothbrushing, irrespective of
the effect of fluoride toothpaste, has not been clearly determined yet.
AIM: To assess the effects of supervised toothbrushing on caries incidence in
children and adolescents.
DESIGN: A systematic review of controlled trials was performed (CRD42014013879). 
Electronic and hand searches retrieved 2046 records, 112 of which were read in
full and independently assessed by two reviewers, who collected data regarding
characteristics of participants, interventions, outcomes, length of follow-up and
risk of bias.
RESULTS: Four trials were included and none of them had low risk of bias. They
were all carried out in schools, but there was great variation regarding
children's age, fluoride content of the toothpaste, baseline caries levels and
the way caries incidence was reported. Among the four trials, two found
statistically significant differences favouring supervised toothbrushing, but
information about the magnitude and/or the precision of the effect estimate was
lacking and in one trial clustering effect was not taken into consideration. No
meta-analysis was performed due to the clinical heterogeneity among the included 
studies and differences in the reporting of data.
CONCLUSIONS: There is no conclusive evidence regarding the effectiveness of
supervised toothbrushing on caries incidence.


Physical activity, diet and other behavioural interventions for improving cognition and school achievement in children and adolescents with obesity or overweight.

Martin A, Booth JN, Laird Y, et al. Cochrane Database Syst Rev. 2018 Jan 29;1:CD009728. doi: 10.1002/14651858.CD009728.pub3. (Review) PMID: 29376563

BACKGROUND: The global prevalence of childhood and adolescent obesity is high. Lifestyle changes towards a healthy diet, increased physical activity and reduced sedentary activities are recommended to prevent and treat obesity. Evidence suggests that changing these health behaviours can benefit cognitive function and school achievement in children and adolescents in general. There are various theoretical mechanisms that suggest that children and adolescents with excessive body fat may benefit particularly from these interventions.

OBJECTIVES: To assess whether lifestyle interventions (in the areas of diet, physical activity, sedentary behaviour and behavioural therapy) improve school achievement, cognitive function (e.g. executive functions) and/or future success in children and adolescents with obesity or overweight, compared with standard care, waiting-list control, no treatment, or an attention placebo control group.

SEARCH METHODS: In February 2017, we searched CENTRAL, MEDLINE and 15 other databases. We also searched two trials registries, reference lists, and handsearched one journal from inception. We also contacted researchers in the field to obtain unpublished data.

SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials (RCTs) of behavioural interventions for weight management in children and adolescents with obesity or overweight. We excluded studies in children and adolescents with medical conditions known to affect weight status, school achievement and cognitive function. We also excluded self- and parent-reported outcomes.

DATA COLLECTION AND ANALYSIS: Four review authors independently selected studies for inclusion. Two review authors extracted data, assessed quality and risks of bias, and evaluated the quality of the evidence using the GRADE approach. We contacted study authors to obtain additional information. We used standard methodological procedures expected by Cochrane. Where the same outcome was assessed across different intervention types, we reported standardised effect sizes for findings from single-study and multiple-study analyses to allow comparison of intervention effects across intervention types. To ease interpretation of the effect size, we also reported the mean difference of effect sizes for single-study outcomes.

MAIN RESULTS: We included 18 studies (59 records) of 2384 children and adolescents with obesity or overweight. Eight studies delivered physical activity interventions, seven studies combined physical activity programmes with healthy lifestyle education, and three studies delivered dietary interventions. We included five RCTs and 13 cluster-RCTs. The studies took place in 10 different countries. Two were carried out in children attending preschool, 11 were conducted in primary/elementary school-aged children, four studies were aimed at adolescents attending secondary/high school and one study included primary/elementary and secondary/high school-aged children. The number of studies included for each outcome was low, with up to only three studies per outcome. The quality of evidence ranged from high to very low and 17 studies had a high risk of bias for at least one item. None of the studies reported data on additional educational support needs and adverse events.Compared to standard practice, analyses of physical activity-only interventions suggested high-quality evidence for improved mean cognitive executive function scores. The mean difference (MD) was 5.00 scale points higher in an after-school exercise group compared to standard practice (95% confidence interval (CI) 0.68 to 9.32; scale mean 100, standard deviation 15; 116 children, 1 study). There was no statistically significant beneficial effect in favour of the intervention for mathematics, reading, or inhibition control. The standardised mean difference (SMD) for mathematics was 0.49 (95% CI -0.04 to 1.01; 2 studies, 255 children, moderate-quality evidence) and for reading was 0.10 (95% CI -0.30 to 0.49; 2 studies, 308 children, moderate-quality evidence). The MD for inhibition control was -1.55 scale points (95% CI -5.85 to 2.75; scale range 0 to 100; SMD -0.15, 95% CI -0.58 to 0.28; 1 study, 84 children, very low-quality evidence). No data were available for average achievement across subjects taught at school.There was no evidence of a beneficial effect of physical activity interventions combined with healthy lifestyle education on average achievement across subjects taught at school, mathematics achievement, reading achievement or inhibition control. The MD for average achievement across subjects taught at school was 6.37 points lower in the intervention group compared to standard practice (95% CI -36.83 to 24.09; scale mean 500, scale SD 70; SMD -0.18, 95% CI -0.93 to 0.58; 1 study, 31 children, low-quality evidence). The effect estimate for mathematics achievement was SMD 0.02 (95% CI -0.19 to 0.22; 3 studies, 384 children, very low-quality evidence), for reading achievement SMD 0.00 (95% CI -0.24 to 0.24; 2 studies, 284 children, low-quality evidence), and for inhibition control SMD -0.67 (95% CI -1.50 to 0.16; 2 studies, 110 children, very low-quality evidence). No data were available for the effect of combined physical activity and healthy lifestyle education on cognitive executive functions.There was a moderate difference in the average achievement across subjects taught at school favouring interventions targeting the improvement of the school food environment compared to standard practice in adolescents with obesity (SMD 0.46, 95% CI 0.25 to 0.66; 2 studies, 382 adolescents, low-quality evidence), but not with overweight. Replacing packed school lunch with a nutrient-rich diet in addition to nutrition education did not improve mathematics (MD -2.18, 95% CI -5.83 to 1.47; scale range 0 to 69; SMD -0.26, 95% CI -0.72 to 0.20; 1 study, 76 children, low-quality evidence) and reading achievement (MD 1.17, 95% CI -4.40 to 6.73; scale range 0 to 108; SMD 0.13, 95% CI -0.35 to 0.61; 1 study, 67 children, low-quality evidence).

AUTHORS' CONCLUSIONS: Despite the large number of childhood and adolescent obesity treatment trials, we were only able to partially assess the impact of obesity treatment interventions on school achievement and cognitive abilities. School and community-based physical activity interventions as part of an obesity prevention or treatment programme can benefit executive functions of children with obesity or overweight specifically. Similarly, school-based dietary interventions may benefit general school achievement in children with obesity. These findings might assist health and education practitioners to make decisions related to promoting physical activity and healthy eating in schools. Future obesity treatment and prevention studies in clinical, school and community settings should consider assessing academic and cognitive as well as physical outcomes.


Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.

Behbod B, Sharma M, Baxi R, et al. Cochrane Database Syst Rev. 2018 Jan 31;1:CD001746. doi: 10.1002/14651858.CD001746.pub4. (Review) PMID: 29383710

BACKGROUND: Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES: To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA: We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS: Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS: A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.


High-Intensity Interval Training Interventions in Children and Adolescents: A Systematic Review.

Eddolls WTB, McNarry MA, Stratton G, Winn CON, Mackintosh KA.
Sports Med. 2017 Nov;47(11):2363-2374. doi: 10.1007/s40279-017-0753-8.

BACKGROUND: Whilst there is increasing interest in the efficacy of high-intensity
interval training in children and adolescents as a time-effective method of
eliciting health benefits, there remains little consensus within the literature
regarding the most effective means for delivering a high-intensity interval
training intervention. Given the global health issues surrounding childhood
obesity and associated health implications, the identification of effective
intervention strategies is imperative.
OBJECTIVES: The aim of this review was to examine high-intensity interval
training as a means of influencing key health parameters and to elucidate the
most effective high-intensity interval training protocol.
METHODS: Studies were included if they: (1) studied healthy children and/or
adolescents (aged 5-18 years); (2) prescribed an intervention that was deemed
high intensity; and (3) reported health-related outcome measures.
RESULTS: A total of 2092 studies were initially retrieved from four databases.
Studies that were deemed to meet the criteria were downloaded in their entirety
and independently assessed for relevance by two authors using the pre-determined 
criteria. From this, 13 studies were deemed suitable. This review found that
high-intensity interval training in children and adolescents is a time-effective 
method of improving cardiovascular disease biomarkers, but evidence regarding
other health-related measures is more equivocal. Running-based sessions, at an
intensity of >90% heart rate maximum/100-130% maximal aerobic velocity, two to
three times a week and with a minimum intervention duration of 7 weeks, elicit
the greatest improvements in participant health.
CONCLUSION: While high-intensity interval training improves cardiovascular
disease biomarkers, and the evidence supports the effectiveness of running-based 
sessions, as outlined above, further recommendations as to optimal exercise
duration and rest intervals remain ambiguous owing to the paucity of literature
and the methodological limitations of studies presently available.


Association of Childhood Body Mass Index and Change in Body Mass Index With First Adult Ischemic Stroke.

Gjærde LK, Gamborg M, Ängquist L, Truelsen TC, Sørensen TIA, Baker JL.

JAMA Neurol. 2017 Aug 21. doi: 10.1001/jamaneurol.2017.1627. [Epub ahead ofprint]
Importance: The incidence of ischemic stroke among young adults is rising and is 
potentially due to an increase in stroke risk factors occurring at younger ages, 
such as obesity.
Objectives: To investigate whether childhood body mass index (BMI) and change in 
BMI are associated with adult ischemic stroke and to assess whether the
associations are age dependent or influenced by birth weight.
Design, Setting, and Participants: This investigation was a population-based
cohort study of schoolchildren born from 1930 to 1987, with follow-up through
national health registers from 1977 to 2012 in Denmark. Participants were 307 677
individuals (8899 ischemic stroke cases) with measured weight and height at ages 
7 to 13 years. The dates of the analysis were September 1, 2015, to May 27, 2016.
Main Outcomes and Measures: Childhood BMI, change in BMI, and birth weight.
Ischemic stroke events were divided into early (≤55 years) or late (>55 years)
age at diagnosis.
Results: The study cohort comprised 307 677 participants (approximately 49%
female and 51% male). During the study period, 3529 women and 5370 men
experienced an ischemic stroke. At all ages from 7 to 13 years, an above-average 
BMI z score was positively associated with early ischemic stroke. At age 13
years, a BMI z score of 1 was associated with hazard ratios (HRs) of 1.26 (95%
CI, 1.11-1.43) in women and 1.21 (95% CI, 1.10-1.33) in men. No significant
associations were found for below-average BMI z scores. Among children with
above-average BMI z scores at age 7 years, a score increase of 0.5 from ages 7 to
13 years was positively associated with early ischemic stroke in women (HR, 1.10;
95% CI, 1.01-1.20) and in men (HR, 1.08; 95% CI, 1.00-1.16). Similarly, among
children with below-average BMI z scores at age 7 years, a score increase of 0.5 
from ages 7 to 13 years was positively associated with early ischemic stroke in
women (HR, 1.14; 95% CI, 1.06-1.23) and in men (HR, 1.10; 95% CI, 1.04-1.18).
Adjusting for birth weight minimally affected the associations.
Conclusions and Relevance: Independent of birth weight, above-average childhood
BMI and increases in BMI during childhood are positively associated with early
adult ischemic stroke. To avoid the occurrence of early ischemic stroke
associated with childhood overweight and obesity, these results suggest that all 
children should be helped to attain and maintain healthy weights.