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Puberty could regulate the effects of outdoor time on refractive development in Chinese children and adolescents
  1. Jingjing Wang1,
  2. Tianyu Cheng2,
  3. Bo Zhang1,
  4. Shuyu Xiong2,
  5. Huijuan Zhao3,
  6. Qiangqiang Li3,
  7. Xiangui He1,2
  1. 1Department of Preventative Ophthalmology, Shanghai Eye Disease Prevention and Treatment Center, Shanghai, China
  2. 2Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
  3. 3Baoshan Center for Disease Prevention and Control, Shanghai, China
  1. Correspondence to Xiangui He, Shanghai Eye Disease Prevention & Treatment Center, shanghai 200040, China; xianhezi{at}


Aim To explore the impact of puberty on refractive development and its interaction with outdoor time in children and adolescents.

Methods In this 2-year observational study, students aged 7–13 years were selected with cluster sampling. All participants underwent cycloplegic refraction and axial length measurements once every year. Information of related factors was acquired through proper questionnaire or inquiry. The level of testosterone/estradiol was detected from the saliva of the subjects using the ELISA kit. Multiple linear regression and generalised estimating equation (GEE) were used to analyse the relationship among puberty, outdoor activities and refractive indicators.

Results A total of 776 children and adolescents were included, with an average baseline age of 9.64±1.54 years and 53.6% boys. There were 350 myopes (55.2% of the 634 cyclopleged subjects) at baseline. There was a significant difference in the mean axial length changes and outdoor time among different puberty groups (for axial length: p=0.017, for outdoor time: p=0.015). Myopic parents, less outdoor time and more changes in estradiol were associated with greater changes in axial length and spherical equivalent (SE) (axial length changes: parental myopia β=0.230, outdoor time β=−0.250, changes in estradiol β=0.261; SE changes: parental myopia β=−0.267, outdoor time β=0.256, changes in estradiol β=−0.297). In the GEE model, the interaction between outdoor time and puberty was significantly associated with axial length (p=0.024, β=1.199).

Conclusions This study implies puberty may play a regulating role on the relationship between outdoor time and refractive development among Chinese children and adolescents, which provides clues for in-depth mechanism interpretation and efficient intervention strategies.

  • child health (paediatrics)
  • public health
  • epidemiology
  • optics and refraction

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  • JW and TC contributed equally.

  • Contributors The study concept and design was conceived by XH. JW, BZ, HZ and QL recruited, screened and obtained consent from the participants and collected information on related factors, including outdoor time and puberty stages. TC and SX conducted the optical examination. JW prepared the first draft of the manuscript. TC, BZ, SX, HZ, QL and XH all provided edits and critiqued the manuscript for intellectual content.

  • Funding This work is supported by the National Natural Science Foundation of China (grant number 81402695) and the Municipal Human Resources Development Program for Outstanding Young Talents in Medical and Health Sciences in Shanghai (grant number 2017YQ019). The funding organisation had no role in the design or conduct of this research.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The research followed the tenets of the Declaration of Helsinki and was approved by the ethics committee of Shanghai General Hospital. The number of the approval is 2015KY148. Informed consent was obtained from the subjects and their guardians after an explanation of the nature and possible consequences of the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. The data used to support the findings of this study are available from the corresponding author upon request.

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