Wang et al. BMC Pediatrics(2024) 24:522
https://doi.org/10.1186/s12887-023-04468-2

BMC Pediatrics

RESEARCH

Open Access

Association between physical activity
and cardiovascular parameters in 7-year-old
children: a Chinese cross-sectional study
Qianchuo Wang1†, Hualin Wang1†, Bowen Du1, Yujian Wu1, Zhuoyan Li1, Yiwei Niu1, Fengxiu Ouyang2, Kai Bai1*,
Jian Wang1* and Kun Sun1*
Abstract
Introduction Physical activity (PA) is believed to play an important part in many aspects during childhood andadolescence, especially cardiorespiratory fitness and cardiometabolic health. However, whether different levels of
PA in daily life influence the structure or function of heart in school-aged children remains unknown. We aimed toinvestigate the association between PA and cardiovascular parameters in 7-year-old children.
Methods Follow-up data from the Shanghai Prenatal Cohort Study and the Shanghai Birth Cohort was analyzed.
Perinatal information including both maternal and offspring datum was recorded. A refined questionnaire was used
to evaluate the frequency and duration of children’s PA levels. Blood pressure, echocardiography, and anthropometry
assessment were conducted during the follow-up of 7-year-old children.
Results Overall, high PA level was associated with higher left ventricle posterior wall thickness in diastole (LVPWd, βcoefficient: 0.36, 95% CI: 0.12, 0.61), higher left ventricle mass index (LVMI, β = 0.28, 95% CI: 0.07, 0.48), mitral E/a ratio(β = 0.47, 95% CI: 0.22, 0.71) and slower heart rate (β = -0.32, 95% CI: -0.57, -0.07), compared to low PA level. Medium
PA level was associated with lower diastolic blood pressure (DBP, β = -0.18, 95% CI: -0.35, -0.01). In subgroup analysis,
increased relative wall thickness (RWT) was found in high PA level boys (β = 0.36, 95% CI: 0.05, 0.67), and systolic bloodpressure (SBP) showed a significant decrease in high PA level girls (β = -0.42, 95% CI: -0.78, -0.06).
Conclusions This study suggested non-athlete children having higher PA level were associated with thicker left
ventricle (LV) walls and better LV diastolic function, as well as slower heart rate and DBP at the age of 7. Furthermore,disparity in the association between PA level with morphological heart patterns and blood pressure existed indifferent sex category.

†

Qianchuo Wang and Hualin Wang have contributed equally to thiswork and share first authorship.
*Correspondence:
Kai Baibaikai@xinhuamed.com.cn
Jian Wangwangjian@xinhuamed.com.cn
Kun Sunsunkun@xinhuamed.com.cn
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not includedin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you willneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.

Wang et al. BMC Pediatrics(2024) 24:522

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Keywords Physical activity, Cardiac adaption, Cardiovascular parameters, Birth cohort study, Sex-disparity

What is Known
Physical activity (PA) is known to play an importantrole in various aspects during childhood and adolescence including cardiometabolic health. Physiologicallymorphological and functional heart modifications areobserved in both adult and pediatric athletes.
What is New
Non-athlete children having higher PA level were associated with thicker left ventricle (LV) walls and better
LV diastolic function, as well as slower heart rate anddiastolic blood pressure at the age of 7. Disparity in theassociation between PA level with morphological heartpatterns and blood pressure existed in different sex
category.
Introduction
Physical activity (PA) is defined as any bodily movement
resulted from skeletal muscles contraction which leads
to energy expenditure [1], including a wide range fromlight intensity like walking in daily life to heavy intensity like exercise training. PA has been proven to play animportant role in various aspects during childhood andadolescence, including physical fitness [2], cardiometabolic health [3–5] and cognitive outcomes [6]. On theother hand, the economic burden of chronic diseases
and premature deaths produced by physical inactivity is
heavy. However, physical inactivity was observed in children and adolescents these years [7], for which frequent
lockdowns and online lessons due to the COVID-19 pandemic were to be blamed.
Left ventricle (LV) geometry and function are bothcritical to cardiovascular health, and LV morphologicalchanges could progress under adverse stimulation before
functional changes [8]. Physiologically morphologicaland functional heart modifications are observed in both
adult and pediatric athletes [9, 10]. However, data of cardiac structure and function in non-athlete children withdifferent physical activity is limited. As far as we know,
there has been no study on the association of cardiovascular parameters and PA in school-aged children.
This study was based on the platforms of Shanghai Prenatal Cohort (SPC) and Shanghai Birth Cohort (SBC).
We aimed to examine the relationship between PA withthe cardiovascular parameters, including blood pressure,
LV geometry and function in school-aged children, andfurther explore if sex-disparity existed.

Methods
Study population

Our study included children from the SPC and SBC.
Both cohorts had parallel including and excluding standards. SPC was an ongoing perspective birth cohort thatenrolled 1043 Han maternal-child pairs between 2012
and 2013 at Xinhua Hospital and International Peace
Maternity and Child Hospital in Shanghai. In this cohort,
women over 20 years old who planned to live in Shanghai for at least 2 years were recruited. SBC recruited
volunteer couples during preconception care or in earlypregnancy in six collaborating hospitals from 2013 to2016 in Shanghai, and 3692 maternal-child pairs were
included. The recruit protocol of SBC has been previously described in detail [11]. In both cohorts, trained
researchers conducted face-to-face questionnaire interviews at enrollment to collect social-demographic characteristics including maternal age and pre-pregnancy
body mass index (BMI). Information on newborn’s sex,
gestational age, birth mode (caesarean section or vaginal
delivery) and anthropometric parameters was obtainedat the time of delivery. Children received examinations
including anthropometric measurements, blood pressure measurement and echocardiogram at the 7-year
follow-up visit from 2020 to 2022. Informed writtenconsent was obtained from parents or caregivers of alleligible children prior to their entry into the study. The
research was approved by the Ethical Committee of
Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine (XHEC-C-2012-003 and
XHEC-C-2013-001-2).
Evaluation of PA

The level of PA was evaluated through a questionnairecompleted by both children and their guardians (parents or other guardians taking care of children most of
the time) by face-to-face interview. PAQ-CN was used toevaluate PA of Chinese children aged 7 to 18, translated
and slightly modified from The Physical Activity Questionnaire for Older Children (PAQ-C) and Adolescents(PAQ-A) [12]. In this questionnaire, PA was evaluatedand calculated as a score according to general PA performance in the school and at home, together with the frequency and duration of PA in the past week. According
to the PA score, children were divided into three groups:
high level group (PA score more than 3.00, representing
metabolic equivalents over 1500 MET-min/week andhaving vigorous PA in over 3 days, or metabolic equivalents over 3000 MET-min/week and having PA in over 7days), medium level group (PA score between 2.00 and
3.00, representing having over 20 min vigorous physicalWang et al. BMC Pediatrics(2024) 24:522

activity in over 3 days, or having over 30 min moderate
physical activity or walking in over 5 days, or metabolic
equivalents over 600 MET-min/week and having PA
in over 5 days) or low level group (PA score below 2.00,
representing PA level lower than medium level). The reliability and validity of questionnaire has been examined inprevious study [13].
Anthropometric measurements

A complete anthropometric evaluation was conducted
for all children according to the standardized protocol. Height was measured barefoot twice to the nearest
0.1 cm. Weight was measured with light clothing and no
shoes to the nearest 0.1 kg. The average of two repeats
was collected, and the third measurement was conducted
if the two readings differed by 0.1 kg or 0.1 cm. BMI was
calculated as weight (kg)/height2 (m2).
Measurement of blood pressure

Blood pressure was measured from the left arm withappropriately sized cuff according to the guideline set
by the American Academy of Pediatrics in 2017 [14],using the professional automatic BP monitor OMRONHBP-1300 (Omron Healthcare, Guangzhou, CHINA).
Blood pressure was measured three times with a 5 min
gap between replicates, after a comfortable rest of 5 min.
Measurements were done by trained coordinators in
duplicate and averaged.
Measurement of cardiovascular parameters

Transthoracic echocardiography was performed for all
children in a comfortable and quiet environment by two
experienced echocardiographers using standard techniques in accordance with the American Society of Echocardiography [15, 16]. Quantitative measurements wereobtained offline by well-trained investigators blinded
to the data of subjects. Detailed information had been
described previously [17]. Sex-specific 95th percentile of
LVMI was used as LV hypertrophy (LVH) cutoff points[18]. LVMI = 27.30 g/m2.7 in girls and LVMI = 30.91 g/m2.7
in boys represented the sex-specific 95th percentile in thecohort.
Statistical analysis

Continuous variables from the three groups werecompared with one-way ANOVA and presented asmean ± SD. Categorical variables were compared with
Pearson’s chi-square test or Fisher’s exact test and presented as percentages. To evaluate and compare theassociation between PA and cardiovascular parameters,
2 separate standardized linear regression models wereused after Z transformations of cardiovascular parameters, and β coefficient with 95% CIs were calculated.
Basic model 1 was crude model. Model 2 was adjusted

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for confounding factors including age, sex and BMI. Sex
was excluded from the model in analyzing sex disparity. P values for trends were calculated using the median
PA score of each PA level (1.74 for low PA level, 2.46 formedium PA level and 3.25 for high PA level; for analyzing sex disparity, 1.76, 2.44 and 3.20 in girls and 1.70, 2.49
and 3.28 in boys, respectively) as a quasi-continuous variable in the model. All statistical analyses were performed
using Stata 16.0 software (StataCorp LP, TX). Twosided P value less than 0.05 was considered statisticallysignificant.

Results
Basic characteristics

A total of 818 maternal-child pairs were invited in the
7-year-old visit. 96 children were excluded due to refusal
to undertake echocardiogram examination or PA questionnaire survey, poor echocardiographic quality or
structural anomalies of heart, and 722 children were
included for data analyses at last (Fig. 1).
According to PA score, 722 children were classified into
three groups: 187 children (25.9%) were at low PA level,
437 (60.5%) were at medium PA level and 98 (13.6%) wereat high PA level. Maternal and child characteristics ofstudy participants across these three groups were summarized in Table 1. The mean (± SD) PA score was 2.36(± 0.60) for girls and 2.44 (± 0.52) for boys, reflecting
more inactiveness in girls compared to boys (P = 0.020).
No significant difference was found in BMI either at birthor at the age of 7 among these three groups.
Cardiovascular parameters in different PA level groups

Comparisons of cardiovascular parameters among threegroups are demonstrated in Table 2. Thicker LV posterior wall thickness in diastole and systole (LVPWd and
LVPWs) were found in children with high PA level (4.84
and 8.20 mm, respectively) than that in low PA level children (4.54 and 7.83 mm). Higher LVMI and E/a ratio
were also found in high PA level children (24.09 g/m2.7
and 1.95) compared with low PA level children (22.25 g/
m2.7 and 1.76). As for LV ejection fraction (LVEF), heart
rate and diastolic blood pressure (DBP), decreases wereshown in high PA level children (68.91%, 80.85 bpm and60.25 mmHg) compared to low PA level children (70.31%,
84.25 bpm and 61.00 mmHg).
Associations of different PA level with cardiovascularparameters in 7-year-olds

The association between different PA levels with cardiovascular parameters at 7-year-old were represented
in Table 3. Positive associations were found between
children with high PA level and LVPWd (β coefficient:0.36, 95% CI: 0.12, 0.61), LVMI (β = 0.28, 95% CI: 0.07,0.48), mitral E/a ratio (β = 0.47, 95% CI: 0.22, 0.71) ,while

Wang et al. BMC Pediatrics(2024) 24:522

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Fig. 1 Flow diagram of participants included in this study

negative association was found in heart rate (β = -0.32,
95% CI: -0.57, -0.07). Medium PA level was significantly
associated with lower diastolic blood pressure (DBP,
β = -0.18, 95% CI: -0.35, -0.01). Trend analyses showed
consistent results in LVPWd (β for trend = 0.22, 95% CI:
0.06, 0.38, P for trend = 0.008), LVMI (β for trend = 0.21,
95% CI: 0.06, 0.37, P for trend = 0.006), E/a ratio (β for
trend = 0.29, 95% CI: 0.13, 0.45, P for trend < 0.001) andheart rate (β for trend = -0.23, 95% CI: -0.39, -0.06, P for
trend = 0.006), while DBP not showing significant linear
trend. Replacing BMI by height or weight in adjustment
did not influence any result (Supplemental Tables 1 and2).

Sex disparity in the association of different PA level withcardiovascular parameters in 7-year-oldsTable 4 compared cardiovascular parameters andblood pressure among different PA groups by sex. Several parameters in each sex category remained similarvariations and patterns as that in all children, including E/a ratio (P = 0.022), LVEF (P = 0.041) and heart
rate (P = 0.010) in boys, and LVPWd (P = 0.026), LVMI
(P = 0.008) and E/a ratio (P = 0.009) in girls. Additionally,both systolic blood pressure (SBP, P = 0.011) and DBP(P = 0.033) showed a decreasing trend with increasing PA
level in girls.

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Table 1 Basic characteristics of different physical activity levels
Characteristics

Maternal characteristics
Age at delivery (yr)Pre-pregnancy BMI (kg/m²)
Child characteristics
Male
Age at 7-y visit (yr)Gestational age at delivery (wk)
Caesarean section
Birth height (cm)Birthweight (kg)
BMI at birth (kg/m²)
Height at 7-y visit (cm)Weight at 7-y visit (kg)
BMI at 7-y visit (kg/m²)
Physical activity score

P-value

Physical activity level
Low level
N = 187

Medium level
N = 437

High level
N = 9829.79 ± 3.82
21.11 ± 2.97

29.85 ± 3.38
21.94 ± 3.70

29.77 ± 3.48
21.39 ± 2.95

0.789
0.080

88 (47%)7.51 ± 0.39
38.88 ± 1.48
137 (73%)
49.79 ± 2.07
3.34 ± 0.48
13.62 ± 1.71
128.52 ± 5.87
27.34 ± 6.30
16.41 ± 2.84
1.71 ± 0.19

220 (50%)
7.33 ± 0.41
38.95 ± 1.80
280 (64%)49.90 ± 1.47
3.38 ± 0.47
13.64 ± 1.33
127.15 ± 5.54
26.01 ± 5.67
15.96 ± 2.50
2.48 ± 0.28

61 (62%)
7.21 ± 0.40
38.93 ± 1.56
50 (51%)49.99 ± 1.49
3.40 ± 0.54
13.81 ± 1.38
126.83 ± 6.02
25.88 ± 5.74
15.95 ± 2.48
3.35 ± 0.31

0.045
< 0.001
0.772
0.396
0.774
0.678
0.549
0.012
0.015
0.136
< 0.001

BMI: body mass index
Values were expressed as means ± SD or numbers (percentages). P-values were calculated using One-way ANOVA tests or Chi-square tests. Boldface indicatesstatistical significance (p < 0.05)

Table 2 Basic and cardiovascular characteristics of different physical activity levels at the age of 7 years
Cardiovascular parameters Physical activity level
Low level
LV diameter
LVPWd (mm)4.54 ± 0.56
LVPWs (mm)7.83 ± 1.03
LVIDd (mm)38.71 ± 3.34
LVIDs (mm)25.09 ± 2.33
IVSd (mm)4.54 ± 0.46
IVSs (mm)7.44 ± 1.00
LV geometry
LVMI (g/m2.7)
22.25 ± 3.79
RWT (%)
23.56 ± 2.62
LVH, N (%)
9 (5.0%)
LV function
E/a ratio
1.76 ± 0.39
LVEF (%)
70.31 ± 4.32
LVFS (%)
35.39 ± 3.27
Heart rate (bpm)
84.25 ± 10.67
Blood pressure
SBP (mmHg)
103.74 ± 7.55
DBP (mmHg)
61.00 ± 5.77
Hypertension, N (%)
18 (9.6%)

P-value
Medium level

High level4.58 ± 0.80
7.87 ± 1.15
38.50 ± 3.16
24.70 ± 2.47
4.54 ± 0.56
7.46 ± 1.75

4.84 ± 1.03
8.20 ± 1.20
38.92 ± 3.46
24.84 ± 2.64
4.64 ± 0.75
7.54 ± 1.10

0.006
0.022
0.456
0.211
0.304
0.858

22.63 ± 3.97
23.85 ± 3.94
20 (4.6%)

24.09 ± 3.89
24.72 ± 5.90
7 (7.3%)< 0.001
0.064
0.564

1.82 ± 0.38
69.32 ± 4.68
35.90 ± 3.66
81.94 ± 8.94

1.95 ± 0.41
68.91 ± 4.71
36.26 ± 3.43
80.85 ± 10.78< 0.001
0.020
0.115
0.006

102.96 ± 7.07
59.70 ± 5.39
34 (9.8%)

103.32 ± 7.98
60.25 ± 5.77
8 (8.2%)

0.469
0.026
0.746

LV: left ventricle; LVMI: LV mass index; LVPWd: LV posterior wall thickness in diastole; LVPWs: LV posterior wall thickness in systole; LVDd: LV internal diameter indiastole; LVDs: LV internal diameter in systole; IVSd: interventricular septum thickness in diastole; IVSs: interventricular septum thickness in systole; RWT: relative wall
thickness; LVH: left ventricle hypertrophy; E: mitral early wave velocities; a: mitral late wave velocities; LVEF: LV ejection fraction; LVFS: LV fractional shortening; SBP:
systolic blood pressure; DBP: diastolic blood pressure
Values were expressed as means ± SD or numbers (percentages). P-values were calculated using One-way ANOVA tests or Chi-square tests. Boldface indicatesstatistical significance (p < 0.05)

Further investigation in adjusted linear model showed
positive associations between high PA level boys and
RWT (β = 0.28, 95% CI: 0.07, 0.48, β for trend = 0.22,
95% CI: 0.03, 0.42, P for trend = 0.025) additionally.

LVPWd and LVMI was associated with high PA level girls(LVPWd β = 0.54, 95% CI: 0.10, 0.98; LVMI β = 0.38, 95%
CI: 0.03, 0.73), however they did not show significant
linear trend with PA (LVPWd β for trend = 0.26, 95% CI:

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Table 3 The association between physical activity and cardiovascular parameters at the age of 7 years
Model 1
Low level
LV diameter
LVPWd
Reference
LVPWs
Reference
LVIDd
Reference
LVIDs
Reference
IVSd
Reference
IVSs
Reference
LV geometry
LVMI
Reference
RWT
Reference
LV function
E/a ratio
Reference
LVEF
Reference
LVFS
Reference
Heart rate Reference
Blood pressure
SBP
Reference
DBP
Reference

Medium level

High level

P for trend

Model 2
Low level

Medium level

High level

P for trend

0.05 (-0.12,0.22)
0.04 (-0.14,0.21)-0.06 (-0.24,0.11)-0.16 (-0.33,0.02)
0.00 (-0.17,0.18)
0.02 (-0.16,0.19)

0.38 (0.13,0.62)
0.32 (0.08,0.57)
0.07 (-0.18,0.31)-0.10 (-0.35,0.14)
0.17 (-0.08,0.42)
0.07 (-0.18,0.32)

0.006
0.021
0.777
0.264
0.237
0.612

Reference
Reference
Reference
Reference
Reference
Reference

0.06 (-0.11,0.23)-0.09 (-0.24,0.07)
0.04 (-0.11,0.19)
0.03 (-0.12,0.18)
0.02 (-0.16,0.19)
0.02 (-0.15,0.19)

0.36 (0.12,0.61)
0.08 (-0.15,0.30)
0.14 (-0.08,0.35)
0.12 (-0.09,0.33)
0.15 (-0.10,0.40)
0.03 (-0.22,0.27)

0.008
0.727
0.230
0.288
0.287
0.802

0.10 (-0.08,0.27)
0.07 (-0.10,0.25)

0.46 (0.22,0.71)
0.29 (0.04,0.54)

0.001
0.029

Reference
Reference

0.07 (-0.09,0.24)
0.02 (-0.15,0.20)

0.35 (0.12,0.59)
0.23 (-0.02,0.48)

0.006
0.101

0.17 (0.00,0.34)-0.21 (-0.39,-0.04)
0.14 (-0.03,0.32)-0.24 (-0.41,-0.07)

0.48 (0.24,0.73)-0.30 (-0.55,-0.06)
0.24 (0.00,0.49)-0.35 (-0.59,-0.11)< 0.001
0.008
0.040
0.002

Reference
Reference
Reference
Reference

0.15 (-0.03,0.32)-0.03 (-0.19,0.13)-0.02 (-0.19,0.14)-0.22 (-0.40,-0.05)

0.47 (0.22,0.71)-0.03 (-0.36,0.19)-0.04 (-0.27,0.20)-0.32 (-0.57,-0.07)< 0.001
0.728
0.735
0.006

-0.11 (-0.28,0.06)-0.23 (-0.41,-0.06)-0.06 (-0.30,0.19)-0.13 (-0.38,0.11)

0.491
0.114

Reference
Reference-0.04 (-0.21,0.12)-0.18 (-0.35,-0.01)-0.02 (-0.25,0.22)-0.06 (-0.30,0.19)

0.820
0.388

LV: left ventricle; LVMI: LV mass indexed to the height in m2.7; LVPWd: LV posterior wall thickness in diastole; LVPWs: LV posterior wall thickness in systole; LVDd:
LV internal diameter in diastole; LVDs: LV internal diameter in systole; IVSd: interventricular septum thickness in diastole; IVSs: interventricular septum thickness insystole; RWT: relative wall thickness; E: mitral early wave velocities; a: mitral late wave velocities; LVEF: LV ejection fraction; LVFS: LV fractional shortening; SBP: systolicblood pressure; DBP: diastolic blood pressure. Results were presented as β coefficient with 95% CI. Boldface indicates statistical significance (p < 0.05)
Model 1: crude model. Model 2: adjusted for age, sex and BMI-0.03, 0.54, P for trend = 0.078; LVMI β for trend = 0.18,
95% CI: -0.05, 0.41, P for trend = 0.122). A negative association between high PA level girls and SBP was shown
after adjustment (β = -0.42, 95% CI: -0.78, -0.06), and thedecreasing trend was found as well (β for trend = -0.29,
95% CI: -0.52, -0.06, P for trend = 0.013) (Table 5).

Discussion
In this study, we demonstrated a significant association
between PA and increased LVPWd, LVMI, mitral E/aratio as well as decreased heart rate and DBP in children
at the age of 7. Furthermore, disparity in the association
between PA level with RWT and blood pressure existed
in different sex category.
Morphological echocardiographic heart patterns ofathletes have been described: predominant augmentation of wall thickness, and major cavity size in chamber
dimensions in the case of prevalent static or dynamic
components [9]. An observational study revealed that
preadolescent athletes developed greater left ventricular mass and greater left and right ventricular chamber
dimensions, while left ventricular function did not differ[10]. Another study demonstrated increased left atrium
diameter, interventricular septum, and left ventricle posterior wall, diastolic diameter of the left ventricle, andright ventricle outflow tract in young athletes [19]. A
randomized controlled trial showed that short-termed
sports intervention in common children also resulted inchanges of LV wall thickness and diastolic function [20].
In 7-year-old common pupils, LVPWd is the only significantly increased one we found among LV wall thicknesses and diameters, indicating LVPWd is one of theearliest parameters reflecting the adaption of LV to PA.
We hypothesized that diastolic function improvement isassociated with the increase of PA, since we observed asignificant association between mitral E/a ratio and PA.
LV systolic function seemed to be influenced in a rather
low extent even in young athletes [21], which is consistent with our results since there was no significant
association between LV systolic function and PA in nonathlete boys and girls. It was reported that greater LVMI
predicted elite athletes status, while endurance elite athletes had lower heart rate and strength elite athletes hadgreater diastolic function in Asian physically fit young
adults [22, 23]. There were similar changes of LVMI,
heart rate and diastolic function in physically active children, which might be the result of mixed type of physicalactivity in natural condition.
PA has been linked to reducing the risk of hypertension in children and adolescents in many studies [12, 24].
However, blood pressure is regulated by multiple organs
involving brain, heart, vasculature and kidney [25], andthe mechanisms underlying this effect of exercise training remain undisclosed. One of the possible explanations of the positive effect of PA on blood pressure wasthat PA decreased the activation of the sympathetic

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Table 4 Sex-specific basic and cardiovascular characteristics of different physical activity levels at the age of 7
Cardiovascular parameters Physical activity level
Low levelBoys (N = 369)
LVPWd (mm)4.59 ± 0.52
LVPWs (mm)7.96 ± 0.98
LVIDd (mm)39.50 ± 3.10
LVIDs (mm)25.12 ± 2.47
IVSd (mm)4.57 ± 0.40
IVSs (mm)7.71 ± 0.93
LVMI (g/m2.7)
23.12 ± 3.58
RWT (%)
22.93 ± 1.97
LVH, N (%)
3 (3.5%)
E/a ratio
1.74 ± 0.37
LVEF (%)
70.55 ± 4.68
LVFS (%)
35.50 ± 3.02
Heart rate (bpm)
85.39 ± 12.10
SBP (mmHg)
104.38 ± 7.43
DBP (mmHg)
60.72 ± 5.82
Hypertension, N (%)
7 (8.0%)Girls (N = 353)
LVPWd (mm)4.50 ± 0.59
LVPWs (mm)7.72 ± 1.07
LVIDd (mm)37.61 ± 3.53
LVIDs (mm)24.44 ± 2.39
IVSd (mm)4.52 ± 0.51
IVSs (mm)7.20 ± 0.99
LVMI (g/m2.7)
21.49 ± 3.82
RWT (%)
24.11 ± 2.99
LVH, N (%)
6 (6.3%)
E/a ratio
1.77 ± 0.41
LVEF (%)
70.10 ± 3.99
LVFS (%)
35.30 ± 3.48
Heart rate (bpm)
83.22 ± 9.17
SBP (mmHg)
103.17 ± 7.65
DBP (mmHg)
61.24 ± 5.74
Hypertension, N (%)
11 (11.1%)

P-value
Medium level

High level4.67 ± 0.66
8.08 ± 1.05
39.96 ± 2.62
25.82 ± 2.02
4.62 ± 0.55
7.68 ± 1.04
23.82 ± 3.80
23.67 ± 3.46
10 (4.7%)
1.81 ± 0.38
69.79 ± 4.54
36.59 ± 3.68
81.07 ± 8.77
104.55 ± 6.62
59.61 ± 5.43
16 (7.3%)

4.77 ± 0.77
8.26 ± 1.08
39.31 ± 3.62
25.12 ± 2.66
4.76 ± 0.83
7.72 ± 1.16
24.69 ± 4.32
24.56 ± 5.63
5 (8.3%)1.90 ± 0.37
68.65 ± 4.63
36.10 ± 3.28
80.71 ± 11.10
105.65 ± 8.41
60.67 ± 5.45
6 (9.8%)

0.360
0.107
0.503
0.124
0.299
0.915
0.050
0.163
0.411
0.022
0.041
0.098
0.010
0.632
0.444
0.766

4.49 ± 0.91
7.66 ± 1.21
37.50 ± 2.90
24.29 ± 2.40
4.47 ± 0.55
7.23 ± 2.22
21.45 ± 3.79
24.03 ± 4.36
10 (4.6%)
1.84 ± 0.37
68.86 ± 4.77
35.22 ± 3.52
82.82 ± 9.04
101.34 ± 7.16
59.78 ± 5.35
18 (8.3%)

4.96 ± 1.38
8.10 ± 1.39
38.27 ± 3.10
24.35 ± 2.58
4.43 ± 0.53
7.23 ± 0.91
23.28 ± 2.83
25.00 ± 6.41
2 (5.6%)2.03 ± 0.47
69.35 ± 4.89
36.53 ± 3.71
81.08 ± 10.37
99.48 ± 5.43
59.55 ± 6.27
2 (5.4%)

0.026
0.221
0.290
0.911
0.553
0.831
0.008
0.384
0.707
0.009
0.095
0.143
0.410
0.011
0.033
0.582

LV: left ventricle; LVMI: LV mass indexed to the height in m2.7; LVPWd: LV posterior wall thickness in diastole; LVPWs: LV posterior wall thickness in systole; LVDd:
LV internal diameter in diastole; LVDs: LV internal diameter in systole; IVSd: interventricular septum thickness in diastole; IVSs: interventricular septum thickness insystole; RWT: relative wall thickness; LVH: left ventricle hypertrophy; E: mitral early wave velocities; a: mitral late wave velocities; LVEF: LV ejection fraction; LVFS: LV
fractional shortening; SBP: systolic blood pressure; DBP: diastolic blood pressure
Values were expressed as means ± SD or numbers (percentages). P-values were calculated using One-way ANOVA tests or Chi-square tests. Boldface indicatesstatistical significance (p < 0.05)

nervous system [26, 27], and decreased heart rate should
be observed together with decreased blood pressure in
active children based on this assumption. A controversial finding in our study showed that decreased bloodpressure did not accompany with decreased heart rate
in more active girls, and decreased blood pressure wasalso not seen in active boys with decreased heart rate,
which questioned this mechanism. Arterial remodelingshould be considered as a reasonable mechanism to thiseffect. It was well established that changes in hemodynamic forces can lead to remodeling arteries and arterioles [28], and evidence showed that endurance trained

individuals displayed a reduced arterial wall thickness
and an increased lumen diameter [29]. Further studies are required to examine this mechanism in young
children.
We demonstrated sex disparity in the association
between cardiovascular parameters and exposure in earlylifespan, which is consistent with our previous study [30].
Previous study had reported significantly larger IVSd andgreater LVH prevalence in male pediatric athletes thanfemale [31]. However, contradictory results were found in
our study that girls were likely to gain more LV mass byincreasing PA at the age of 7. Sex hormonal differences

Wang et al. BMC Pediatrics(2024) 24:522

Page 8 of 10

Table 5 Sex differences in the association between physical activity and cardiovascular parameters

Boys
LVPWd
LVPWs
LVIDd
LVIDs
IVSd
IVSs
LVMI
RWT
E/a ratio
LVEF
LVFS
Heart
rate
SBP
DBP
Girl
LVPWd
LVPWs
LVIDd
LVIDs
IVSd
IVSs
LVMI
RWT
E/a ratio
LVEF
LVFS
Heart
rate
SBP
DBP

Model 1
Low level

Medium level

High level

P for trend

Model 2
Low level

Medium level

High level

P for trend

Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference

0.11 (-0.10,0.32)
0.11 (-0.12,0.34)-0.14 (-0.38,0.10)-0.29 (-0.53,-0.04)
0.09 (-0.17,0.35)-0.02 (-0.19,0.16)
0.18 (-0.07,0.42)
0.19 (-0.04,0.42)
0.17 (-0.07,0.40)-0.17 (-0.42,0.09)
0.30 (0.06,0.55)-0.44 (-0.70,-0.19)

0.23 (-0.04,0.51)
0.26 (-0.04,0.57)-0.20 (-0.51,0.11)-0.28 (-0.61,0.04)
0.34 (0.00,0.68)
0.01 (-0.22,0.24)
0.40 (0.07,0.72)
0.41 (0.11,0.71)
0.40 (0.08,0.71)-0.41 (-0.74,-0.08)
0.17 (-0.15,0.19)-0.48 (-0.82,-0.14)

0.092
0.089
0.189
0.055
0.060
0.956
0.016
0.008
0.014
0.015
0.196
0.002

Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference

0.18 (-0.03,0.39)-0.02 (-0.24,0.19)
0.02 (-0.21,0.24)-0.03 (-0.25,0.19)
0.11 (-0.16,0.37)
0.00 (-0.17,0.18)
0.18 (-0.07,0.42)
0.14 (-0.09,0.38)
0.13 (-0.12,0.37)
0.08 (-0.15,0.31)
0.10 (-0.14,0.34)-0.42 (-0.69,-0.16)

0.30 (0.03,0.57)
0.06 (-0.23,0.34)-0.04 (-0.33,0.25)
0.01 (-0.28,0.30)
0.34 (0.00,0.69)
0.01 (-0.21,0.24)
0.37 (0.05,0.69)
0.36 (0.05,0.67)
0.34 (0.02,0.67)-0.08 (-0.38,0.22)-0.10 (-0.41,0.22)-0.46 (-0.80,-0.11)

0.028
0.735
0.817
0.974
0.057
0.913
0.024
0.025
0.041
0.706
0.637
0.006

Reference
Reference

0.02 (-0.22,0.26)-0.20 (-0.45,0.05)

0.17 (-0.15,0.49)-0.01 (-0.33,0.32)

0.321
0.752

Reference
Reference

0.15 (-0.09,0.39)-0.11 (-0.37,0.14)

0.31 (-0.01,0.62)
0.09 (-0.24,0.42)

0.055
0.716

Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference-0.02 (-0.29,0.26)-0.06 (-0.31,0.20)-0.03 (-0.26,0.20)-0.06 (-0.30,0.17)-0.09 (-0.32,0.14)
0.02 (-0.27,0.32)-0.01 (-0.24,0.22)-0.02 (-0.28,0.24)
0.17 (-0.07,0.42)-0.27 (-0.51,-0.03)-0.02 (-0.26,0.22)-0.04 (-0.27,0.18)

0.58 (0.14,1.01)
0.33 (-0.07,0.74)
0.20 (-0.16,0.57)-0.04 (-0.41,0.34)-0.15 (-0.52,0.22)
0.02 (-0.45,0.49)
0.40 (0.04,0.77)
0.22 (-0.19,0.63)
0.66 (0.27,1.05)-0.16 (-0.54,0.22)
0.35 (-0.03,0.73)-0.22 (-0.58,0.14)

0.050
0.269
0.461
0.732
0.360
0.904
0.093
0.445
0.002
0.141
0.187
0.281

Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference
Reference-0.04 (-0.31,0.24)-0.16 (-0.38,0.07)
0.05 (-0.15,0.25)
0.07 (-0.13,0.27)-0.07 (-0.30,0.15)
0.03 (-0.27,0.32)-0.03 (-0.24,0.19)-0.07 (-0.33,0.19)
0.16 (-0.09,0.41)-0.14 (-0.36,0.08)-0.14 (-0.36,0.09)-0.03 (-0.26,0.20)

0.54 (0.10,0.98)
0.14 (-0.22,0.50)
0.38 (0.05,0.70)
0.25 (-0.08,0.57)-0.12 (-0.48,0.25)
0.03 (-0.44,0.50)
0.38 (0.03,0.73)
0.12 (-0.30,0.53)
0.64 (0.24,1.04)
0.10 (-0.25,0.45)
0.12 (-0.24,0.48)-0.21 (-0.57,0.16)

0.078
0.912
0.052
0.152
0.473
0.856
0.122
0.810
0.003
0.972
0.941
0.334

Reference
Reference-0.25 (-0.48,-0.02)-0.26 (-0.50,-0.02)-0.50 (-0.87,-0.13)-0.30 (-0.68,0.08)

0.004
0.043

Reference
Reference-0.22 (-0.44,0.01)-0.24 (-0.48,0.00)-0.42 (-0.78,-0.06)-0.25 (-0.63,0.14)

0.013
0.089

LVPWd: LV posterior wall thickness in diastole; LVPWs: LV posterior wall thickness in systole; LVDd: LV internal diameter in diastole; LVDs: LV internal diameter insystole; IVSd: interventricular septum thickness in diastole; IVSs: interventricular septum thickness in systole; LVMI: LV mass indexed to the height in m2.7; RWT:
relative wall thickness; E: mitral early wave velocities; a: mitral late wave velocities; LVEF: LV ejection fraction; LVFS: LV fractional shortening; SBP: systolic bloodpressure; DBP: diastolic blood pressure. Results were presented as β coefficient with 95% CI. Boldface indicates statistical significance (p < 0.05)
Model 1: crude model. Model 2: adjusted for age and BMI

could be the possible explanation of these different
findings. Due to the difference of hypothalamic-pituitary-gonadal axis between male and female, hormonal
environment begins to differ when gonadotropin-releasing hormone is secreted from the hypothalamus tofacilitate pubertal onset [32]. Some studies pointed outthat sex hormones play a role in the variation of cardiac
structure and function [33–35]. Our studies focused onchildren far before puberty, thus excluded the potential
confounding effect of sex hormones.
Our cross-sectional study was based on SBC, a prospective birth cohort study platform in China, containing
detailed measurement and assessment of cardiovascularparameters in early childhood, which is pioneering compared to previous epidemiology studies. Furthermore,

for the first time, our study revealed sex disparity in theassociation between PA and cardiac remodeling in earlyschool-aged children. The limitations in our study should
also be considered. Firstly, although our study was able
to adjust for several key biological factors, such as age,sex and BMI, data on other factors (diet, sleep, etc.) were
not available. The observed exposure-outcome associations could change if those factors were considered. Further research is warranted encompassing a broad rangeof socioeconomic and lifestyle factors. Next, we chose arefined questionnaire for Chinese children as the assessment to PA due to its high convenience, where there
was at risk of recall bias. Though we observed stable
and consistent results in our research and the reliabilityof questionnaire had been examined in previous study,

Wang et al. BMC Pediatrics(2024) 24:522

which made our findings credible. In addition, white-coat
hypertension and masked hypertension were not considered in our study. We have standardized the procedure ofmeasuring blood pressure to minimize the measurement
error.

Conclusions
Physically active non-athlete children were associatedwith thicker LV walls and better LV diastolic function as
well as decreased heart rate and DBP as early as the ageof 7. Disparity in the association between PA level withmorphological heart patterns and blood pressure existed
in different sex category. Our results suggested that there
was cardiac adaption by undergoing a certain amount ofintensity of daily PA instead of athletic training as earlyas the age of 7. It remains to be elucidated whether thisadaption is beneficial for cardiovascular health in further
investigations.
Abbreviations
DBP	diastolic blood pressure
IPAQ	International Physical Activity Questionnaire
LV	left ventricle
LVEF	LV ejection fraction
LVH	LV hypertrophy
LVMI	LV mass indexed to the height in m2.7
LVPWd	LV posterior wall thickness in diastole
LVPWs	LV posterior wall thickness in systole
RWT	relative wall thickness
SBC	Shanghai Birth Cohort
SBP	systolic blood pressure
SPC	Shanghai Prenatal CohortPA	physical activity

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12887-023-04468-2.
Supplementary Material 1
Acknowledgements
We gratefully acknowledge all the children and their parents for their
participation and the research 334 staff who have contributed to patient
recruitment and data collection in the SBC.
Author contributions
JW, KB and KS contributed equally to the study, conceived and designed
the study, collected data; QCW and HLW prepared an analytical plan,
analyzed data, and drafted the initial manuscript; BWD, YJW, YWN, andZYL were involved in echocardiography examinations and data collection;
FXOY collaborated in the revision and interpretation of the data and results.
All authors reviewed and revised the manuscript, and approved the final
manuscript as submitted, and agreed to be accountable for all aspects of thework.
Funding
This study was supported by Collaborative Innovation Program of Shanghai
Municipal Health Commission (Grant Number: 2020CXJQ01), Youth Medical
Talents-Specialist Program and National Natural Science Foundation of China(82100320; 82130015).

Page 9 of 10

Data availability
The datasets used and/or analysed during the current study are available fromthe corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
The studies involving human participants were reviewed and approved by the
research ethics boards of Shanghai Xinhua Hospital (the coordination center,approved on August 23, 2013, ref no. M2013-010). Written informed consent
to participate in this study was provided by the participants’ legal guardian/next of kin. All methods were performed in accordance with the relevant
guidelines and regulations.
Consent for publication
No individual person’s data in any form was contained in this study.
Competing interests
The authors have no competing interests to declare that are relevant to thecontent of this article.
Author details
1
Department of Pediatric Cardiology, Xinhua Hospital, School of Medicine,
Shanghai Jiao Tong University, No.1665, Kongjiang Road, Yangpu District,
Shanghai 200092, China
2
Shanghai Key Laboratory of Children’s Environmental Health, Xinhua
Hospital, School of Medicine, Ministry of Education, Shanghai Jiao Tong
University, Shanghai, China
Received: 18 March 2023 / Accepted: 6 December 2023

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