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Weight-Loss Behaviors of Avoiding Between Mealand Midnight Snack in Teenagers Associated withGestational Diabetes: The Japan Environment andChildren’s StudyMarina Minami 

Kochi UniversityTakafumi Watanabe 

Kochi UniversityMasamitsu Eitoku  ( meitoku@kochi-u.ac.jp )

Kochi UniversityNagamasa Maeda 

Kochi UniversityMikiya Fujieda 

Kochi UniversityNarufumi Suganuma 

Kochi University

Research Article

Keywords: Gestational diabetes, snack, teenage years, Japan Environment and Children’s study

Posted Date: October 26th, 2021

DOI: https://doi.org/10.21203/rs.3.rs-962177/v1

License: This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License

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AbstractBackground: Dietary habits and weight control before pregnancy are important in preventing gestationaldiabetes. This study aims to examine whether the weight-loss behavior of avoiding between meal andmidnight snacks in teenagers is associated with subsequent gestational diabetes mellitus (GDM).

Methods: A total of 89,227 (85.7% of the total) mother-infant pairs of live births were included in ourstudy of the Japan Environment and Children's Study (JECS). In the second or third trimesters,participants were asked to report their weight-loss behaviors during their teenage years. Response itemsincluded avoidance of meals and midnight snacking. The main outcome of our study was the prevalenceof GDM.

Results: Overall, 2,066 (2.3%) participants had GDM. Relative to those without GDM, women with GDMwere older, were smokers, had a higher prevalence of hypertension, previous cesarean delivery, mentalillness, and higher body mass index (BMI). Weight-loss behavior in their teenage years was associatedwith a decreased risk of GDM (unadjusted crude odds ratio, 0.83; 95% con�dence interval [CI]: 0.76–0.91),model 1 (adjusted odds ratio [aOR], 0.86; 95% CI: 0.79–0.94), and model 2 (aOR, 0.80; 95% CI: 0.73–0.88).Weight-loss behavior in teens was associated with a decreased risk of GDM in the normal weight [aOR,0.79; 95% CI: 0.70–0.89) and overweight (aOR, 0.82; 95% CI: 0.69–0.98) groups.

Conclusions: The results suggest that weight-loss behaviors of avoiding in-between meals and midnightsnacking as teenagers are associated with a decreased risk of developing GDM.

BackgroundGestational diabetes mellitus (GDM) is caused by an abnormality in glucose metabolism (1) resulting inthe inability to control blood glucose levels during pregnancy (2). Blood glucose levels should bemeasured at any time during the �rst and second trimester of pregnancy, and if the blood glucose levelsare high, a glucose tolerance test should be performed to make the diagnosis of GDM (3). The treatmentof GDM is based on using dietary therapy to control blood sugar levels. To avoid a sudden increase inblood glucose levels due to the intake of too many calories at one time, it is recommended that patientsdiagnosed with GDM eat six small meals a day (three main meals and three in-between) (4).

It is di�cult to change pre-pregnancy eating habits, and the establishment of healthy eating habits beforepregnancy is important for the prevention of GDM (5). Previous studies have shown that the eating habitsof teenagers in�uence their eating habits in adulthood. Eating habits are established through daily dietaryhabits (6). Poor eating habits include skipping breakfast, fast eating, picky eating, midnight snacking, andexcessive snacking. Family eating habits in�uence the establishment of healthy eating habits in children(7, 8). Therefore, to establish healthy eating habits, various efforts are being made targeting children at ayoung age in Japan (9).

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Between meal and midnight snacks are a way of compensating for a low-calorie intake which can causefatigue. However, these snacks can lead to obesity and overweight, depending on the way that they areconsumed (10). Consumption can be managed by setting a time, eating moderate amounts, and avoidinghigh fat, high-calorie foods (11).

Excessive weight-loss behavior has been linked to psychological dysregulation. Gowey (12) hassuggested that psychological dysregulation is associated with a greater body mass index (BMI),problematic eating patterns and behaviors, and body dissatisfaction, especially in adolescents and youngadults. To the best of our knowledge, no studies have investigated the association between teenageweight-loss behavior and GDM.

Dietary habits (13) and weight control before pregnancy (14) are important in preventing GDM. Thus, thisstudy aims to examine whether an association exists between eating habits in teenagers and subsequentGDM.

Methods

Study design and settingThis study used a dataset (jecs-an-20180131) from a nationwide, prospective birth cohort study, theJapan Environment and Children's Study (JECS). The detailed protocol and baseline information ofparticipants have been previously reported (15, 16). As a brief description, approximately 100,000pregnant women living in Study Areas were recruited during early pregnancy at Co-operating health careproviders or at local government o�ces between January 2011 and March 2014. The JECS protocol wasreviewed and approved by the Ministry of the Environment’s Institutional Review Board onEpidemiological Studies and the Ethics Committees of all participating institutions. Participants will befollowed up until the participating children reach 13 years of age. Eligibility was considered if a pregnantwoman was (1) residing in a Study Area at the time of recruitment and was expected to reside continuallyin Japan; (2) expected to give birth between August 1, 2011, and mid-2014; and (3) capable ofunderstanding the Japanese language and completing the self-administered questionnaires. The JECScollected demographic data and clinical and obstetric information through self-administeredquestionnaires or medical record transcripts. The questionnaires were distributed during the �rst trimesterand second or third trimesters. Written informed consent was obtained from all study participants.

Study populationThe dataset comprised 104,065 fetal records. In our analyses, we excluded participants with a history ofstillbirth or missing birth status (n = 3,921), multiple gestations (n = 1,889); multiple pregnancies (n =5,465), under 20 years old (n = 1,132), who did not report weight-loss behavior during their teenage years(n=1,643), with biologically implausible weight values measured before delivery (n = 4), and with a historyof type 1, type 2, or gestational diabetes mellitus (n = 784). Subsequently, 89,227 (85.7%) mother-infantpairs of live births were included in our study (Figure 1).

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Pregnant women’s weight-loss behavior during teensIn the second or third trimester, participants were asked to report their dietary behaviors during theirteenage years. Response items included avoiding between-meal and midnight snacks.

Outcome measurementsThe main outcome of our study was GDM. GDM cases were identi�ed using medical record transcripts,which were completed after delivery by physicians, Research Co-ordinators, midwives, nurses, or doctors.

Other variablesThe JECS questionnaire and the records of Co-operating health care providers were used as possibleadjustment factors. Maternal characteristics including maternal age, educational level, total energy intake(kcal/d), daily physical activity, smoking habit, alcohol consumption, marital status, and past medicalhistory were obtained through the �rst and second waves of the questionnaires. Information on maternalage, height and weight, parity, and previous cesarean delivery were retrieved from medical records.

Daily energy intake during pregnancy (kcal/d) was calculated based on the information collected throughself-reported food frequency questionnaires (FFQ) (17) and used to form three groups (tertiles) with anapproximately equal number of participants.

Daily physical activity during pregnancy was obtained using the shortened Japanese version of theInternational Physical Activity Questionnaires, which considers all types of activities, including work-related and leisure-time activities and household chores (18, 19). We calculated metabolic equivalentminutes per day (MET-mins/day) and categorized it into three physical activity levels (tertiles).

Maternal age was divided into two groups: 20–34 years and ≥35 years. Pre-pregnancy BMI wascalculated as self-reported pre-pregnancy weight in kilograms divided by height in meters squared andstrati�ed into underweight (<18.5 kg/m2), normal weight (18.5–24.9 kg/m2), and overweight (≥25 kg/m2)according to the Guidelines for Obstetrical Practice in Japan (20). Smoking habits were categorized intothree groups: never smoked, quit (before or after becoming pregnant), or currently smoking. Other factorsincluded educational level (high school or less, vocational school/college, university or higher), parity (0,1, 2, or more), alcohol consumption (never, quit, currently drinking), history of medical conditions(hypertension, mental illness, etc.), and previous cesarean delivery.

Ethics statementThe JECS protocol was approved by the Institutional Review Board on Epidemiological Studies of theMinis- try of the Environment and by the ethics committees of all participating institutions. This was alsoconducted in accordance with the Declaration of Helsinki and other nationally valid regulations. Writteninformed consent was obtained from all participants.

Statistical analyses

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GDM group differences concerning maternal characteristics were examined using the chi-squared test forcategorical variables. We then constructed crude and adjusted logistic regression models to assess theassociations of behavior with weight-loss behaviors of avoiding between meal and midnight snack inteens. In the adjusted model 1, we included the following maternal characteristics considered to be thedeterminants of group membership: maternal age, educational level, total energy intake, physical activity,smoking, alcohol consumption, marital status, parity, past medical history, history of hypertension,pregnancy hypertension mental illness, and previous cesarean delivery. In the adjusted model 2, weincluded model 1 plus BMI, with a 95% con�dence interval (CI). We then performed subgroup analyses ofadjusted logistic regression analysis by BMI category. A two-tailed p-value <0.05 was consideredstatistically signi�cant. All analyses were performed using Stata/MP 16.1 software (StataCorp., CollegeStation, TX, USA).

Results

Characteristics of women with gestational diabetesThe maternal characteristics and study outcomes of women with GDM are summarized in Table 1.Overall, 2,066 (2.3%) participants were diagnosed with GDM. Women with GDM were older, smokers, hada higher prevalence of pre-pregnancy hypertension, pregnancy hypertension, previous cesarean delivery,mental illness, and an elevated BMI. The group with GDM had predominantly less weight-loss behavior inteens than the group without GDM. Half of the participants reported weight-loss behaviors of avoidingbetween meal and midnight snack in teens.

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Table 1Characteristics of women with GDM (N = 89,227)

  All GDM no-GDM

  89,227 2,066 (2.3) 87,161 (97.7)

  n (%)

Maternal age, years      

20–34 67,433 (75.6) 1,221 (59.1) 66,212 (76.0)

≥35 21,778 (24.4) 845 (40.9) 20,933 (24.0)

Missing 16 (0.0) (0.0) 16 (0.0)

Educational level      

High school or less 31,433 (35.2) 744 (36.0) 30,689 (35.2)

Vocational school/College 37,759 (42.3) 883 (42.7) 36,876 (42.3)

University or higher 19,531 (21.9) 425 (20.6) 19,106 (21.9)

Missing 504 (0.6) 14 (0.7) 490 (0.6)

Total energy intake, kcal/d      

1st (lowest tertile) 29,671 (33.3) 667 (32.3) 29,004 (33.3)

2nd 29,596 (33.2) 670 (32.4) 28,926 (33.2)

3rd 29,502 (33.1) 716 (34.7) 28,786 (33.0)

Missing 458 (0.5) 13 (0.6) 445 (0.5)

Physical activity, MET-mins/d      

1st (lowest tertile) 30,727 (34.4) 714 (34.6) 30,013 (34.4)

2nd 27,466 (30.8) 659 (31.9) 26,807 (30.8)

3rd 28,914 (32.4) 646 (31.3) 28,268 (32.4)

Missing 2,120 (2.4) 47 (2.3) 2,073 (2.4)

Smoking      

Never smoked 51,560 (57.8) 1,132 (54.8) 50,428 (57.9)

Quit smoking 32,454 (36.4) 790 (38.2) 31,664 (36.3)

BMI, body mass index;

P-values are the results of Chi square test

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  All GDM no-GDM

Currently smoking 4,128 (4.6) 118 (5.7) 4,010 (4.6)

Missing 1,085 (1.2) 26 (1.3) 1,059 (1.2)

Alcohol      

Never drank 30,264 (33.9) 757 (36.6) 29,507 (33.9)

Quit drinking 49,132 (55.1) 1,088 (52.7) 48,044 (55.1)

Currently drinking 8,992 (10.1) 195 (9.4) 8,797 (10.1)

Missing 839 (0.9) 26 (1.3) 813 (0.9)

Single mother 3,597 (4.0) 85 (4.1) 3,512 (4.0)

Parity      

0 36,715 (41.2) 867 (42.0) 35,848 (41.1)

1 32,779 (36.7) 749 (36.3) 32,030 (36.8)

2 or more 17,545 (19.7) 407 (19.7) 17,138 (19.7)

Missing 2,188 (2.5) 43 (2.1) 2,145 (2.5)

Past medical history      

Pre-pregnancy hypertension (yes) 2,059 (2.3) 91 (4.4) 1,968 (2.3)

Pregnancy hypertension (yes) 844 (1.0) 46 (2.2) 798 (0.9)

Mother's mental illness (yes) 7,086 (7.9) 186 (9.0) 6,900 (7.9)

Previous cesarean delivery (yes) 6,978 (7.8) 262 (12.7) 6,716 (7.7)

BMI categories, kg/m2      

<18.5 14,435 (16.2) 212 (10.3) 14,223 (16.3)

18.5–24.9 65,475 (73.4) 1,253 (60.7) 64,222 (73.7)

≥25 9,259 (10.4) 598 (28.9) 8,661 (9.9)

Missing 58 (0.1) 3 (0.2) 55 (0.1)

Weight-loss behaviors in teens      

Avoiding between meal and midnight snack 44,455 (49.8) 936 (45.3) 43,519 (49.9)

BMI, body mass index;

P-values are the results of Chi square test

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Association between avoiding between meal and midnightsnack and gestational diabetesThe results of the logistic regression analysis are presented in Table 2. Weight-loss behavior in teens wasassociated with a decreased risk of GDM [unadjusted crude odds ratio 0.83 (95% CI 0.76–0.91), model 1adjusted odds ratio (aOR) 0.86 (95% CI 0.79–0.94), and model 2 aOR 0.80 (95% CI 0.73–0.88)].

Table 2Weight-loss behaviors of avoiding between meal and midnight snack in teens linked to GDM (N = 89,227)

    Model 1 Model 2

  crude OR 95%CI

aOR 95% CI aOR 95% CI

Avoiding between meal and midnightsnack

0.83 (0.76-0.91) 0.86 (0.79-0.94)

0.80 (0.73-0.88)

Note: Bold font indicates signi�cant result.

Model 1: Adjusted for maternal age, educational level, total energy intake, physical activity, smokingduring pregnancy, alcohol consumption, marital status, parity, pre-pregnancy hypertension, pregnancyhypertension, mental illness, and previous cesarean delivery.

Model 2: Adjusted for model 1 plus BMI; CI, con�dence interval; OR, odds ratio

Association between avoiding between meal and midnightsnack and gestational diabetes by BMI categoryThe results of the crude and adjusted logistic regression analyzing the association between weight-lossbehavior and GDM by BMI category are presented in Table 3. Weight-loss behavior in teens wasassociated with a decreased risk of GDM in the normal weight [aOR 0.79 (95% CI 0.70–0.89)] andoverweight [aOR 0.82 (95% CI 0.69–0.98)] groups. No association was found in the underweight group[aOR 0.87 (95% CI 0.65–1.18)].

Table 3Weight-loss behaviors of avoiding between meal and midnight snack in teens by BMI category

associated with GDM (N = 89,227)

  Underweight Normal weight Overweight

  aOR 95% CI aOR 95% CI aOR 95% CI

Avoiding between meal and midnight snack 0.87 (0.65-1.18) 0.79 (0.70-0.89) 0.82 (0.69-0.98)

Note: Bold font indicates signi�cant result.

Adjusted for maternal age, educational level, total energy intake, physical activity, smoking duringpregnancy, alcohol consumption, marital status, parity, pre-pregnancy hypertension, pregnancy

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hypertension, mental illness, and previous cesarean delivery.

CI, con�dence interval; OR, odds ratio

DiscussionThe study is unique in that it analyzed the teenage weight-loss behaviors of avoiding between meal andmidnight snacking. About half of the respondents chose “avoiding eating between meals and having amidnight snack” as a dietary behavior during their teenage years. It is very important to develop a dietthat includes three solid meals and not too many snacks (11, 21). It has been reported that eating toomany snacks prevents the body from getting minerals, �bers, and other nutrients that would otherwise beavailable with a healthy meal (22, 23). It is said that forming habits from an early age are central to thedevelopment of regular and healthy eating habits (24, 25). It is important to approach the parents as theyin�uence their teenagers' eating habits (7) (8). However, parents do not always have a clearunderstanding of their children's diet and lifestyle (26). From the perspective of gestational maternalmanagement, we believe that it is very important to acquire correct knowledge about diet from teenagers(27). In the future, we will be required to obtain information on snack intake and nutrition, incorporate itinto our daily lives, and make decisions for ourselves (28).

In this study, we focused on " avoiding between meal and midnight snacks " in teenagers. Although eatinghabits are ingrained in us from an early age, teenagers inevitably make more independent choices abouttheir meals and snacks (29). Teenagers are more likely to spend their allowance freely and withautonomy. They also tend to spend more of their allowance on snacks (30). Snacking not only providespeople with nutrients that they cannot obtain through food alone, but it also serves as a refreshingchange of pace from work or study and gives a sense of well-being. Sweet food satis�es people's desireto eat, and for those who like sweet food, eating sweet food is an emotional experience. However, thereare various risks associated with eating too much sweet food. A previous study has shown that too muchadded sugar can put an undue strain on the heart, regardless of whether a person is obese or not (31, 32).Additionally, sugar is one of the main causes of weight gain. It has been reported that sugar is addictive,and once a person consumes a high-calorie food (21), he or she craves more, which leads to extra calorieintake and weight gain. It is very important to control one's sugar cravings from the teenage years.

GDM is caused by a genetic predisposition to type 2 diabetes (33) and insulin resistance duringpregnancy (34) (especially in the second or third trimesters of pregnancy). In healthy individuals,maternal pancreatic beta cells become hypertrophic and hyperplastic in response to insulin resistance,thereby enhancing insulin secretion. Insulin resistance is caused by the breakdown of insulin in theplacenta and a decrease in adiponectin levels (34). In addition, overeating and obesity may increase therisk of GDM (35). The other risk factors that predispose to GDM include a family history of diabetes (36),obesity (37), high body mass index (BMI) (38), older age (>35 years) (38), gestational hypertension, ahistory of delivery of a large-for-gestational-age (LGA) baby, unexplained habitual preterm labor,unexplained perinatal death, and delivery of a congenitally malformed baby. Gestational diabetes can

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lead to complications in both infants and mothers. Maternal complications of diabetes includegestational hypertension, abnormal amniotic �uid volume, shoulder dystocia, and retinopathy, while fetaland neonatal complications include miscarriage, morphological abnormalities, giant babies, enlargedheart, hypoglycemia, polycythemia, electrolyte abnormalities, jaundice, and fetal death. To the best of ourknowledge, this is the �rst study to show that eating behavior from the teenage years is associated withgestational diabetes. To avoid developing GDM, it is important to have a diet that avoids between mealand midnight snacks and does not lead to overweight and obesity.

The main strengths of our study include the large sample size, which is representative of pregnantwomen in Japan, comprehensive information about maternal diet, and a wide range of potentialconfounding factors which were adjusted for in the models. Our study had some potential limitations. Forexample, owing to our exclusion criteria, our subject represented only full-term, live-born, singletons.Another potential limitation might be that our analyses relied solely on dietary information collected at asingle time-point during pregnancy and the dietary intake could have changed at different pregnancystages. However, a previous study reported no signi�cant changes in dietary intake among pregnantJapanese women (39). The energy from FFQ may not re�ect actual energy intake and may result inunder- or over-reporting (40, 41). However, our analyses examined energy intake on ordinal scales, and theFFQ is a validated tool for grouping pregnant women according to high- or low-level energy intake at thepopulation level (41). Additionally, the questionnaires used to assess diet behaviors during teenage yearswere not validated. However, while there are several other questions related to weight gain as a teenager,the questions used in our study are the more common actions taken to lose weight. Moreover, ouranalysis was adjusted for many confounders, although there may be others. There was a long timebetween questionnaire and response owing to the exclusion of teenagers, which may have introducedrecall bias. Furthermore, we were unable to adjust for a family history of gestational diabetes.

ConclusionThe results suggest that weight-loss behaviors of avoiding between meal and midnight snacking asteenagers are associated with a decreased risk of developing GDM. It is important to establishappropriate snack eating habits at an early age and to acquire the correct knowledge on snacking in thedietary management of pregnancy.

AbbreviationsaOR, adjusted odds ratio

BMI, Body Mass Index

CI, Con�dence Interval

FFQ, Food Frequency Questionnaires

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GDM, Gestational diabetes mellitus

JECS, Japan Environment and Children's Study

MET-mins/day, Metabolic Equivalent Minutes per Day

DeclarationsEthics approval and Consent to Participate: The JECS protocol was approved by the Institutional ReviewBoard on Epidemiological Studies of the Ministry of the Environment and by the ethics committees of allthe participating institutions, i.e., the National Institute for Environmental Studies, the National Center forChild Health and Develop‐ ment, Hokkaido University, Sapporo Medical University, Asahikawa Medi‐ calUniversity, Japanese Red Cross Hokkaido College of Nursing, Tohoku University, Fukushima MedicalUniversity, Chiba University, Yokohama City University, University of Yamanashi, Shinshu University,University of Toyama, Nagoya City University, Kyoto University, Doshisha University, Osaka University,Osaka Medical Center and Research Institute for Maternal and Child Health, Hyogo College of Medicine,Tottori University, Kochi University, University of Occupational and Environmental University, KyushuUniversity, Kumamoto University, University of Miyazaki, and University of the Ryukyus. The JECS wasconducted in accordance with the Declaration of Helsinki and other nationally valid regulations. Writteninformed consent was obtained from all participat‐ ing mothers.

Funding: This study was funded by the Ministry of the Environment, Japan. The �ndings and conclusionsof this article are solely the responsibility of the authors and do not represent the o�cial views of theabove government.

Competing interests: The authors declare that they have no competing interests.

Consent for publication: Not applicable

Availability of data and materials: Data are unsuitable for public deposition because of ethicalconsiderations and restrictions as per legal framework of Japan. It is prohibited by the Act on theProtection of Personal Information (Act No. 57 of 30 May 2003, amended on 9 September 2015) topublicly deposit data containing personal information. Ethical Guidelines for Medical and HealthResearch Involving Human Subjects, enforced by the Japan Ministry of Education, Culture, Sports,Science and Technology and the Ministry of Health, Labour and Welfare, also restricts the open sharingof epidemiologic data. All inquiries about access to data should be addressed Dr. Shoji F. Nakayama,JECS Programme O�ce, National Institute for Environmental Studies, at jecs-en@nies.go.jp. 

Author contributions: Conceptualization, Methodology: MM; Formal analysis and interpretation: MM, TW,ME, NM, MF, and NS; Writing Original draft: MM and NS; Critical revision of the manuscript: MM, TW, ME,NM, MF, NS, and JECS group. All authors have read and approved the �nal manuscript.

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Acknowledgments: The authors are grateful to all the participants in the study. We thank all staffmembers of the JECS. This study was funded by the Ministry of the Environment, Japan. The �ndingsand conclusions of this article are solely the responsibility of the authors and do not represent the o�cialviews of the above government. Members of the JECS Group as of 2021: Michihiro Kamijima (principalinvestigator, Nagoya City University, Nagoya, Japan), Shin Yamazaki (National Institute for EnvironmentalStudies, Tsukuba, Japan), Yukihiro Ohya (National Center for Child Health and Development, Tokyo,Japan), Reiko Kishi (Hokkaido University, Sapporo, Japan), Nobuo Yaegashi (Tohoku University, Sendai,Japan), Koichi Hashimoto (Fukushima Medical University, Fukushima, Japan), Chisato Mori (ChibaUniversity, Chiba, Japan), Shuichi Ito (Yokohama City University, Yokohama, Japan), Zentaro Yamagata(University of Yamanashi, Chuo, Japan), Hidekuni Inadera (University of Toyama, Toyama, Japan), TakeoNakayama (Kyoto University, Kyoto, Japan), Hiroyasu Iso (Osaka University, Suita, Japan), MasayukiShima (Hyogo College of Medicine, Nishinomiya, Japan), Youichi Kurozawa (Tottori University, Yonago,Japan), Narufumi Suganuma (Kochi University, Nankoku, Japan), Koichi Kusuhara (University ofOccupational and Environmental Health, Kitakyushu, Japan), and Takahiko Katoh (Kumamoto University,Kumamoto, Japan). We also acknowledge all members of the Environmental Medicine Department ofKochi University for their support.

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Figures

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Figure 1

Flowchart for selection of participants from JECS JECS = Japan Environment and Children’s Study