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BACKGROUND: This study aims to investigate age- and gender-specific effects of household solid fuels for heating on major depression and buffering effects of outdoor time in a high-income country. METHODS: Data were obtained from the UK Biobank. Participants with complete information on our studied variables and no prior diagnosis of major depression at baseline were included. Cox proportional hazards regression models were used to examine the effects of household solid fuels for heating on major depression. Subgroup analyses were conducted to investigate the buffering effects of outdoor time in summer and winter. Sensitivity analyses were performed to test the robustness of the main findings. RESULTS: Of 255,505 participants (50.2 % women), the 12-year cumulative incidence of major depression was 4.4 %. Household solid fuels for heating increased the risk of major depression only in women aged <45 years (HR (95%CI) = 1.30 (1.04, 1.63)). In this group, the solid fuel effect was moderated by outdoor time spending both in summer (HR (95%CI), ≤2 h/day: 1.61 (1.13, 2.28); >2 h/day: 1.13 (0.84, 1.52)) and winter (≤1 h/day: 1.35 (1.01, 1.08); >1 h/day: 1.24 (0.86, 1.77)). LIMITATIONS: Self-reported measures might lead to recall bias and some potential confounders, such as ventilation efficiency, were not measured and controlled in data analyses. CONCLUSIONS: Younger women are more vulnerable to the impact of domestic air pollution on major depression. Promoting outdoor activities is a cost-effective and efficient approach to mitigating the risk of major depression caused by household solid fuels.

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According to a NIH study, Lung cancer among individuals who have never smoked is more prevalent in women and occurs at an earlier age than in smokers. The rise in lung cancer rates among female non-smokers might be linked to radon inhalation and should be further investigated. Our theory is based on the differences in radon exposure between males and females, which can be attributed to the variations in time spent indoors versus outdoors. Over the past few years, the smoking rates have shown a steady decline in the United States and other developed countries. This decrease in smoking prevalence has led to a new shift in the primary risk factors associated with lung cancer. Although tobacco smoke historically served as the primary cause of lung cancer, the reduction in smoking rates has allowed other risk factors, such as radon exposure, to come to the forefront. Given that women in certain countries, on average, might spend more time indoors compared to men, they are potentially exposed to higher levels of radon. This increased exposure could explain the rising rates of lung cancer among female non-smokers. The theory is still in its nascent stages and requires further research and validation. However, if proven correct, it could significantly alter our understanding of lung cancer risk factors and lead to new prevention. It is therefore crucial to expedite the review and publication of this theory, given its potential implications for public health.

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Young children's physical activity (PA) has been decreasing while their sports participation has been increasing. Therefore, the aim of this research was to longitudinally examine whether and, if so, how organised and non-organised PA participation by early childhood education and care (ECEC)-aged children (T1; 3-8 years) predicted their accelerometer-measured PA at primary school age (T2; 7-11 years). Secondarily, changes in organised and non-organised PA participation over time were investigated. The cluster-randomised study participants comprised 501 Finnish children (52.3% girls: T1, Mage = 5.57 ± 1.06; T2, Mage = 8.80 ± 1.07). PA participation was queried via guardian questionnaire at T1 and T2. Organised PA participation was operationalised as non-participation, participation in one sport or multisport (two or more) participation; non-organised PA was operationalised as time spent outdoors on weekdays and on weekend days. PA at T2 was measured using accelerometers. The primary outcome was tested using linear regressions, while a paired sample t-test and Mann-Whitney U test assessed differences between T1 and T2. The results showed outdoor time and organised sports participation increased from T1 to T2. Moreover, outdoor time at T1 predicted more moderate-to-vigorous PA (MVPA) and less sedentary time at T2, while multisport participation predicted significantly more MVPA and less sedentary time at T2. Overall, being outdoors and multisport participation at younger ages appear to have predicted Finnish children's later (MV) PA and sedentary behaviour.

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Objective: To investigate the association between dietary and some other environmental factors and the risk of inflammatory bowel diseases (IBD) in Chinese population. Materials and methods: A multicenter case-control study was conducted involving 11 hospitals across China. A total of 1,230 subjects were enrolled consecutively, and diet and environmental factor questionnaires were collected. IBD patients were matched with healthy controls (HC) using propensity-score matching (PSM) at a 1:1 ratio with a caliper value of 0.02. Multivariate conditional logistic regression analyses were performed to evaluate the associations between diet, environmental factors, and IBD. Results: Moderate alcohol and milk consumption, as well as daily intake of fresh fruit, were protective factors for both Crohn's disease (CD) and ulcerative colitis (UC). Conversely, the consumption of eggs and chocolate increased the risk of IBD. Outdoor time for more than 25% of the day was a protective factor only for CD. In eastern regions of China, CD patients had higher egg consumption and less outdoor time, while UC patients consumed more chocolate. IBD patients from urban areas or with higher per capita monthly income consumed more fruit, eggs, and chocolate. Conclusions: This study reveals an association between specific foods, outdoor time, and the emergence of IBD in the Chinese population. The findings emphasize the importance of a balanced diet, sufficient outdoor time and activities, and tailored prevention strategies considering regional variations.

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INTRODUCTION: Spending more time outdoors was treated as a safe and cost-effective method to prevent and control myopia. While prior research has established an inverse association between outdoor time and the risk of myopia onset, the effect of increasing outdoor time in delaying the progression of myopia remains a subject of debate. The present meta-analysis aimed to assess the relationship between outdoor time and the myopia onset, and further examine whether there is a dose-response relationship between outdoor time and the risk of myopia onset. Meanwhile, perform whether the outdoor time is related to delaying the progression of myopia. METHODS: Studies were retrieved from PubMed, Web of Science, Embase, Medline, and the Cochrane Database, spanning from their inception to February 2023. Three cohort studies and 5 prospective intervention studies were included, with a total of 12,922 participants aged 6-16 years. RESULTS: Comparing the highest with the lowest exposure levels of time spent outdoors, the highest outdoor time was strongly associated with a reduced risk of myopia onset (odds ratio [OR]: 0.53; 95% confidence interval [CI]: 0.34, 0.82). A nonlinear dose-response relationship was found between outdoor time and myopia onset risk. Compared to 3.5 h of outdoor time per week, an increase to 7, 16.3, and 27 h per week corresponded with a respective reduction in the risk of myopia onset by 20%, 53%, and 69%. Among children and adolescents who were not myopic, spending more time outdoors significantly slowed down the speed of change in spherical equivalent refractive (weighted mean difference [WMD] = 0.10D, 95% CI: 0.07, 0.14) and axial length (WMD = -0.05 mm, 95% CI: -0.06, -0.03). Among children and adolescents who were already myopic, spending more time outdoors did not slow myopia progression. CONCLUSIONS: Overall, spending more time outdoors can prevent the onset of myopia, but it does not seem to slow its progression. Further studies are needed to better understand these trends.

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What is already known about this topic?: Myopia has been identified as a significant emerging challenge and policy priority among children and adolescents in China by the Ministry of Education and seven other departments. Limited research has been conducted to investigate the collective impact of outdoor time and other modifiable factors on the incidence of myopia. What is added by this report?: This study provides support for the protective effect of combining increased outdoor time with other prevention strategies in reducing the incidence of myopia. The results indicate the presence of a dose-response relationship. What are the implications for public health practice?: To effectively prevent myopia, it is important to implement comprehensive interventions that encompass various aspects such as outdoor time, eye-use habits, eye-use environments, and lifestyle modifications.

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This study explores whether children's refractive errors and visual behaviors reverted to pre-COVID-19 levels a year after normal schooling resumed in Hong Kong as well as the impact of corneal and internal astigmatism on refractive astigmatism development. Vision survey data and questionnaire results collected in 2022 (n = 119) and 2020 (n = 173) were compared. Cross-sectional data showed similar proportions of astigmatism (cylindrical power ≥ 0.75 D) in the 2020 (49.1%) and 2022 cohorts (55.5%). Despite a 0.28 D increase in corneal astigmatism, a compensatory 0.24 D increase in internal astigmatism of opposite direction kept refractive astigmatism relatively stable. The questionnaire data showed that children spent an additional 0.5 h/day outdoors on weekends post-resumption of normal schooling but engaged in more near-work activities, especially non-screen near-work, by approximately 1 h/day on both weekdays and weekends. These findings were supported by longitudinal data from 72 children who participated in both surveys. This study highlights the significant role of corneal and internal astigmatism in refractive astigmatism changes. Despite the return to in-person classes, children's total near-work time increased and astigmatism remained high. These findings underscore the need for comprehensive strategies to reduce the high environmental risks for refractive error development in children.

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BACKGROUND: Myopia, commonly known as near-sightedness, has emerged as a global epidemic, impacting almost one in three individuals across the world. The increasing prevalence of myopia during early childhood has heightened the risk of developing high myopia and related sight-threatening eye conditions in adulthood. This surge in myopia rates, occurring within a relatively stable genetic framework, underscores the profound influence of environmental and lifestyle factors on this condition. In this comprehensive narrative review, we shed light on both established and potential environmental and lifestyle contributors that affect the development and progression of myopia. MAIN BODY: Epidemiological and interventional research has consistently revealed a compelling connection between increased outdoor time and a decreased risk of myopia in children. This protective effect may primarily be attributed to exposure to the characteristics of natural light (i.e., sunlight) and the release of retinal dopamine. Conversely, irrespective of outdoor time, excessive engagement in near work can further worsen the onset of myopia. While the exact mechanisms behind this exacerbation are not fully comprehended, it appears to involve shifts in relative peripheral refraction, the overstimulation of accommodation, or a complex interplay of these factors, leading to issues like retinal image defocus, blur, and chromatic aberration. Other potential factors like the spatial frequency of the visual environment, circadian rhythm, sleep, nutrition, smoking, socio-economic status, and education have debatable independent influences on myopia development. CONCLUSION: The environment exerts a significant influence on the development and progression of myopia. Improving the modifiable key environmental predictors like time spent outdoors and engagement in near work can prevent or slow the progression of myopia. The intricate connections between lifestyle and environmental factors often obscure research findings, making it challenging to disentangle their individual effects. This complexity underscores the necessity for prospective studies that employ objective assessments, such as quantifying light exposure and near work, among others. These studies are crucial for gaining a more comprehensive understanding of how various environmental factors can be modified to prevent or slow the progression of myopia.

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A growing body of literature suggests that outdoor time is beneficial for physical and mental health in childhood. Profound disparities exist in access to outdoor spaces (and the health benefits thereof) for children in communities of color. The objectives of this research were to: (1) identify challenges and solutions to outdoor time for children; (2) assess the importance of outdoor time for children; and (3) evaluate results stratified by race/ethnicity. Using a convergent mixed methods approach, we conducted a thematic analysis from 14 focus groups (n = 50) with outdoor educators, parents with children attending outdoor preschools, and community members with children. In addition, 49 participants completed a survey to identify challenges and solutions, perceived importance, and culturally relevant perspectives of outdoor time. The main challenges identified for outdoor time were safety concerns, inclement weather, lack of access to outdoor spaces, and parent work schedules. The primary proposed solution was integrating outdoor time into the school day. Nearly all participants, independent of racial identity, reported that outdoor time improved physical and mental health. Overall outdoor time was lower in participants from communities of color (~8 h/week) compared to their White counterparts (~10 h/week). While 50% of people of color (POC) reported that outdoor time was an important cultural value, only 18% reported that people in their respective culture spent time outside. This work contributes to accumulating knowledge that unique barriers to outdoor time exist for communities of color, and the children that live, learn, and play in these communities. Increasing outdoor time in school settings offers a potential solution to reduce identified barriers and to promote health equity in childhood.

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Significance: Myopia holds significant public health concern given its social, ocular disease and economic burdens. Although environmental factors are primarily to blame for the rapid rise in prevalence, key risk factors remain unresolved. Purpose: The aim of this study was to objectively characterize, using a wearable technology, the temporal indoor and outdoor behavioral patterns and associated environmental lighting characteristics of young myopic and nonmyopic University students. Methods: Participants were recruited to continuously wear an Actiwatch for 3 weeks, during either or both academic and non-academic periods. The device allows continuous recording of activity and incident light. Recorded illuminance levels were used as a proxy for outdoors (>1,000 lux), with the dynamics (interval frequency and duration) of indoor and outdoor activities, as well as lighting characteristics derived. In addition, participant input regarding near work was obtained daily. Participants were classified by both myopia and axial length status (based on collected refractive error and biometry data) for the purpose of data analysis. Result: A total of 55 students, aged 18 to 25 years of age, participated. Overall, the dosing of indoor and outdoor activities was similar across participants, regardless of myopia status, during the academic period. Nonetheless, an apparent difference in the timing of outdoor activities was noted with myopes going outdoors later in the day, particularly during the weekend (p = 0.03). While a trend was observed between increased lighting levels experienced outdoors and shorter axial lengths, there was no significant relationship with myopia status. Noteworthy, participants generally significantly overestimated time spent outdoors, compared to Actiwatch-derived estimates of the same. Conclusion: While the findings from this cohort of young adult students did not reveal substantial myopia-related differences in behavior, the power of a more objective and dynamic approach to quantifying behavior cannot be understated, providing argument for general adoption of wearable technologies in future clinical myopia studies.

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The study aimed to investigate the impact of COVID-19 restrictions on children's access to the outdoors in early childhood education and care (ECEC) settings. An online survey comprised of a standardised scale and questions used in previous related studies was completed by 143 early childhood educators across Australia. Participants were asked to report children's time spent outdoors, access to outdoor space, and restrictions imposed on children's play during the pandemic compared to the pre-pandemic period. The survey responses were imported into SPSS for descriptive, correlation, and ordinal regression analyses. We examined the relationship between children's outdoor time, space, restrictions imposed on children's play, and educators' characteristics, such as qualifications, professional development, and tolerance of risk or staff-child ratios during the pandemic in Australia. Most educators reported that children's outdoor time and access to outdoor space remained the same compared to before the pandemic, while imposed restrictions on children's outdoor play increased. The results of ordinal regressions indicated that educators with a higher tolerance of risk were less likely to impose additional restrictions on children's outdoor play. The findings contribute to the understanding of how educators' tolerance of risk influences children's outdoor play opportunities and provide directions for future risk-reframing interventions.

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Myopia has become a global epidemic with significant public health impacts. Identifying the child at risk of developing myopia, i.e. the pre-myopic child and implementing strategies to prevent the onset of myopia, could significantly reduce the burden of myopia on an individual and society. This paper is a review of publications that have identified ocular characteristics of children at risk of future myopia development including a lower than age normal amount of hyperopia and accelerated axial length elongation. Risk factors associated with increased risk of myopia development such as education exposure and reduced outdoor time, and strategies that could be implemented to prevent myopia onset in children are also explored. The strong causal role of education and outdoor time on myopia development suggests that lifestyle modifications could be implemented as preventative measures to at-risk children and may significantly impact the myopia epidemic by preventing or delaying myopia onset and its associated ocular health consequences.

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Objective: Low levels of outdoor activity are known to be an important risk factor for the development of myopia in schoolchildren. This study aimed to determine outdoor and near work patterns in Polish schoolchildren before and during school closure due to the SARS-CoV-2 pandemic. Methods: All children undergoing a routine pediatric examination in the Elblag branch of the Hygeia Clinic, together with their parents, were asked to fill an anonymous questionnaire. The subject's age, spherical equivalent (SE) refractive error, time spent outdoors, screen time and total near work in hours per day before and during the pandemic, were recorded. As substantial differences in physical activity by time of year were reported, activity patterns for June (summer) and December (winter) were recorded. Multiple logistic regression analysis was used to analyze the association between the presence of myopia and outdoor and total near work time at different timepoints. Results: A total of 61 schoolchildren aged 11.95 ± 2.74 (range 7 to 17) years were included in this study. The mean SE in the right eye was -1.78 ± 2.11 with 46% of the individuals (n=28) classified as myopic. Before the pandemic, higher time outdoors was associated with less myopic SE (OR=0.47, 95% Confidence Interval [CI] 0.24 to 0.93). During the pandemic, time outdoors among non-myopic children was similar to myopic children, both during winter and summer months (2.18 ± 1.81 vs. 1.89 ± 1.50; P=.51, and 3.47 ± 2.66 vs. 3.31 ± 1.65; P=.79 respectively). Time outdoors was not significantly associated with myopia during the pandemic (OR=1.17, 95% CI 0.64 to 2.14). Total near work was not associated with myopia at any time point. Conclusion: The long-term influence of the changing patterns of outdoor and near work on myopia prevalence and progression in our population is still to be established. Nevertheless, it is likely that the decrease of outdoor time may influence the rates of myopia in this region.

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BACKGROUND: To explore the relationship between outdoor time and academic performance among school-aged children. METHODS: This study was designed as a cross-sectional study. Data were derived from a school-based prospective children myopia intervention study (STORM). Outdoor time was recorded by self-developed algorithm-validated wristwatches in real-time and calculated as the cumulative average of 10 months. The academic performance was recorded and provided by the participating schools and further standardized. Other information was collected using an online standardized questionnaire. Mixed-effects model and B-Spline method were used to investigate the association between time spent on different types of daily activity, including outdoor activity and academic performance. RESULTS: A total of 3291 children with mean age 9.25 years were included in the final analysis. Overall, outdoor time was associated with academic performance in a non-linear manner; specifically, not exceeding 2.3 h per day, outdoor time was positively associated with academic performance; exceeding 2.3 h per day, this association became non-significant. Likewise, daily sleep duration and out-of-school learning time were associated with academic performance in a non-linear manner, resulting in turning points of 11.3 and 1.4 h per day, respectively. Separate analysis showed that outdoor time and sleep duration but not out-of-school learning time were positively associated with academic performance in Chinese, mathematics and English. CONCLUSION: Outdoor time, sleep duration and out-of-school learning time were associated with academic performance in a non-linear manner. Promotion of outdoor time may not negatively impact on academic performance. TRIAL REGISTRATION: Our study was registered in ClinicalTrials.gov (Identifier: NCT02980445).

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PURPOSE: Accumulating evidence suggests that time outdoors is protective against myopia development and that the choroid may be involved in this effect. The goal of this study was to examine the effect of 2 h of time outdoors in sunlight on retinal and choroidal thickness in adults. METHODS: Twenty adults, ages 23-46 years, each participated in three experimental sessions on different days, consisting of 2 h of exposure to (1) indoor illumination (350 lux), (2) darkness (<0.1 lux) or (3) outdoor environment (6000-50,000 lux). Spectral-domain optical coherence tomography (SD-OCT) imaging was conducted at baseline, after 1 and 2 h of exposure, and after 1 and 2 h of follow-up. Choroidal, total retinal, photoreceptor outer segment + retinal pigment epithelium (RPE) and photoreceptor inner segment thicknesses were determined. RESULTS: At 2 h, the choroid was significantly thinner during the outdoor compared with the indoor and dark conditions (p < 0.01) but was not significantly different at follow-up. Total retinal thickness was significantly thicker during and after the outdoor compared with the indoor and dark conditions. The outer segment + RPE was significantly thinner during the outdoor compared with the indoor condition but was not significantly different at follow-up. The inner segment was significantly thicker during the outdoor compared with the indoor and dark conditions during exposure and follow-up. CONCLUSIONS: Spending 2 h outdoors under high-intensity sunlight resulted in an unexpected thinning of the choroid, which recovered post-exposure. Retinal thickness showed different responses to the outdoor and indoor environments and was sensitive to the duration of exposure.

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OBJECTIVE: Regular physical activity is essential for asthma control in children, but it remains understudied within the context of COVID-19. Physical activity and sedentary time levels before and during the COVID-19 pandemic among children with asthma were documented and differences by characteristics were explored. METHODS: This was a cross-sectional self-administered online survey study of 5- to 17-year-old children with asthma from the United States between December 2020 and April 2021. RESULTS: This study included 68 children with asthma. Although only 4.6% of the children were fully inactive before the pandemic, this number increased to 24.6% during the survey period (p < 0.001). Children spent significantly less time outdoors and more time in front of screens during the pandemic versus before (p < 0.001). The variety of activities in which children with asthma engaged in during the pandemic was lower than what they used to do prior to the COVID-19 crisis. Boys, Hispanic children, those of low-income households, and those not attending school in-person were significantly associated with less participation in physical activity during the pandemic. Ethnicity remained significantly associated after adjusting for multiple comparisons. CONCLUSIONS: During the COVID-19 pandemic, children with asthma were less active and spent more time in front of screens and less time outdoors. Subgroup analyses revealed individual, parental, and organizational characteristics being associated with differential participation in physical activity, highlighting disparities in opportunities for children with asthma of different circumstances to remain active and healthy during the pandemic. Additional, more robust longitudinal studies are needed to confirm these results.

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BACKGROUND: Understanding the developmental trajectories of outdoor time, screen time and sleep is necessary to inform early interventions that promote healthy behaviours. This study aimed to describe concurrent trajectories of outdoor time, screen time and sleep across the early childhood period and their maternal predictors. METHODS: Data across five time points at child age 4, 9, 19, 42 and 60 months from the INFANT intervention were analysed. Mothers reported their child's usual outdoor time, screen time and sleep duration, in addition to a range of maternal beliefs, attitudes, expectations and behaviours. Group-based multi-trajectory modelling was used to model concurrent trajectories of children's behaviours. Multinomial logistic regression models determined the associations of maternal predictors with trajectory groups, adjusting for child sex and baseline age, intervention allocation, and clustering by recruitment. RESULTS: Of the 542 children recruited, 528 had data for outdoor time, screen time and sleep at one or more time points and were included in trajectory analyses Four trajectories were identified: 'unstable sleep, increasing outdoor time, low screen' (~ 22% of sample), 'high outdoor time, low screen, high sleep' (~ 24%), 'high sleep, increasing outdoor time, low screen' (~ 45%), 'high screen, increasing outdoor time, high sleep' (~ 10%). The 'high sleep, increasing outdoor time, low screen' group, comprising the largest percentage of the sample, demonstrated the healthiest behaviours. Predictors of group membership included: views of physically active children, screen time knowledge, screen time use, self-efficacy, physical activity optimism, future expectations for children's physical activity and screen time, perceptions of floor play safety, and maternal physical activity, screen time, and sleep quality. CONCLUSIONS: Four distinct trajectories of outdoor time, screen time and sleep were identified, with the most common (and healthiest) characterized by high levels of sleep. Maternal beliefs, attitudes, expectations and behaviours are important in the development of movement behaviour trajectories across early childhood. Future interventions and public policy may benefit from targeting these factors to support healthy movement behaviours from a young age.

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BACKGROUND: Physical activity (PA) deficiency, outdoor time reduction during college have been associated with higher cumulative physiological burden as measured by allostatic load (AL). Therefore, the present research sought to analyze the independent and interaction effects of PA and outdoor time on AL in college students. METHODS: A cross-sectional survey was conducted in two universities from April to May 2019. Self-assessment questionnaire and International Physical Activity Questionnaire Short Version (IPAQ-SF) were used in the investigation, AL level was assessed according to the results of biochemical examination, blood pressure and human body morphological measurements. Binary Logistic Analysis was used to analyze the relationships between PA, outdoor time and AL. RESULTS: The prevalence of low PA, low outdoor time and high AL were 16.3%, 71.1% and 47.6%, respectively. Low PA (OR=1.83, 95%CI: 1.20~2.78) and low outdoor time (OR=1.90, 95%CI: 1.35~2.67) are independently associated with high AL (P<0.05, for each). Interaction analysis indicated that low PA and low outdoor time were interactively associated with high AL (OR=2.93, 95%CI: 1.73~4.94, P<0.05). CONCLUSIONS: There were the significant independent and interaction effects between PA and outdoor time on AL. In the future, college students' physical education can be arranged reasonably to reduce the health risks.

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PURPOSE: Outdoor light exposure is considered a safe and effective strategy to reduce myopia development and aligns with existing public health initiatives to promote healthier lifestyles in children. However, it is unclear whether this strategy reduces myopia progression in eyes that are already myopic. This study aims to conduct an overview of systematic reviews (SRs) reporting time spent outdoors as a strategy to prevent myopia or slow its progression in children. METHODS: We searched the Cochrane Library, EMBASE, MEDLINE and CINAHL from inception to 1 November 2020 to identify SRs that evaluated the association between outdoor light exposure and myopia development or progression in children. Outcomes included incident myopia, prevalent myopia and change in spherical equivalent refraction (SER) and axial length (AL) to evaluate annual rates of myopia progression. The methodological quality and risk of bias of included SRs were assessed using the AMSTAR-2 and ROBIS tools, respectively. RESULTS: Seven SRs were identified, which included data from 47 primary studies with 63,920 participants. Pooled estimates (risk or odds ratios) consistently demonstrated that time outdoors was associated with a reduction in prevalence and incidence of myopia. In terms of slowing progression in eyes that were already myopic, the reported annual reductions in SER and AL from baseline were small (0.13-0.17 D) and regarded as clinically insignificant. Methodological quality assessment using AMSTAR-2 found that all reviews had one or more critical flaws and the ROBIS tool identified a low risk of bias in only two of the included SRs. CONCLUSION: This overview found that increased exposure to outdoor light reduces myopia development. However, based on annual change in SER and AL, there is insufficient evidence for a clinically significant effect on myopia progression. The poor methodological quality and inconsistent reporting of the included systematic reviews reduce confidence in the estimates of effect.

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PURPOSE: To examine the association between near work, screen time including TV and outdoor time with myopia in children from the Sunflower Myopia Asian Eye Epidemiology Consortium (AEEC). METHODS: We analysed AEEC cross-sectional data (12 241 children) on risk factors (near work, screen time including TV and outdoor time) and myopia of six population-based studies (China, Hong Kong and Singapore). Cycloplegic refraction and axial length (AL) measurements were included. Risk factors were determined using questionnaires. Data were pooled from each study, and multivariable regression analysis was performed to evaluate the associations between risks factors and myopia, spherical equivalent (SE) and AL. RESULTS: Among the included children, 52.1% were boys, 98.1% were Chinese and 69.7% lived in urban areas. Mean±standard deviation (SD) for age was 8.8 ± 2.9 years, for SE was -0.14 ± 1.8 D and for AL was 23.3 ± 1.1 mm. Myopia prevalence was 30.6%. In multivariate analysis, more reading and writing (OR = 1.17; 95% CI, 1.11-1.24), more total near work (OR = 1.05; 95% CI, 1.02-1.09) and less outdoor time (OR = 0.82, 95% CI, 0.75-0.88) were associated with myopia (p's < 0.05). These factors were similarly associated with SE and AL (p's < 0.05), except for total near work and AL (p = 0.15). Screen time including TV was not significantly associated with myopia (p = 0.49), SE (p = 0.49) or AL (p = 0.83). CONCLUSION: In this study, increased reading and writing and decreased outdoor time were associated with myopia. Screen time may be a surrogate factor of near work or outdoor time, but further research is needed to assess its role as an independent risk factor for myopia.

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