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1.  Changes in occupational class differences in leisure-time physical activity: a follow-up study 
Background
Physical activity is known to have health benefits across population groups. However, less is known about changes over time in socioeconomic differences in leisure-time physical activity and the reasons for the changes. We hypothesised that class differences in leisure-time physical activity would widen over time due to declining physical activity among the lower occupational classes. We examined whether occupational class differences in leisure-time physical activity change over time in a cohort of Finnish middle-aged women and men. We also examined whether a set of selected covariates could account for the observed changes.
Methods
The data were derived from the Helsinki Health Study cohort mail surveys; the respondents were 40-60-year-old employees of the City of Helsinki at baseline in 2000-2002 (n = 8960, response rate 67%). Follow-up questionnaires were sent to the baseline respondents in 2007 (n = 7332, response rate 83%). The outcome measure was leisure-time physical activity, including commuting, converted to metabolic equivalent tasks (MET). Socioeconomic position was measured by occupational class (professionals, semi-professionals, routine non-manual employees and manual workers). The covariates included baseline age, marital status, limiting long-lasting illness, common mental disorders, job strain, physical and mental health functioning, smoking, body mass index, and employment status at follow-up. Firstly the analyses focused on changes over time in age adjusted prevalence of leisure-time physical activity. Secondly, logistic regression analysis was used to adjust for covariates of changes in occupational class differences in leisure-time physical activity.
Results
At baseline there were no occupational class differences in leisure-time physical activity. Over the follow-up leisure-time physical activity increased among those in the higher classes and decreased among manual workers, suggesting the emergence of occupational class differences at follow-up. Women in routine non-manual and manual classes and men in the manual class tended to be more often physically inactive in their leisure-time (<14 MET hours/week) and to be less often active (>30 MET hours/week) than those in the top two classes. Adjustment for the covariates did not substantially affect the observed occupational class differences in leisure-time physical activity at follow-up.
Conclusions
Occupational class differences in leisure-time physical activity emerged over the follow-up period among both women and men. Leisure-time physical activity needs to be promoted among ageing employees, especially among manual workers.
doi:10.1186/1479-5868-8-14
PMCID: PMC3058076  PMID: 21362168
2.  Leisure Time Physical Activity of Moderate to Vigorous Intensity and Mortality: A Large Pooled Cohort Analysis 
PLoS Medicine  2012;9(11):e1001335.
Analyzing data from over 650,000 individuals, Dr. Steven Moore and colleagues report that greater amounts of leisure-time physical activity were associated with higher life expectancy across a wide range of activity levels and body mass index groups.
Background
Leisure time physical activity reduces the risk of premature mortality, but the years of life expectancy gained at different levels remains unclear. Our objective was to determine the years of life gained after age 40 associated with various levels of physical activity, both overall and according to body mass index (BMI) groups, in a large pooled analysis.
Methods and Findings
We examined the association of leisure time physical activity with mortality during follow-up in pooled data from six prospective cohort studies in the National Cancer Institute Cohort Consortium, comprising 654,827 individuals, 21–90 y of age. Physical activity was categorized by metabolic equivalent hours per week (MET-h/wk). Life expectancies and years of life gained/lost were calculated using direct adjusted survival curves (for participants 40+ years of age), with 95% confidence intervals (CIs) derived by bootstrap. The study includes a median 10 y of follow-up and 82,465 deaths. A physical activity level of 0.1–3.74 MET-h/wk, equivalent to brisk walking for up to 75 min/wk, was associated with a gain of 1.8 (95% CI: 1.6–2.0) y in life expectancy relative to no leisure time activity (0 MET-h/wk). Higher levels of physical activity were associated with greater gains in life expectancy, with a gain of 4.5 (95% CI: 4.3–4.7) y at the highest level (22.5+ MET-h/wk, equivalent to brisk walking for 450+ min/wk). Substantial gains were also observed in each BMI group. In joint analyses, being active (7.5+ MET-h/wk) and normal weight (BMI 18.5–24.9) was associated with a gain of 7.2 (95% CI: 6.5–7.9) y of life compared to being inactive (0 MET-h/wk) and obese (BMI 35.0+). A limitation was that physical activity and BMI were ascertained by self report.
Conclusions
More leisure time physical activity was associated with longer life expectancy across a range of activity levels and BMI groups.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Regular physical activity is essential for human health. It helps to maintain a healthy body weight and prevents or delays heart disease, type 2 diabetes, and some cancers. It also makes people feel better and increases life expectancy. The World Health Organization (WHO) currently recommends that adults do at least 150 minutes of moderate- to vigorous-intensity physical activity every week. Moderate-intensity physical activities (for example, brisk walking and gardening) require a moderate amount of effort and noticeably increase the heart rate; vigorous-intensity physical activities (for example, running or fast swimming) require a large amount of effort and cause rapid breathing and a substantial heart rate increase. Worryingly, people in both developed and developing countries are becoming increasingly physically inactive. People are sitting at desks all day instead of doing manual labor; they are driving to work in cars instead of walking or cycling; and they are participating in fewer leisure time physical activities.
Why Was This Study Done?
Although various studies suggest that physical activity increases life expectancy, few have quantified the years of life gained at distinct levels of physical activity. Moreover, the difference in life expectancy between active, overweight individuals and inactive, normal weight individuals has not been quantified. Thus, it is hard to develop a simple public health message to maximize the population benefits of physical activity. In this pooled prospective cohort analysis, the researchers determine the association between levels of leisure time physical activities, such as recreational walking, and years of life gained after age 40, both overall and within body mass index (BMI) groups. A pooled prospective cohort analysis analyzes the combined data from multiple studies that have followed groups of people to investigate associations between baseline characteristics and outcomes such as death. BMI is a ratio of weight to height, calculated by dividing a person's weight by their height squared; normal weight is defined as a BMI of 18.5–24.9 kg/m2, obesity (excessive body fat) is defined as a BMI of more than 30 kg/m2.
What Did the Researchers Do and Find?
The researchers pooled self-reported data on leisure time physical activities and BMIs from nearly 650,000 individuals over the age of 40 years enrolled in one Swedish and five US prospective cohort studies, most of which were investigating associations between lifestyle factors and disease risk. They used these and other data to calculate the gain in life expectancy associated with specific levels of physical activity. A physical activity level equivalent to brisk walking for up to 75 minutes per week was associated with a gain of 1.8 years in life expectancy relative to no leisure time activity. Being active—having a physical activity level at or above the WHO-recommended minimum of 150 minutes of brisk walking per week—was associated with an overall gain of life expectancy of 3.4–4.5 years. Gains in life expectancy were seen also for black individuals and former smokers, groups for whom relatively few data had been previously available. The physical activity and life expectancy association was also evident at all BMI levels. Being active and normal weight was associated with a gain of 7.2 years of life compared to being inactive and class II+ obese (having a BMI of more than 35.0 kg/m2). However, being inactive but normal weight was associated with 3.1 fewer years of life compared to being active but class I obese (having a BMI of 30–34.9 kg/m2).
What Do These Findings Mean?
These findings suggest that participation in leisure time physical activity, even below the recommended level, is associated with a reduced risk of mortality compared to participation in no leisure time physical activity. This result may help convince currently inactive people that a modest physical activity program may have health benefits, even if it does not result in weight loss. The findings also suggest that physical activity at recommended levels or higher may increase longevity further, and that a lack of leisure time physical activity may markedly reduce life expectancy when combined with obesity. Although the accuracy and generalizability of these findings may be limited by certain aspects of the study's design (for example, some study participants may have overestimated their leisure time physical activity), these findings reinforce the public health message that both a physically active lifestyle and a normal body weight are important for increasing longevity.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001335.
The World Health Organization provides information about physical activity and health (in several languages); its 2010 Global Recommendations on Physical Activity for Health is available in several languages
The US Centers for Disease Control and Prevention provides information on physical activity for different age groups; its Physical Activity for Everyone webpages include guidelines, instructional videos, and personal success stories
The UK National Health Service information source NHS Choices also explains the benefits of regular physical activity and includes physical activity guidelines, tips for exercising, and some personal stories
MedlinePlus has links to other resources about exercise and physical fitness (in English and Spanish)
doi:10.1371/journal.pmed.1001335
PMCID: PMC3491006  PMID: 23139642
3.  Associations between Active Travel to Work and Overweight, Hypertension, and Diabetes in India: A Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001459.
Using data from the Indian Migration Study, Christopher Millett and colleagues examine the associations between active travel to work and overweight, hypertension, and diabetes.
Please see later in the article for the Editors' Summary
Background
Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes.
Methods and Findings
Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58–0.88) or bicycling to work (ARR 0.66; 95% CI 0.55–0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36–0.71) or diabetes (ARR 0.65; 95% CI 0.44–0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found.
Conclusions
Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs) and obesity (excessive body fat) are major threats to global health. Every year, more than 36 million people (including 29 million in LMICs) die from NCDs—nearly two-thirds of the world's annual deaths. Cardiovascular diseases (conditions that affect the heart and the circulation), diabetes, cancer, and respiratory diseases are responsible for most NCD-related deaths. Obesity is a risk factor for all these NCDs and the global prevalence of obesity (the proportion of the world's population that is obese) has nearly doubled since 1980. In 2008, 35% of adults were overweight and 11% were obese. One reason for the growing burden of both obesity and NCDs is increasing physical inactivity. Regular physical activity helps to maintain a healthy body weight and to prevent or delay the onset of NCDs. For an adult, 30 minutes of moderate physical activity—walking briskly or cycling, for example—five times a week is sufficient to promote and maintain health. But the daily lives of people in both developed and developing countries are becoming increasingly sedentary and, nowadays, at least 60% of the world's population does not do even this modest amount of exercise.
Why Was This Study Done?
Strategies to increase physical activity levels often promote active travel (walking, cycling, and using public transport). The positive impact of active travel on physical activity levels and cardiovascular health is well established in high-income countries, but little is known about the patterns of active travel or the health benefits associated with active travel in poorer countries. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers examine the mode and duration of travel to work in rural and urban India and associations between active travel and overweight/obesity, hypertension (high blood pressure, a risk factor for cardiovascular disease), and diabetes. In India, a lower middle-income country, the prevalence of overweight and NCDs is projected to increase rapidly over the next two decades. Moreover, rapid unplanned urbanization and a large increase in registered motor vehicles has resulted in inadequate development of the public transport infrastructure and hazardous conditions for walking and cycling in most Indian towns and cities.
What Did the Researchers Do and Find?
For their study, researchers analyzed physical activity and health data collected from participants in the Indian Migration Study, which examined the association between migration from rural to urban areas and obesity and diabetes risk. People living in rural areas were more likely to cycle to work than people living in towns and cities (68.3% versus 15.9%). Among people who travelled to work by private transport, public transport, walking, and cycling, the prevalence of overweight or obesity was 50.0%, 37.6%, 24.9%, and 24.2%, respectively. Similar patterns were seen for the prevalence of hypertension and diabetes. After adjustment for factors that affect the risk of obesity, hypertension, and diabetes (for example, daily fat intake and leisure time physical activity), people walking or cycling to work were less likely to be overweight or obese than those travelling by public transport, and those cycling to walk were less likely to have hypertension or diabetes. Finally, people with long cycle rides to work had a lower risk of being overweight or having hypertension or diabetes than people with short cycle rides.
What Do These Findings Mean?
These findings suggest that, as in high-income settings, walking and cycling to work are associated with a reduced risk of cardiovascular disease in India. Because this was a cross-sectional study, these findings do not prove that active travel reduces the risk of cardiovascular disease—people who cycle to work may share other unknown characteristics that are actually responsible for their reduced risk of cardiovascular disease. Moreover, this study did not consider non-cardiovascular outcomes associated with active travel that might affect health such as increased exposure to air pollution. Nevertheless, these findings suggest that programs designed to maintain healthy weight and prevent NCDs in India should endeavor to increase active travel in urban areas and to halt declines in rural areas by, for example, increasing investment in public transport and improving the safety and convenience of walking and cycling routes in urban areas.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001459.
This study is further discussed in a PLOS Medicine Perspective by Kavi Bhalla
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living, on chronic diseases and health promotion, on overweight and obesity and on non-communicable diseases around the world; its Physical Activity for Everyone web pages include guidelines, instructional videos and personal success stories (some information in English and Spanish)
The World Health Organization provides information about physical activity and health, about obesity, and about non-communicable diseases (in several languages); its 2010 Global Recommendations on Physical Activity for Health are available in several languages; its Global Noncommunicable Disease Network (NCDnet) aims to help low- and middle- income countries reduce NCD-related illnesses and death through implementation of the 20082013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases (also available in French); Face to face with chronic diseases is a selection of personal stories from around the world about dealing with NCDs
The American Heart Association provides information on many important risk factors for non-communicable diseases and provides tips for becoming more active
Information about the Indian Migration Study is available
doi:10.1371/journal.pmed.1001459
PMCID: PMC3679004  PMID: 23776412
4.  Physical activity and risk of Metabolic Syndrome in an urban Mexican cohort 
BMC Public Health  2009;9:276.
Background
In the Mexican population metabolic syndrome (MS) is highly prevalent. It is well documented that regular physical activity (PA) prevents coronary diseases, type 2 diabetes and MS. Most studies of PA have focused on moderate-vigorous leisure-time activity, because it involves higher energy expenditures, increase physical fitness, and decrease the risk of MS. However, for most people it is difficult to get a significant amount of PA from only moderately-vigorous leisure activity, so workplace activity may be an option for working populations, because, although may not be as vigorous in terms of cardio-respiratory efforts, it comprises a considerable proportion of the total daily activity with important energy expenditure. Since studies have also documented that different types and intensity of daily PA, including low-intensity, seem to confer important health benefits such as prevent MS, we sought to assess the impact of different amounts of leisure-time and workplace activities, including low-intensity level on MS prevention, in a sample of urban Mexican adults.
Methods
The study population consisted of 5118 employees and their relatives, aged 20 to 70 years, who were enrolled in the baseline evaluation of a cohort study. MS was assessed according to the criteria of the National Cholesterol Education Program, ATP III and physical activity with a validated self-administered questionnaire. Associations between physical activity and MS risk were assessed with multivariate logistic regression models.
Results
The prevalence of the components of MS in the study population were: high glucose levels 14.2%, high triglycerides 40.9%, high blood pressure 20.4%, greater than healthful waist circumference 43.2% and low-high density lipoprotein 76.9%. The prevalence of MS was 24.4%; 25.3% in men and 21.8% in women. MS risk was reduced among men (OR 0.72; 95%CI 0.57–0.95) and women (OR 0.78; 95%CI 0.64–0.94) who reported an amount of ≥30 minutes/day of leisure-time activity, and among women who reported an amount of ≥3 hours/day of workplace activity (OR 0.75; 95%CI 0.59–0.96).
Conclusion
Our results indicate that both leisure-time and workplace activity at different intensity levels, including low-intensity significantly reduce the risk of MS. This finding highlights the need for more recommendations regarding the specific amount and intensity of leisure-time and workplace activity needed to prevent MS.
doi:10.1186/1471-2458-9-276
PMCID: PMC2734848  PMID: 19646257
5.  Occupational and leisure time physical activity: risk of all-cause mortality and myocardial infarction in the Copenhagen City Heart Study. A prospective cohort study 
BMJ Open  2012;2(1):e000556.
Objectives
Men with low physical fitness and high occupational physical activity are recently shown to have an increased risk of cardiovascular disease and all-cause mortality. The association between occupational physical activity with cardiovascular disease and all-cause mortality may also depend on leisure time physical activity.
Design
A prospective cohort study.
Setting
The Copenhagen City Heart Study.
Participants
7819 men and women aged 25–66 years without a history of cardiovascular disease who attended an initial examination in the Copenhagen City Heart Study in 1976–1978.
Outcome measures
Myocardial infarction and all-cause mortality. Occupational physical activity was defined by combining information from baseline (1976–1978) with reassessment in 1981–1983. Conventional risk factors were controlled for in Cox analyses.
Results
During the follow-up from 1976 to 1978 until 2010, 2888 subjects died of all-cause mortality and 787 had a first event of myocardial infarction. Overall, occupational physical activity predicted all-cause mortality and myocardial infarction in men but not in women (test for interaction p=0.02). High occupational physical activity was associated with an increased risk of all-cause mortality among men with low (HR 1.56; 95% CI 1.11 to 2.18) and moderate (HR 1.31; 95% CI 1.05 to 1.63) leisure time physical activity but not among men with high leisure time physical activity (HR 1.00; 95% CI 0.78 to 1.26) (test for interaction p=0.04). Similar but weaker tendencies were found for myocardial infarction. Among women, occupational physical activity was not associated with subsequent all-cause mortality or myocardial infarction.
Conclusions
The findings suggest that high occupational physical activity imposes harmful effects particularly among men with low levels of leisure time physical activity.
Article summary
Article focus
Men with low physical fitness and high occupational physical activity are recently shown to have an increased risk of cardiovascular disease and all-cause mortality.
It is unknown if the association between occupational physical activity with cardiovascular disease and all-cause mortality also depends on leisure time physical activity.
Key messages
This study shows that men with high occupational physical activity have an increased risk of all-cause mortality.
Leisure time physical activity was found to modify the positive association between occupational physical activity and risk of all-cause mortality. High occupational physical activity imposes harmful effects particularly among men with low levels of leisure time physical activity.
Strengths and limitations of this study
Study strengths include the long follow-up time, repeated assessment of the occupational physical activity, objective measures of several covariates from clinical examinations, information on outcomes obtained from valid registers, and participation of both sexes. Some limitations are the lack of control for psychosocial work factors and the self-reported exposures.
doi:10.1136/bmjopen-2011-000556
PMCID: PMC3282285  PMID: 22331387
6.  Association of Leisure Time Physical Activity and Metabolic Syndrome over 40 Years 
Background
This study aimed to investigate the relationship between leisure time physical activities (LTPA) and metabolic syndrome (MS).
Methods
Five thousand seven hundred and thirty two adults 40 years old or older were enrolled in the study from April 2009 to December 2010. National Cholesterol Education Program's Adult Treatment Panel III was used for the criteria of MS, and Minnesota Leisure Time Physical Activity Questionnaire was used to measure LTPA. After adjusted covariates (age, hypertension, smoking, drinking, education level, household income level, work time physical activities, and menopause for females), the relationship between LTPA and MS was analyzed using logistic regression analysis.
Results
The prevalence of MS was 22.8% in men, and 14.1% in women. Average LTPA was 1,498 kcal/wk in men, and 1,308 kcal/wk in women. After adjustment for covariates, the odds ratios of middle and low LTPA compared with high LTPA were 1.06 (0.87-1.34), 1.54 (1.08-1.75), for women, this same association was not seen in men. The prevalence of MS was 22.8% in men and 14.1% in women, and their LTPA burned 1,498 and 1,308 kcal/wk, respectively. When the odds ratio of MS for the high LTPA group was set at 1.0, the odds ratio of MS was 1.06 (0.87-1.34) in the middle LTPA group and 1.54 (1.08-1.75) in the low LTPA group in women, which showed that the MS risk increased when the LTPA was lower. This same association was not seen in men.
Conclusion
LTPA was independently associated with metabolic syndrome, but only for women.
doi:10.4082/kjfm.2014.35.2.65
PMCID: PMC3978187  PMID: 24724001
Physical Activity; Metabolic Syndrome; Health Behavior
7.  Metabolic syndrome in Russian adults: associated factors and mortality from cardiovascular diseases and all causes 
BMC Public Health  2010;10:582.
Background
Metabolic syndrome (MetS) is a cluster of four major obesity-related risk factors for cardiovascular disease (CVD). Russia has one of the highest CVD mortality in the world, but its association with MetS remains unknown. Also little is known about factors associated with MetS and its components in Russia.
Methods
Data on 3555 adults aged 18-90 years were collected in a cross-sectional study in 2000. MetS was defined by the International Diabetes Federation (IDF) and National Cholesterol Education Program (NCEP) criteria. Sex-specific associations between the IDF-defined MetS, its components, and life-style, socio-economic factors and laboratory indicators, were analysed using multivariable Poisson regression. Vital status of the study participants was identified by July 2009. Sex-specific associations between MetS and stroke, Coronary Heart Disease (CHD), CVD and all-cause death, were studied by Poisson regression adjusted for age, smoking, alcohol and history of CVDs.
Results
After adjustment for all studied factors except BMI, age, serum GGT, C-reactive protein and AST-to-ALT ratio were associated with MetS in both genders. Additionally, MetS was associated with sedentary lifestyle in women and with smoking in men. In the same regression model drinking alcohol 2-4 times a month and consumption of five or more alcohol units at one occasion in men, and drinking alcohol 5 times or more a month in women were inversely associated with MetS. After a 9-year follow-up, MetS was associated with higher risk of death from stroke (RR = 3.76, 95% CI:1.35-10.46) and from either stroke or myocardial infarction (MI, RR = 2.87, 95% CI:1.32-6.23) in men. No associations between MetS and any of the studied causes of death were observed in women.
Conclusion
Factors associated with MetS in both genders were age, GGT, C-reactive protein, and AST-to-ALT ratio. Moderate frequency of alcohol consumption and binge drinking in men and higher leisure time physical activity in women, were inversely associated with MetS.
Positive associations between MetS and mortality were only observed for deaths from stroke and either stroke or MI in men.
doi:10.1186/1471-2458-10-582
PMCID: PMC2955695  PMID: 20920226
8.  Leisure Time Physical Activity and Its Determinants among Adults in Tehran: Tehran Lipid and Glucose Study 
Objectives:
The aim of this study was to assess leisure time physical activity and its determinants among adults in Tehran.
Methods:
This cross-sectional study comprised adults (n = 7285), aged 20 years and older. The subjects were participants of the Tehran Lipid and Glucose Study between 2002 and 2004. Information on the number of days spent on different activities during a week and the time devoted to each activity on a typical day was recorded. In addition, each activity, weighted by its relative intensity, was referred to as a metabolic equivalent.
Results:
The prevalence of inactivity was 69.8% (95% CI: 68.7-70.8) in the whole population and 30.2% (95% CI: 27.2-33.1%) of men and 30.3% (95% CI: 27.7-32.8%) of women were considered as active. Leisure time physical activity less than 30 min/week was scored in 1590 (50.6%) men and 1803 (43.5%) women. The most frequent leisure time physical activity performed by men (96.1%) and women (95.2%) was walking. A negative association was observed in men between leisure time physical activity and increased work hours, older age, more cigarette smoking and higher body mass index (69.8% were overweight and 75.3% were obese; P < 0.05). Leisure time physical activity was more likely to be associated with high educational levels in men. In addition, there was a statistically significant relationship between physical inactivity and occupation in both men and women.
Conclusions:
The prevalence of physical inactivity among adults in Tehran was high. Leisure time physical inactivity was more likely to be associated with older age, more cigarette smoking, more working hours, and higher body mass index. Public health efforts are needed to improve people's participation in physical activities in Iran.
PMCID: PMC3237267  PMID: 22174964
Physical inactivity; Adults; Tehran; Leisure time
9.  Effect of leisure time physical activity on severe knee or hip osteoarthritis leading to total joint replacement: a population-based prospective cohort study 
Background
Studies on leisure time physical activity as risk factor or protective factor for knee or hip osteoarthritis (OA) show divergent results. Longitudinal prospective studies are needed to clarify the association of physical activity with future OA. The aim was to explore in a prospective population-based cohort study the influence of leisure time physical activity on severe knee or hip OA, defined as knee or hip replacement due to OA.
Methods
Leisure time physical activity was reported by 28320 participants (mean age 58 years (SD 7.6), 60% women) at baseline. An overall leisure time physical activity score, taking both duration and intensity of physical activities into account, was created. The most commonly reported activities were also used for analysis. The incidence of knee or hip replacement due to OA over 11 years was monitored by linkage with the Swedish hospital discharge register. Cox’s proportional hazards model (crude and adjusted for potential confounding factors) was used to assess the incidence of total joint replacement, or osteotomy (knee), in separate analyses of leisure time physical activity.
Results
There was no significant overall association between leisure time physical activity and risk for knee or hip replacement due to OA over the 11-year observation time. For women only, the adjusted RR (95% CI) for hip replacement was 0.66 (0.48, 0.89) (fourth vs. first quartile), indicating a lower risk of hip replacement in those with the highest compared with the lowest physical activity. The most commonly reported activities were walking, bicycling, using stairs, and gardening. Walking was associated with a lower risk of hip replacement (adjusted RR 0.76 (95% CI 0.61, 0.94), specifically for women (adjusted RR 0.75 (95% CI 0.57, 0.98)).
Conclusions
In this population-based study of middle-aged men and women, leisure time physical activity showed no consistent overall relationship with incidence of severe knee or hip OA, defined as joint replacement due to OA, over 11 years. For women, higher leisure time physical activity may have a protective role for the incidence of hip replacement. Walking may have a protective role for hip replacement, specifically for women.
doi:10.1186/1471-2474-13-73
PMCID: PMC3462680  PMID: 22595023
Osteoarthritis; Arthroplasty; Exercise; Workload; Risk factors
10.  Risk factors for ischaemic heart disease mortality among men with different occupational physical demands. A 30-year prospective cohort study 
BMJ Open  2012;2(1):e000279.
Objectives
Men with high physical work demands have elevated cardiovascular strain, which may lead to enhanced atherosclerosis. Theoretically, the impact of risk factors for ischaemic heart disease (IHD) may thus depend on physical work demands. The authors investigated this hypothesis.
Design
Prospective 30-year follow-up.
Setting
The Copenhagen Male Study.
Participants
5249 gainfully employed men aged 40–59 years; 311 men with cardiovascular disease/diabetes were excluded.
Primary and secondary outcome measures
IHD and all-cause mortality.
Results
579 men (11.8%) died due to IHD and 2628 (53.7%) from all-cause mortality. Similarities and differences in risk predictors were found between men with low (n=1219), medium (n=2636) and high (n=846) physical work demands. After control for potential confounders, high physical fitness conferred a reduced risk of IHD mortality only among men with high physical work demands (HR: 0.48, 95% CI 0.24 to 0.96), a moderate/high level of leisure-time physical activity was associated with reduced risk of IHD mortality only among men with moderate and high physical work demands. High systolic blood pressure and smoking were risk factors in all groups. Similar, but less pronounced differences in risk factors for all-cause mortality between groups were found.
Conclusions
The risk factors for IHD and all-cause mortality, low physical fitness and low leisure-time physical activity are not identical for men with different physical work demands. Preventive initiatives for IHD should be tailored to the physical work demands.
Article summary
Article focus
Men with high physical work demands have elevated cardiovascular strain and risk of ischaemic heart disease (IHD).
Unknown if established risk factors for IHD impose divergent risk for IHD mortality among men with different levels of occupational physical activity.
Key messages
Risk factors for IHD and all-cause mortality are not identical for men with different physical work demands.
Low physical fitness and leisure-time physical activity particularly increase the risk of IHD mortality among men with high physical work demands.
Preventive initiatives for IHD ought not to be general but tailored to the physical work demands of employees.
Strengths and limitations of this study
Study strengths are the 30-year follow-up on objective outcomes, inclusion of several objectively measured risk factors for IHD and mortality and exclusion of workers with pre-existing cardiovascular disease at baseline.
Study limitations are that physical work demands were based on self-assessment and lacking repeated measures of exposure during the relatively long follow-up period.
doi:10.1136/bmjopen-2011-000279
PMCID: PMC3253417  PMID: 22218719
11.  Patterns, levels and correlates of self-reported physical activity in urban black Soweto women 
BMC Public Health  2014;14(1):934.
Background
Urban black South African women have a high prevalence of non-communicable diseases such as obesity and type 2 diabetes. The aim of this study was to assess the physical activity patterns of a cohort of middle-aged urban-dwelling black African women and to determine if physical activity is associated with anthropometric measures and metabolic outcomes in this population.
Methods
Physical activity and sitting time were assessed using the Global Physical Activity Questionnaire (GPAQ) in a cross-sectional study of 977 black African women (mean age 41.0 ± 7.84 years) from the Birth to Twenty study based in Soweto, Johannesburg. Anthropometric outcomes were measured and fasting blood glucose, insulin and lipid profile were analysed to determine metabolic disease risk and prevalence.
Results
Sixty-seven percent of the population were classified as active according to GPAQ criteria, and the domain that contributed most to overall weekly physical activity was walking for travel. Only 45.0% of women participated in leisure time activity. The prevalence of metabolic syndrome in this sample was 40.0%, and the prevalence of overweight and obesity was 29.2% and 48.0%, respectively. Women who reported owning a motor vehicle walked for travel less, and participated in more leisure-time activity (both p < 0.01), while women who owned a television reported significantly lower moderate-vigorous physical activity (MVPA), and walking for travel (both p < 0.01). Sitting time (mins/wk) was not different between the activity groups, but was associated with triglycerides and diastolic blood pressure. Total physical activity was inversely associated with fasting insulin, and physical activity in the work domain was associated with fat free soft tissue mass.
Conclusions
The findings of this study show that the majority of urban dwelling black South African women are classified as physically active despite a high prevalence of obesity and metabolic disease risk factors. Sitting time had detrimental effects on both triglyceride levels and diastolic blood pressure whilst total physical activity attenuated fasting insulin levels. As walking for travel is a major contributor to physical activity, future research should attempt to determine whether the intensity of this activity plays a role in the prevention of cardiometabolic diseases.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-934) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-934
PMCID: PMC4176558  PMID: 25200747
Physical activity; Sitting time; Women; Black African; Cardiometabolic disease; South Africa
12.  Television Viewing and Low Leisure-Time Physical Activity in Adolescence Independently Predict the Metabolic Syndrome in Mid-Adulthood 
Diabetes Care  2013;36(7):2090-2097.
OBJECTIVE
We investigated whether television (TV) viewing and low leisure-time physical activity in adolescence predict the metabolic syndrome in mid-adulthood.
RESEARCH DESIGN AND METHODS
TV viewing habits and participation in leisure-time physical activity at age 16 years were assessed by self-administered questionnaires in a population-based cohort in Northern Sweden. The presence of the metabolic syndrome at age 43 years was ascertained in 888 participants (82% of the baseline sample) using the International Diabetes Federation criteria. Odds ratios (ORs) and CIs were calculated using logistic regression.
RESULTS
The overall prevalence of the metabolic syndrome at age 43 years was 26.9%. Adjusted OR for the metabolic syndrome at age 43 years was 2.14 (95% CI 1.24–3.71) for those who reported “watching several shows a day” versus “one show/week” or less and 2.31 (1.13–4.69) for leisure-time physical activity “several times/month” or less compared with “daily” leisure-time physical activity at age 16 years. TV viewing at age 16 years was associated with central obesity, low HDL cholesterol, and hypertension at age 43 years, whereas low leisure-time physical activity at age 16 years was associated with central obesity and triglycerides at age 43 years.
CONCLUSIONS
Both TV viewing and low leisure-time physical activity in adolescence independently predicted the metabolic syndrome and several of the metabolic syndrome components in mid-adulthood. These findings suggest that reduced TV viewing in adolescence, in addition to regular physical activity, may contribute to cardiometabolic health later in life.
doi:10.2337/dc12-1948
PMCID: PMC3687313  PMID: 23340896
13.  Impact of BMI and the Metabolic Syndrome on the Risk of Diabetes in Middle-Aged Men 
Diabetes Care  2010;34(1):61-65.
OBJECTIVE
The existence of an obese subgroup with a healthy metabolic profile and low diabetes risk has been proposed; yet long-term data are lacking. We aimed to investigate associations between combinations of BMI categories and metabolic syndrome and risk of type 2 diabetes in middle-aged men.
RESEARCH DESIGN AND METHODS
At age 50, cardiovascular risk factors were assessed in 1,675 participants without diabetes in the community-based Uppsala Longitudinal Study of Adult Men (ULSAM) study. According to BMI/metabolic syndrome status, they were categorized as normal weight (BMI <25 kg/m2) without metabolic syndrome (National Cholesterol Education Program criteria, n = 853), normal weight with metabolic syndrome (n = 60), overweight (BMI 25–30 kg/m2) without metabolic syndrome (n = 557), overweight with metabolic syndrome (n = 117), obese (BMI >30 kg/m2) without metabolic syndrome (n = 28), and obese with metabolic syndrome (n = 60). We investigated the associations between BMI/metabolic syndrome categories at baseline and diabetes incidence.
RESULTS
After 20 years, 160 participants had developed diabetes. In logistic regression models adjusting for age, smoking, and physical activity, increased risks for diabetes were observed in the normal weight with metabolic syndrome (odds ratio 3.28 [95% CI] 1.38–7.81; P = 0.007), overweight without metabolic syndrome (3.49 [2.26–5.42]; P < 0.001), overweight with metabolic syndrome (7.77 [4.44–13.62]; P < 0.001), obese without metabolic syndrome (11.72 [4.88–28.16]; P < 0.001), and obese with metabolic syndrome (10.06 [5.19–19.51]; P < 0.001) categories compared with the normal weight without metabolic syndrome category.
CONCLUSIONS
Overweight or obese men without metabolic syndrome were at increased risk for diabetes. Our data provide further evidence that overweight and obesity in the absence of the metabolic syndrome should not be considered a harmless condition.
doi:10.2337/dc10-0955
PMCID: PMC3005442  PMID: 20852030
14.  Associations of Leisure-Time Internet and Computer Use With Overweight and Obesity, Physical Activity and Sedentary Behaviors: Cross-Sectional Study 
Background
Internet and computer use are increasingly common leisure-time sedentary behaviors, which have the potential to impact negatively on health outcomes. However, little is known about the extent to which adults’ Internet and computer use is associated with weight status and time spent in leisure-time physical activity.
Objective
The objective is to examine associations of leisure-time Internet and computer use with overweight and obesity, leisure-time physical activity, and other sedentary behaviors.
Methods
Participants (2650 adults living in Adelaide, Australia) completed a mail-back questionnaire including items on their height and weight, past seven day recall of leisure-time physical activity, Internet and computer use, and other leisure-time sedentary behaviors. Leisure-time Internet and computer use was categorized into no use, low use (less than three hours per week), or high use (three hours or more per week).
Results
Participants with low leisure-time Internet and computer use had the highest levels of educational attainment and employment, and engaged in less other sedentary behaviors when compared to participants with no or high Internet and computer use. Multinomial logistic regression, adjusted for gender, age, employment, education, other sedentary behaviors and physical activity, determined that participants with a high leisure-time Internet and computer use were 1.46 (95% CI = 1.10 - 1.93) times more likely to be overweight (BMI≥25 and < 30 kg/m2) and 2.52 times more likely (95% CI = 1.82 - 3.52) to be obese (BMI≥30 kg/m2), compared to those who reported no Internet and computer use in their leisure-time. Adults with high leisure-time Internet and computer use were more likely to be overweight or obese even if they were highly active in their leisure time (OR = 1.86; 95% CI = 1.21 - 2.88), as compared to participants who did not use the Internet or computer. Leisure-time physical activity levels were largely independent of Internet and computer use.
Conclusion
These findings suggest that, apart from nutritional and physical activity interventions, it may also be necessary to decrease time spent in sedentary behaviors, such as leisure-time Internet and computer use, in order to reduce the prevalence of overweight and obesity. Future Internet interventions to reduce weight or increase physical activity may need to differentiate between participants with different levels of Internet use in order to increase their effectiveness. Longitudinal studies are required to examine further the potential causal relationships between the development of overweight and specific sedentary behaviors such as Internet and computer use.
doi:10.2196/jmir.1084
PMCID: PMC2762849  PMID: 19666455
Internet; computer; overweight; obese; BMI; body mass index; physical activity; human activities; sedentary behavior; leisure-time; leisure activities
15.  Housework Reduces All-Cause and Cancer Mortality in Chinese Men 
PLoS ONE  2013;8(5):e61529.
Background
Leisure time physical activity has been extensively studied. However, the health benefits of non-leisure time physical activity, particular those undertaken at home on all-cause and cancer mortality are limited, particularly among the elderly.
Methods
We studied physical activity in relation to all-cause and cancer mortality in a cohort of 4,000 community-dwelling elderly aged 65 and older. Leisure time physical activity (sport/recreational activity and lawn work/yard care/gardening) and non-leisure time physical activity (housework, home repairs and caring for another person) were self-reported on the Physical Activity Scale for the Elderly. Subjects with heart diseases, stroke, cancer or diabetes at baseline were excluded (n = 1,133).
Results
Among the 2,867 subjects with a mean age of 72 years at baseline, 452 died from all-cause and 185 died from cancer during the follow-up period (2001–2012). With the adjustment for age, education level and lifestyle factors, we found an inverse association between risk of all-cause mortality and heavy housework among men, with the adjusted hazard ratio (HR) of 0.72 (95%CI = 0.57–0.92). Further adjustment for BMI, frailty index, living arrangement, and leisure time activity did not change the result (HR = 0.71, 95%CI = 0.56–0.91). Among women, however, heavy housework was not associated with all-cause mortality. The risk of cancer mortality was significantly lower among men who participated in heavy housework (HR = 0.52, 95%CI = 0.35–0.78), whereas among women the risk was not significant. Men participated in light housework also were at lower risk of cancer mortality than were their counterparts, however, the association was not significant. Leisure time physical activity was not related to all-cause or cancer mortality in either men or women.
Conclusion
Heavy housework is associated with reduced mortality and cancer deaths over a 9-year period. The underlying mechanism needs further study.
doi:10.1371/journal.pone.0061529
PMCID: PMC3647044  PMID: 23667441
16.  Physical Activity and High-Sensitivity C-Reactive Protein 
Background
Previous studies have suggested an inverse relationship between physical activity and markers of inflammation such as high-sensitivity C-reactive protein (hs-CRP). However, these were inconsistent, and few examined whether race and gender influenced the relationship. This study determined a cross-sectional association between physical activity and hs-CRP level in 6142 middle-aged white, Chinese, black, and Hispanic participants enrolled in the Multi Ethnic Study of Atherosclerosis in 2000–2002.
Methods
Combined moderate and vigorous physical activity was measured by self-reported leisure, conditioning, occupational, and household activities. ANCOVA was used to assess the association between moderate/vigorous physical activity and hs-CRP by gender and race.
Results
Hs-CRP was higher in women. Blacks had the highest hs-CRP, and Chinese participants had the lowest. Hs-CRP decreased across tertiles of moderate/vigorous physical activity in Hispanic men in models adjusted for age, education, study site, and physical activity questionnaire mode of administration (p=0.005) and further adjusted for smoking, infection, and aspirin use (p=0.020). The trend remained significant after further adjustment for BMI; blood pressure; low-density lipoprotein cholesterol; high-density lipoprotein cholesterol; diabetes; and the use of antihypertensive, statin, and diabetes medication (p=0.044). There was a downward trend in hs-CRP across tertiles of physical activity in black and white men, but the association was weaker. No clear trend was observed in any female racial/ethnic groups.
Conclusions
These findings suggest that the association between moderate/vigorous physical activity and hs-CRP differs by race and gender. Further studies are needed to confirm this and to examine the mechanisms for these race and gender differences.
doi:10.1016/j.amepre.2008.09.031
PMCID: PMC4122519  PMID: 19013748
17.  Combined effect of physical activity and leisure time sitting on long-term risk of incident obesity and metabolic risk factor clustering 
Diabetologia  2014;57(10):2048-2056.
Aims/hypothesis
Our study aimed to investigate the combined effects of moderate-to-vigorous physical activity and leisure time sitting on the long-term risk of obesity and clustering of metabolic risk factors.
Methods
The duration of moderate and vigorous physical activity and of leisure time sitting was assessed by questionnaire between 1997 and 1999 among 3,670 participants from the Whitehall II cohort study (73% male; mean age 56 years). Multivariable-adjusted logistic regression models examined associations of physical activity and leisure time sitting tertiles with odds of incident obesity (BMI ≥ 30 kg/m2) and incident metabolic risk factor clustering (two or more of the following: low HDL-cholesterol, high triacylglycerol, hypertension, hyperglycaemia, insulin resistance) at 5 and 10 year follow-ups.
Results
Physical activity, but not leisure time sitting, was associated with incident obesity. The lowest odds of incident obesity after 5 years were observed for individuals reporting both high physical activity and low leisure time sitting (OR = 0.26; 95% CI 0.11, 0.64), with weaker effects after 10 years. Compared with individuals in the low physical activity/high leisure time sitting group, those with intermediate levels of both physical activity and leisure time sitting had lower odds of incident metabolic risk factor clustering after 5 years (OR 0.53; 95% CI 0.36, 0.78), with similar odds after 10 years.
Conclusions/interpretation
Both high levels of physical activity and low levels of leisure time sitting may be required to substantially reduce the risk of obesity. Associations with developing metabolic risk factor clustering were less clear.
Electronic supplementary material
The online version of this article (doi:10.1007/s00125-014-3323-8) contains peer-reviewed but unedited supplementary material, which is available to authorised users.
doi:10.1007/s00125-014-3323-8
PMCID: PMC4153972  PMID: 25078481
Epidemiology; Exercise; Metabolic syndrome; Obesity; Weight regulation
18.  Temporal trends in non-occupational sedentary behaviours from Australian Time Use Surveys 1992, 1997 and 2006 
Background
Current epidemiological data highlight the potential detrimental associations between sedentary behaviours and health outcomes, yet little is known about temporal trends in adult sedentary time. This study used time use data to examine population trends in sedentary behaviours in non-occupational domains and more specifically during leisure time.
Methods
We conducted secondary analysis of population representative data from the Australian Time Use Surveys 1992, 1997 and 2006 involving respondents aged 20 years and over with completed time use diaries for two days. Weighted samples for each survey year were: n = 5851 (1992), n = 6419 (1997) and n = 5505 (2006). We recoded all primary activities by domain (sleep, occupational, transport, leisure, household, education) and intensity (sedentary, light, moderate). Adjusted multiple linear regressions tested for differences in time spent in non-occupational sedentary behaviours in 1992 and 1997 with 2006 as the reference year.
Results
Total non-occupational sedentary time was slightly lower in 1997 than in 2006 (mean = 894 min/2d and 906 min/2d, respectively; B = −11.2; 95%CI: -21.5, -0.9). Compared with 2006, less time was spent in 1997 in sedentary transport (B-6.7; 95%CI: -10.4, -3.0) and sedentary education (B = −6.3; 95%CI: -10.5, -2.2) while household and leisure sedentary time remained stable. Time engaged in different types of leisure-time sedentary activities changed between 1997 and 2006: leisure-time computer use increased (B = −26.7; 95%CI: -29.5, -23.8), while other leisure-time sedentary behaviours (e.g., reading, listening to music, hobbies and crafts) showed small concurrent reductions. In 1992, leisure screen time was lower than in 2006: TV-viewing (B = −24.2; 95%CI: -31.2, -17.2), computer use (B = −35.3; 95%CI: -37.7, -32.8). In 2006, 90 % of leisure time was spent sedentary, of which 53 % was screen time.
Conclusions
Non-occupational sedentary time has increased slightly from 1997 to 2006 in the Australian adult population. This seems to be the result of small increases in sedentary transport and education time while sedentary household and leisure time were stable over this time period. However, almost all leisure time is spent sedentary and the composition of sedentary leisure time changed between 1992 and 2006 towards a larger proportion being screen-based activities. This could be an important observation for public health, as most of the evidence on the detrimental effects of sedentary behaviour is around watching television and health.
doi:10.1186/1479-5868-9-76
PMCID: PMC3419123  PMID: 22713740
19.  Association between the metabolic syndrome and its components and gait speed among U.S. adults aged 50 years and older: a cross-sectional analysis 
BMC Public Health  2006;6:282.
Background
To examine the relationship between the metabolic syndrome and its components and gait speed among older U.S. men and women. Whether these associations are independent of physical activity was also explored.
Methods
Eight hundred and thirty-five men and 850 women aged ≥50 years from the continuous National Health and Nutrition Examination Survey 1999–2002 were examined. We used the definition of the metabolic syndrome developed by the U.S. National Cholesterol Education Program Adult Treatment Panel III. Gait speed was measured with a 6.10-meter timed walk examination.
Results
The prevalence of the metabolic syndrome was 40.2% in men and 45.6% in women (P = .127). The prevalence of gait speed impairment was 29.3% in men and 12.5% in women (P < .001). No association was found between the metabolic syndrome and gait speed impairment. After including the individual components of the metabolic syndrome in a logistic model adjusted for age and leisure-time physical activity, abdominal obesity, low HDL cholesterol, and high fasting glucose were significantly associated with gait speed impairment among women (adjusted odds ratio [AOR] = 0.48, 95% confidence interval [CI] = 0.26 to 0.89; AOR = 2.26, 95% CI = 1.08 to 4.75; and AOR = 2.05, 95% CI = 1.12 to 3.74, respectively). Further adjustment for race/ethnicity, education, smoking status, alcohol consumption, arthritis status, and use of an assistive device attenuated these associations; among women, abdominal obesity and low HDL cholesterol remained significantly associated with gait speed impairment (AOR = 0.37, 95% CI = 0.18 to 0.76 and AOR = 2.45, 95% CI = 1.07 to 5.63, respectively) while the association between hyperglycemia and impaired gait speed attenuated to nonsignificance.
Conclusion
Among women, gait speed impairment is associated with low HDL cholesterol and inversely with abdominal obesity. These associations may be sex-dependent and warrant further research.
doi:10.1186/1471-2458-6-282
PMCID: PMC1654157  PMID: 17105659
20.  Longitudinal, cross-cohort comparison of physical activity patterns in Chinese mothers and children 
Background
There is limited evidence comparing adult and child physical activity (PA) trends and examining parent–child PA associations within a newly industrialized country setting. PA research within a newly industrialized country setting is particularly important given the negative effects of rapid urbanization, socioeconomic growth, and technological advances on PA behaviors. The purpose of our study was to examine trends and associations in PA behaviors in Chinese mother-child pairs and to investigate relationships between PA behaviors and socioeconomic variables in this dyad.
Methods
We studied PA behaviors in 2 separate cohorts of mother-child pairs (n = 353) followed over a 2–4 year time period using longitudinal data from the China Health and Nutrition Survey (2000 Cohort: 2000–2004; 2004 Cohort: 2004–2006). Comparable mother-child PA behaviors included total metabolic equivalent hours per week (MET-hrs/wk) from active commuting, leisure-time sports, and sedentary behaviors. Logistic regression models were used to examine associations between mother and child PA and relationships between PA behaviors and socioeconomic variables.
Results
Children experienced increases in active commuting and leisure-time sports activities with increasing child age, whereas mothers experienced temporal declines in active commuting and minimal change in leisure-time sports activity. Sedentary behavior was high for children and mothers over time. Mother-child associations were positive for active commuting and leisure-time sports activities and negative for sedentary behavior (P < 0.05). Maternal education was associated with a greater likelihood of high leisure-time sports activity and high sedentary behavior in mothers but not in children (P < 0.05).
Conclusion
Efforts to reduce sedentary behavior in Chinese mothers and children are imperative. While increased leisure-time and active commuting activities in children is encouraging, continued PA promotion in children and more intensive efforts to promote leisure-time sports and active commuting in mothers is needed.
doi:10.1186/1479-5868-9-39
PMCID: PMC3420306  PMID: 22472289
Physical activity; Sedentary behavior; China; Longitudinal; Mothers; Children; Socioeconomic
21.  Elevated resting heart rate, physical fitness and all-cause mortality: a 16-year follow-up in the Copenhagen Male Study 
Heart  2013;99(12):882-887.
Objective
To examine whether elevated resting heart rate (RHR) is an independent risk factor for mortality or a mere marker of physical fitness (VO2Max).
Methods
This was a prospective cohort study: the Copenhagen Male Study, a longitudinal study of healthy middle-aged employed men. Subjects with sinus rhythm and without known cardiovascular disease or diabetes were included. RHR was assessed from a resting ECG at study visit in 1985–1986. VO2Max was determined by the Åstrand bicycle ergometer test in 1970–1971. Subjects were classified into categories according to level of RHR. Associations with mortality were studied in multivariate Cox models adjusted for physical fitness, leisure-time physical activity and conventional cardiovascular risk factors.
Results
2798 subjects were followed for 16 years. 1082 deaths occurred. RHR was inversely related to physical fitness (p<0.001). Overall, increasing RHR was highly associated with mortality in a graded manner after adjusting for physical fitness, leisure-time physical activity and other cardiovascular risk factors. Compared to men with RHR ≤50, those with RHR >90 had an HR (95% CI) of 3.06 (1.97 to 4.75). With RHR as a continuous variable, risk of mortality increased with 16% (10–22) per 10 beats per minute (bpm). There was a borderline interaction with smoking (p=0.07); risk per 10 bpm increase in RHR was 20% (12–27) in smokers, and 14% (4–24) in non-smokers.
Conclusions
Elevated RHR is a risk factor for mortality independent of physical fitness, leisure-time physical activity and other major cardiovascular risk factors.
doi:10.1136/heartjnl-2012-303375
PMCID: PMC3664385  PMID: 23595657
Coronary Physiology; Cardiac Function
22.  The influence of self-reported leisure time physical activity and the body mass index on recovery from persistent back pain among men and women: a population-based cohort study 
BMC Public Health  2013;13:385.
Background
There is limited knowledge about leisure time physical activity and the body mass index (BMI) as prognostic factors for recovery from persistent back pain. The aim of this study was to assess the influence of leisure time physical activity and BMI on recovery from persistent back pain among men and women in a general population.
Methods
The study population (n=1836) in this longitudinal cohort study consisted of participants reporting persistent back pain in the baseline questionnaire in 2002-2003. Data on leisure time physical activity, BMI and potential confounders were also collected at baseline. Information on recovery from persistent back pain (no back pain periods ≥ 7 days during the last 5 years) was obtained from the follow-up questionnaire in 2007. Log-binomial models were applied to calculate Risk Ratios with 95 percent Confidence Intervals (CI) comparing physically active and normal weight groups versus sedentary and overweight groups.
Results
Compared to a sedentary leisure time, all measured levels of leisure time physical activity were associated with a greater chance of recovery from persistent back pain among women. The adjusted Risk Ratios was 1.46 (95% CI: 1.06, 2.01) for low leisure time physical activity, 1.51 (95% CI: 1.02, 2.23) for moderate leisure time physical activity, and 1.67 (95% CI: 1.08, 2.58) for high leisure time physical activity. There were no indications that leisure time physical activity influenced recovery among men, or that BMI was associated with recovery from persistent back pain either among men or among women.
Conclusions
Regular leisure time physical activity seems to improve recovery from persistent back pain among women.
doi:10.1186/1471-2458-13-385
PMCID: PMC3641961  PMID: 23617707
Low back pain; Physical activity; Obesity; Epidemiology; Public health
23.  Lewis phenotypes, leisure time physical activity, and risk of ischaemic heart disease: an 11 year follow up in the Copenhagen male study 
Heart  2001;85(2):159-164.
OBJECTIVE—To test the hypothesis that the predictive value for risk of fatal ischaemic heart disease associated with Lewis phenotypes depends on the level of leisure time physical activity.
DESIGN—Prospective study controlling for alcohol, tobacco, serum cotinine, blood pressure, body mass index, serum lipids, work related physical activity, and social class.
SETTING—The Copenhagen male study, Denmark.
SUBJECTS—2826 white men aged 53-75 years without overt cardiovascular disease; 266 (9.4%) had the Le(a−b−) phenotype.
MAIN OUTCOME MEASURE—Incidence of death from ischaemic heart disease during 11 years.
RESULTS—107 men died of ischaemic heart disease. Among men with a low level of leisure time physical activity (⩽ 4 hours/week moderate or ⩽ 2 hours/week more vigorous activity), being Le(a−b−) was associated with an increased risk of having a fatal ischaemic heart disease event compared with men with other Lewis phenotypes (relative risk (RR) 2.7, 95% confidence interval (CI) 1.4 to 5.2; p < 0.01). Among men with a high level of leisure time physical activity, the RR associated with being Le(a−b−) was 1.3 (95% CI 0.5 to 3.1; NS). Compared with all other alternatives tested, being Le(a−b−) and having a low level of leisure time physical activity was associated with an RR of 3.2 (95% CI 1.7 to 5.8; p < 0.001). As a point estimate and adjusted for confounding variables, among men with low leisure time physical activity the attributable risk associated with Le(a−b−) was 12%—that is, assuming that all sedentary men had phenotypes other than Le(a−b−), 12% of all fatal ischaemic heart disease events would not have occurred. The corresponding point estimate among those more active was 2%.
CONCLUSIONS—The excess risk of fatal ischaemic heart disease in middle aged and elderly men with the Le(a−b−) phenotype is strongly modified by leisure time physical activity. Public health and clinical implications may be important in populations with a predominantly sedentary lifestyle and in a high proportion of men with the Le(a−b−) phenotype.


Keywords: genetics; ischaemic heart disease; risk factors
doi:10.1136/heart.85.2.159
PMCID: PMC1729618  PMID: 11156665
24.  Lifestyle Risk Factors and New-Onset Diabetes Mellitus in Older Adults 
Archives of internal medicine  2009;169(8):798-807.
Background
The combined impact of lifestyle factors on incidence of diabetes mellitus later in life is not well established. The objective of this study was to determine how lifestyle factors, assessed in combination, relate to new-onset diabetes in a broad and relatively unselected population of older adults.
Methods
We prospectively examined associations of lifestyle factors, measured using repeated assessments later in life, with incident diabetes mellitus during a 10-year period (1989–1998) among 4883 men and women 65 years or older (mean [SD] age at baseline, 73[6] years) enrolled in the Cardiovascular Health Study. Low-risk lifestyle groups were defined by physical activity level (leisure-time activity and walking pace) above the median; dietary score (higher fiber intake and polyunsaturated to saturated fat ratio, lower trans-fat intake and lower mean glycemic index) in the top 2 quintiles; never smoked or former smoker more than 20 years ago or for fewer than 5 pack-years; alcohol use (predominantly light or moderate); body mass index less than 25 (calculated as weight in kilograms divided by height in meters squared); and waist circumference of 88 cm for women or 92 cm for men. The main outcome measure was incident diabetes defined annually by new use of insulin or oral hypoglycemic medications. We also evaluated fasting and 2-hour postchallenge glucose levels.
Results
During 34 539 person-years, 337 new cases of drug-treated diabetes mellitus occurred (9.8 per 1000 person-years). After adjustment for age, sex, race, educational level, and annual income, each lifestyle factor was independently associated with incident diabetes. Overall, the rate of incident diabetes was 35% lower (relative risk, 0.65; 95% confidence interval, 0.59–0.71) for each 1 additional lifestyle factor in the low-risk group. Participants whose physical activity level and dietary, smoking, and alcohol habits were all in the low-risk group had an 82% lower incidence of diabetes (relative risk, 0.18; 95% confidence interval, 0.06–0.56) compared with all other participants. When absence of adiposity (either body mass index <25 or waist circumference ≤88/92 cm for women/men) was added to the other 4 low-risk lifestyle factors, incidence of diabetes was 89% lower (relative risk, 0.11; 95% confidence interval, 0.01–0.76). Overall, 9 of 10 new cases of diabetes appeared to be attributable to these 5 lifestyle factors. Associations were slightly attenuated, but still highly significant, for incident diabetes defined by medication use or glucose level.
Conclusion
Even later in life, combined lifestyle factors are associated with a markedly lower incidence of new-onset diabetes mellitus.
doi:10.1001/archinternmed.2009.21
PMCID: PMC2828342  PMID: 19398692
25.  Television Viewing and Incident Cardiovascular Disease: Prospective Associations and Mediation Analysis in the EPIC Norfolk Study 
PLoS ONE  2011;6(5):e20058.
Background
Although television viewing time is detrimentally associated with intermediate cardiovascular risk factors, the relationship with incident total (i.e. combined fatal and non-fatal) cardiovascular disease (CVD), non-fatal CVD and coronary heart disease is largely unknown. This study examined whether television viewing time is associated with these three outcomes, independently of physical activity energy expenditure and other confounding variables.
Methodology/Principal Findings
A population-based cohort of 12,608 men and women (aged 61.4±9.0), free from stroke, myocardial infarction and cancer at baseline in 1998–2000 were followed up until 2007 (6.9±1.9 years). Participants self-reported education, smoking, alcohol use, antihypertensive, lipid lowering and antidepressant medication, disease history, total energy intake, sleep duration, physical activity and television viewing. BMI, waist circumference, blood pressure, triglycerides, HDL cholesterol and glycated haemoglobin (HbA1c) were measured by standardized procedures; a clustered metabolic risk score was constructed. Every one hour/day increase in television viewing was associated with an increased hazard for total (HR = 1.06, 95%CI = 1.03–1.08; 2,620 cases), non-fatal CVD (HR = 1.06, 95%CI = 1.03–1.09; 2,134 cases), and coronary heart disease (HR = 1.08, 95%CI = 1.03–1.13; 940 cases), independent of gender, age, education, smoking, alcohol, medication, diabetes status, CVD family history, sleep duration and physical activity energy expenditure. Energy intake, BMI, waist circumference, blood pressure, triglycerides, HDL cholesterol, HbA1c and the clustered metabolic risk score only partially mediated these associations.
Conclusions
These results indicate that the most prevalent leisure time (sedentary) behaviour, television viewing, independently contributes to increased CVD risk. Recommendations on reducing television viewing time should be considered.
doi:10.1371/journal.pone.0020058
PMCID: PMC3102066  PMID: 21647437

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