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author:("eklund, Ulf")
2.  Physical activity, sedentary time and gain in overall and central body fat: seven year follow-up of the ProActive trial cohort 
To examine the independent associations of time spent in moderate-to-vigorous physical activity (MVPA) and sedentary (SED-time), with total and abdominal body fat (BF), and the bidirectionality of these associations in adults at high risk of type 2 diabetes.
Design and subjects
We measured MVPA (min/day) and SED-time (h/day) by accelerometry, and indices of total [body weight, fat mass (FM), body-fat-percentage and fat mass index] and abdominal BF [waist circumference (WC)] using standard procedures in 231 adults (41.3±6.4y) with parental history of type 2 diabetes (ProActive UK), at baseline, 1y and 7y follow-up. Mixed effects models were used to quantify the independent associations [expressed as standardised β-coefficients (95% CI)] of MVPA and SED-time with fat-indices, using data from all 3 time points. All models were adjusted for age, sex, intervention arm, monitor wear time, follow-up time, smoking status, socioeconomic status and MVPA/SED-time.
MVPA was inversely and independently associated with all indices of total BF [e.g. 1SD higher MVPA was associated with a reduction in FM, β=-0.09 (95% CI −0.14,−0.04) SD] and abdominal BF [e.g. WC: β=-0.07 (−0.12, −0.02)]. Similarly, higher fat-indices were independently associated with a reduction in MVPA [e.g. WC: β= −0.25 (−0.36,−0.15); FM: β=-0.27 (−0.36,−0.18)]. SED-time was positively and independently associated with most fat-indices [e.g. WC: β=0.03 (−0.04, 0.09); FM: β=0.10 (0.03, 0.17)]. Higher values of all fat-indices independently predicted longer SED-time [e.g. WC: β= 0.10 (0.02, 0.18), FM: β= 0.15 (0.07, 0.22)].
The associations of MVPA and SED-time with total and abdominal BF are bidirectional and independent among individuals at high risk for diabetes. The association between BF and MVPA is stronger than the reciprocal association, highlighting the importance of considering BF as a determinant of decreasing activity and a potential consequence. Promoting more MVPA and less SED-time may reduce total and abdominal BF.
PMCID: PMC4113455  PMID: 24732143
moderate to vigorous physical activity; sedentary time; body fat; type 2 diabetes; family history
3.  Patterns and correlates of objectively measured free-living physical activity in adults in rural and urban Cameroon 
Urbanisation in sub-Saharan Africa is changing lifestyles and raising non-communicable disease burden. Understanding the underlying pattern of physical activity and its correlates may inform preventive interventions. We examined correlates of objectively-measured physical activity in rural and urban Cameroon.
Participants were 544 adults resident in rural (W-156, M-89) or urban (W-189, M-110) regions. Physical activity was measured using individually-calibrated combined heart rate and movement sensing over seven continuous days. Sociodemographic data were collected by self-report. Independent associations of sociodemographic correlates with physical activity energy expenditure (PAEE) or moderate-to-vigorous physical activity (MVPA) were analysed in multivariate regression models.
Rural dwellers were significantly more active than their urban counterparts (PAEE: 58.0 vs 42.9 kJ/kg/day; MVPA: 107 vs 62 min/day; MVPA of 150 min/week in >10 min bouts: 62 vs 39%) and less sedentary (923 vs 1026 min/day); p<0.001. There was no significant seasonal difference (dry vs rainy) in activity in urban dwellers whereas in rural dwellers activity was higher during dry seasons compared to rainy seasons (p<0.001). Age, obesity and education showed significant inverse associations with activity. Urban dwellers who considered themselves adequately active were only as active as rural dwellers who thought they were not adequately active.
This is the first study providing data on sociodemographic patterning of objectively-measured physical activity in rural and urban sub-Saharan Africa. Age, urban residence, obesity and higher educational level are important correlates of lower levels of physical activity. These suggest targets for public health interventions to improve physical activity in Cameroon.
PMCID: PMC4484252  PMID: 25841243
PHYSICAL ACTIVITY; Epidemiology of chronic non communicable diseases; DEVELOPING COUNTR
4.  Skåne Emergency Department Assessment of Patient Load (SEAL)—A Model to Estimate Crowding Based on Workload in Swedish Emergency Departments 
PLoS ONE  2015;10(6):e0130020.
Emergency department (ED) crowding is an increasing problem in many countries. The purpose of this study was to develop a quantitative model that estimates the degree of crowding based on workload in Swedish EDs.
At five different EDs, the head nurse and physician assessed the workload on a scale from 1 to 6 at randomized time points during a three week period in 2013. Based on these assessments, a regression model was created using data from the computerized patient log system to estimate the level of crowding based on workload. The final model was prospectively validated at the two EDs with the largest census.
Workload assessments and data on 14 variables in the patient log system were collected at 233 time points. The variables Patient hours, Occupancy, Time waiting for the physician and Fraction of high priority (acuity) patients all correlated significantly with the workload assessments. A regression model based on these four variables correlated well with the assessed workload in the initial dataset (r2 = 0.509, p < 0.001) and with the assessments in both EDs during validation (r2 = 0.641; p < 0.001 and r2 = 0.624; p < 0.001).
It is possible to estimate the level of crowding based on workload in Swedish EDs using data from the patient log system. Our model may be applicable to EDs with different sizes and characteristics, and may be used for continuous monitoring of ED workload. Before widespread use, additional validation of the model is needed.
PMCID: PMC4470939  PMID: 26083596
5.  Change in objectively measured physical activity during the transition to adolescence 
British Journal of Sports Medicine  2013;49(11):730-736.
Physical activity (PA) declines during adolescence but change in different PA intensities across population subgroups is rarely explored. We describe change in sedentary (SED) time, light (LPA), moderate (MPA) and vigorous PA (VPA) assessed at three time points over 4 years.
Accelerometer-assessed PA (min) was obtained at baseline (N=2064), 1 and 4 years later among British children (baseline mean±SD 10.2±0.3-year-old; 42.5% male). Change in SED (<100 counts/min (cpm)), LPA (101–1999 cpm), MPA (2000–3999 cpm) and VPA (≥4000 cpm) was studied using three-level (age, individual and school) mixed-effects linear regression including participants with data at ≥2 time points (N=990). Differences in change by sex, home location and weight status were explored with interactions for SED, LPA and moderate and vigorous PA (MVPA).
SED increased by 10.6 (95% CI 9.1 to 12.2) min/day/year. MPA and VPA decreased by 1.4 (1.0 to 1.8) and 1.5 (1.1 to 1.8) min/day/year, respectively. VPA decreased more than MPA as a percentage of the baseline value. MVPA declined more steeply among boys (3.9 (3.0 to 4.8)) versus girls (2.0 (1.2 to 2.7) min/day/year) despite lower MVPA among girls at all ages; rural (4.4 (3.5 to 5.2)) versus urban individuals (1.3 (0.4 to 2.3) min/day/year) and on weekends (6.7 (5.2 to 8.1)) versus weekdays (2.8 (1.9 to 3.7) min/day/year). MVPA was consistently lower among overweight/obese individuals (−17.5 (−3.9 to −2.5) min/day/year).
PA decreases and is replaced by SED during early adolescence in British youth. Results indicate the urgency of PA promotion among all adolescents but especially girls and in rural areas. Increasing VPA and targeting PA promotion during weekends appear important.
PMCID: PMC4453714  PMID: 24273308
Health Promotion Through Physical Activity; Adolescents; Physical Activity Promotion in Primary Care
6.  Prospective associations between sedentary time, sleep duration and adiposity in adolescents 
Sleep Medicine  2015;16(6):717-722.
•We examined sedentary time and sleep length relative to changes in youth adiposity.•Sedentary time was not associated with change in adiposity in either gender.•Sleep duration was significantly inversely associated with adiposity gain in boys.•The association for sleep in boys was attenuated by physical activity and depression.
The objective of this study was to investigate whether objectively measured sedentary time and sleep duration are associated with changes in adiposity from mid- to late adolescence.
Students (n = 504, 42% boys) were recruited from schools in Cambridgeshire, UK. At baseline (mean age 15.0 ± 0.3 years), sedentary time was objectively measured by ≥3 days of combined heart rate and movement sensing. Concurrently, sleep duration was measured by combined sensing in conjunction with self-reported bed times. Fat mass index (FMI; kg/m2) was estimated at baseline and follow-up (17.5 ± 0.3 years) by anthropometry and bioelectrical impedance. FMI change (ΔFMI) was calculated by subtracting the baseline from follow-up values. Linear regression models adjusted for basic demographics, moderate-to-vigorous physical activity (MVPA), and depressive symptoms were used to investigate associations of sedentary time and sleep duration (mutually adjusted for one another) with ΔFMI.
FMI increased by 0.5 and 0.6 kg/m2 in boys and girls, respectively, but there was no association between sedentary time and ΔFMI in either gender (p ≥ 0.087), and no association between sleep duration and ΔFMI in girls (p ≥ 0.61). In boys, each additional hour of baseline sleep significantly reduced the ΔFMI by 0.13 kg/m2 (p = 0.049), but there was little evidence for this association after adjusting for MVPA and depressive symptoms (p = 0.15).
Sedentary time may not determine changes in adiposity from mid- to late adolescence, nor may sleep duration in girls. However, sleep length may be inversely associated with adiposity gain in boys, depending on whether the relationship is confounded or mediated by MVPA and depression.
PMCID: PMC4465960  PMID: 25959093
Sedentariness; Sleep length; Body fatness; Obesity; Youth; Cohort study; FM, fat mass; FFM, fat-free mass; FFMI, fat-free mass index; FMI, fat mass index; METs, metabolic equivalents of thermogenesis; MVPA, moderate-to-vigorous physical activity; PAEE, physical activity energy expenditure; SES, socio-economic status; ΔFFMI, change in fat-free mass index; ΔFMI, change in fat mass index
7.  Magnitude and determinants of change in objectively-measured physical activity, sedentary time and sleep duration from ages 15 to 17.5y in UK adolescents: the ROOTS study 
Self-reported physical activity (PA) and sleep duration (SLP) change markedly throughout adolescence. We sought to quantify changes in objectively-measured PA, sedentary time (ST) and SLP through adolescence, and to investigate baseline body composition and baseline activity levels as determinants of change.
Individually calibrated combined heart rate and movement sensing was used to estimate PA energy expenditure (PAEE), SLP, daily ST and time in light (LPA), moderate (MPA), vigorous (VPA), and moderate-to-vigorous physical activity (MVPA) in 144 adolescents (50 % boys) of mean age 15.1(±0.3)y at baseline and 17.5(±0.3)y at follow-up. Changes in PA (ΔPA), ST (ΔST) and SLP (ΔSLP) were calculated as follow-up minus baseline values. Waist circumference (WC) was measured at baseline and follow-up, as was fat mass index (FMI) and fat-free mass index (FFMI) by a pooled estimation method including bio-impedance. Comparison of baseline and follow-up activity was made by mixed-model ANOVA. Linear regression adjusted for baseline demographics, total and weekend hours of monitor wear time and the seasons of activity measurements, was used to investigate baseline body composition as determinants of ΔPA, ΔST and ΔSLP. A further model adjusted for baseline of the outcome assessed baseline activity as a predictor of behaviour change, and investigated associations for baseline body composition independent of the baseline level of the outcome.
From baseline to follow-up levels of MPA and VPA declined (p ≤ 0.039). The annual decline in MVPA was equivalent to -4.5 and -3.0 min/d in boys and girls, respectively. Baseline FMI, FFMI and WC were positively associated with ΔLPA and negatively associated with ΔST in boys when adjusted for baseline of the outcome (p ≤ 0.037 for all). SLP increased from baseline to follow-up (p = 0.004) but ΔSLP was not associated with baseline body composition (p ≥ 0.13). For all variables, higher baseline levels were associated with greater declines over time (p ≤ 0.003).
Levels of higher-intensity PA decline from mid-to-late adolescence, whereas the duration of sleep increases. Changes in LPA and ST may be associated with baseline body composition, but the baseline level of the outcome is consistently the strongest predictor of changes in adolescent activity.
PMCID: PMC4437669  PMID: 25971606
Motor activity; Energy Expenditure; Physical activity intensity; Sedentary time; Sleep duration; Reverse causation; Adolescents
8.  A cluster-randomised controlled trial to assess the effectiveness and cost-effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6–7 year old children: the WAVES study protocol 
BMC Public Health  2015;15:488.
There is some evidence that school-based interventions are effective in preventing childhood obesity. However, longer term outcomes, equity of effects and cost-effectiveness of interventions have not been assessed.
The aim of this trial is to assess the clinical and cost-effectiveness of a multi-component intervention programme targeting the school and family environment through primary schools, in preventing obesity in 6–7 year old children, compared to usual practice.
This cluster randomised controlled trial is set in 54 primary schools within the West Midlands, UK, including a multi-ethnic, socioeconomically diverse population of children aged 6–7 years.
The 12-month intervention consists of healthy diet and physical activity promotion. These include: activities to increase time spent doing physical activity within the school day, participation in the ‘Villa Vitality’ programme (a programme that is delivered by an iconic sporting institution (Aston Villa Football Club), which provides interactive learning opportunities for physical activity and healthy eating), healthy cooking skills workshops in school time for parents and children, and provision of information to families signposting local leisure opportunities. The primary (clinical) outcome is the difference in body mass index (BMI) z-scores between arms at 3 and 18 months post-intervention completion. Cost per Quality Adjusted Life Year (QALY) will also be assessed. The sample size estimate (1000 children split across 50 schools at follow-up) is based on 90% power to detect differences in BMI z-score of 0.25 (estimated ICC ≤ 0.04), assuming a correlation between baseline and follow-up BMI z-score of 0.9. Treatment effects will be examined using mixed model ANCOVA. Primary analysis will adjust for baseline BMI z-score, and secondary analysis will adjust for pre-specified baseline school and child level covariates.
The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study is the first trial that will examine the cost-effectiveness and long term outcomes of a childhood obesity prevention programme in a multi-ethnic population, with a sufficient sample size to detect clinically important differences in adiposity. The intervention was developed using the Medical Research Council framework for complex interventions, and outcomes are measured objectively, together with a comprehensive process evaluation.
Trial registration
Current Controlled Trials ISRCTN97000586 (registered May 2010).
PMCID: PMC4457211  PMID: 25968599
Cluster randomised controlled trial; Complex intervention; Childhood obesity prevention; Physical activity; Healthy eating; Cost-effectiveness
9.  Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department 
SpringerPlus  2015;4:219.
In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions (‘gestalt’). The aim of this study was to determine the diagnostic value of the ED physician’s overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included. The ED physician’s interpretation of the chest pain history, the ECG, and the global likelihood of ACS were recorded on special forms. The discharge diagnoses were retrieved from the medical records. A chart review was carried out to determine whether patients with a non-ACS diagnosis at the index visit had ACS or suffered cardiac death within 30 days. The gestalt was better than its components both at ruling in (“Obvious ACS”, LR 29) and at ruling out (“No Suspicion of ACS”, LR 0.01) ACS. In the “Strong suspicion of ACS” group, 60% of the patients did not have ACS. A positive TnT (LR 24.9) and an ischemic ECG (LR 8.3) were strong predictors of ACS and seemed superior to pain history for ruling in ACS. In patients with a normal TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI (LR 1.9) while pain history typical of unstable angina (UA) was a moderate predictor of UA (LR 4.7). Clinical gestalt was better than its components both at ruling in and at ruling out ACS, but overestimated the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS.
Electronic supplementary material
The online version of this article (doi:10.1186/s40064-015-0992-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4431985  PMID: 25992314
Acute coronary syndrome; Chest pain; ECG; Diagnosis; Gestalt; Probability
10.  A New Approach to Define and Diagnose Cardiometabolic Disorder in Children 
Journal of Diabetes Research  2015;2015:539835.
The aim of the study was to test the performance of a new definition of metabolic syndrome (MetS), which better describes metabolic dysfunction in children. Methods. 15,794 youths aged 6–18 years participated. Mean z-score for CVD risk factors was calculated. Sensitivity analyses were performed to evaluate which parameters best described the metabolic dysfunction by analysing the score against independent variables not included in the score. Results. More youth had clustering of CVD risk factors (>6.2%) compared to the number selected by existing MetS definitions (International Diabetes Federation (IDF) < 1%). Waist circumference and BMI were interchangeable, but using insulin resistance homeostasis model assessment (HOMA) instead of fasting glucose increased the score. The continuous MetS score was increased when cardiorespiratory fitness (CRF) and leptin were included. A mean z-score of 0.40–0.85 indicated borderline and above 0.85 indicated clustering of risk factors. A noninvasive risk score based on adiposity and CRF showed sensitivity and specificity of 0.85 and an area under the curve of 0.92 against IDF definition of MetS. Conclusions. Diagnosis for MetS in youth can be improved by using continuous variables for risk factors and by including CRF and leptin.
PMCID: PMC4402570  PMID: 25945355
11.  Associations between diet, physical activity and body fat distribution: a cross sectional study in an Indian population 
BMC Public Health  2015;15:281.
Obesity is a growing health problem in India and worldwide, due to changes in lifestyle. This study aimed to explore the independent associations between dietary and physical activity exposure variables and total body fat and distribution in an Indian setting.
Individuals who had participated in the Indian Migration Study (IMS) or the Andhra Pradesh Children And Parents' Study (APCAPS), were invited to participate in the Hyderabad DXA Study. Total and abdominal body fat of study participants was measured using DXA scans. Diet and physical activity (PA) levels were measured using questionnaires.
Data on 2208 participants was available for analysis; mean age was 49 yrs in IMS, 21 yrs in APCAPS. Total energy intake was positively associated with total body fat in the APCAPS sample: a 100 kcal higher energy intake was associated with 45 g higher body fat (95% CI 22, 68). In the IMS sample no association was found with total energy intake, but there was a positive association with percent protein intake (1% higher proportion of energy from protein associated with 509 g (95% CI 138,880) higher total body fat). Broadly the same pattern of associations was found with proportion of fat in the abdominal region as the outcome. PA was inversely associated with total body fat in both populations (in APCAPS, one MET-hour higher activity was associated with 46 g (95% CI 12, 81) less body fat; in the IMS it was associated with 145 g less body fat (95% CI 73, 218)). An inverse association was observed between PA and percentage abdominal fat in the IMS but no association was seen in the APCAPS population.
In this Indian population, there was an inverse association between PA and body fat. Associations between body fat and dietary variables differed between the younger APCAPS population and older IMS population. Further longitudinal research is needed to elucidate causality and directions of these associations across the life course.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-1550-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4381479  PMID: 25885589
Obesity; Body fat; Diet; Physical activity; India
12.  The changing relationship between rainfall and children’s physical activity in spring and summer: a longitudinal study 
Weather conditions, along with day length, are proposed as the main drivers of the seasonal patterns in children’s physical activity (PA), but little is known about how they affect children at different ages. This study examines the relationship between rainfall and PA in a longitudinal cohort of initially 9–10 year-old children in Norfolk, UK.
Participants were 283 children from the SPEEDY study who wore accelerometers ≤7 days on three occasions in the summer of 2007, 2008 and 2011 at ages 9–10, 10–11, and 13-14y. Daily weather data were obtained for two local weather stations. Relationships between rainfall and PA (moderate-to-vigorous-PA (MVPA; ≥2000) vigorous PA (VPA; ≥4000), counts per minute (cpm)) and sedentary time were assessed in multiple-membership multilevel models. PA was assessed over the whole day, and over parts of the school day; commute time (8 am-9 am and 3 pm-4 pm), lunchtime (12noon-2 pm), and after school (4 pm-9 pm).
At ages 9–10 and 10-11y, PA declined with increasing rainfall, with an average of 14.0 (SE 2.9) and 11.4 (3.0) minutes less MVPA on the wettest days (≥1.7 mm rain) compared to dry days respectively. There was no significant trend in MVPA across rainfall categories at age 13–14 years. Between ages 9–10 and 13–14, MVPA decline was largest on dry days (-15.2 (2.7) minutes). These patterns were also apparent during school lunchtime and after school, however they were not seen during school commute times. Similar patterns were seen for other PA intensities.
Increased rainfall is associated with significant decreases in PA among primary school children, but not secondary school children. PA declines most steeply between the ages of 9–10 and 13–14 on dry days. Interventions to increase activity on wet days may be most relevant at primary schools. Our results also highlight the importance of habitualising behavior to make children more resilient both to bad weather, and potentially age-related decline in activity.
Electronic supplementary material
The online version of this article (doi:10.1186/s12966-015-0202-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4377032  PMID: 25890259
Physical activity; Weather; School; Children; Rainfall
13.  Perceived family functioning and friendship quality: cross-sectional associations with physical activity and sedentary behaviours 
This study examined the association of adolescent-reported family functioning and friendship quality with objectively-measured moderate to vigorous physical activity (MVPA), sedentary time, and self-reported sedentary behaviours.
Data are from the ROOTS study. MVPA and sedentary time were assessed using combined movement and heart rate sensing. Time spent TV viewing, using the internet, playing video games, doing homework and reading for pleasure was self-reported. Data on objectively-measured and self-reported outcomes for weekdays was available for 738 (age 14.5y, 55.7% female) and 800 (56.3% female) participants, respectively. Adolescents perceived family functioning and friendship quality (Two subscales: ‘Good friendship qualities’, ‘Friendship difficulties’) was assessed by questionnaire. Analyses were conducted using multi-level linear or logistic regression.
Adolescents reporting better family functioning accumulated more MVPA on weekdays (beta; 95% confidence interval: 0.57; 0.17,0.98). Higher scores on the good friendship qualities subscale was associated with greater MVPA throughout the week (weekdays: 1.13; 0.62,1.65, weekend: 0.56; 0.09,1.02) and lower sedentary time on weekdays (−10.34; −17.03,-3.66). Boys from better functioning families were less likely to report playing video games at the weekend (OR; 95% confidence interval: 0.73; 0.57,0.93) or reading for pleasure (weekday: 0.73; 0.56,0.96 weekend: 0.75; 0.58,0.96). Boys who attained higher scores on the good friendship qualities scale were less likely to play video games at the weekend (0.61; 0.44,0.86) or report high homework on weekdays (0.54; 0.31,0.94). A higher score for good friendship qualities was associated with lower odds of girls playing video games during the week (0.76; 0.58,1.00) or reading for pleasure at the weekend (0.61; 0.42,0.88). Girls that reported fewer friendship difficulties had lower odds of high TV viewing (0.76; 0.62,0.93) or playing video games (0.71; 0.52,0.97) at the weekend, and lower odds of reading for pleasure (0.63; 0.49,0.81) or reporting high homework on weekdays (0.70; 0.52,0.95).
Family functioning and friendship quality exhibit a complex pattern of association with physical activity and sedentary behaviour that varies by sex and day of the week. Findings highlight the potential value of targeting interpersonal aspects of the family and friendships as an adjunct to behaviour change interventions.
PMCID: PMC4340106  PMID: 25886077
Adolescents; Family; Peers; Physical activity; Sedentary behaviour
14.  Association of car ownership and physical activity across the spectrum of human development: Modeling the Epidemiologic Transition Study (METS) 
BMC Public Health  2015;15:173.
Variations in physical activity (PA) across nations may be driven by socioeconomic position. As national incomes increase, car ownership becomes within reach of more individuals. This report characterizes associations between car ownership and PA in African-origin populations across 5 sites at different levels of economic development and with different transportation infrastructures: US, Seychelles, Jamaica, South Africa, and Ghana.
Twenty-five hundred adults, ages 25–45, were enrolled in the study. A total of 2,101 subjects had valid accelerometer-based PA measures (reported as average daily duration of moderate to vigorous PA, MVPA) and complete socioeconomic information. Our primary exposure of interest was whether the household owned a car. We adjusted for socioeconomic position using household income and ownership of common goods.
Overall, PA levels did not vary largely between sites, with highest levels in South Africa, lowest in the US. Across all sites, greater PA was consistently associated with male gender, fewer years of education, manual occupations, lower income, and owning fewer material goods. We found heterogeneity across sites in car ownership: after adjustment for confounders, car owners in the US had 24.3 fewer minutes of MVPA compared to non-car owners in the US (20.7 vs. 45.1 minutes/day of MVPA); in the non-US sites, car-owners had an average of 9.7 fewer minutes of MVPA than non-car owners (24.9 vs. 34.6 minutes/day of MVPA).
PA levels are similar across all study sites except Jamaica, despite very different levels of socioeconomic development. Not owning a car in the US is associated with especially high levels of MVPA. As car ownership becomes prevalent in the developing world, strategies to promote alternative forms of active transit may become important.
PMCID: PMC4359522  PMID: 25885263
Physical Activity; Socioeconomic Status; African American; African Populations; Automobile Ownership
15.  A Primary Care Nurse-Delivered Walking Intervention in Older Adults: PACE (Pedometer Accelerometer Consultation Evaluation)-Lift Cluster Randomised Controlled Trial 
PLoS Medicine  2015;12(2):e1001783.
Brisk walking in older people can increase step-counts and moderate to vigorous intensity physical activity (MVPA) in ≥10-minute bouts, as advised in World Health Organization guidelines. Previous interventions have reported step-count increases, but not change in objectively measured MVPA in older people. We assessed whether a primary care nurse-delivered complex intervention increased objectively measured step-counts and MVPA.
Methods and Findings
A total of 988 60–75 year olds, able to increase walking and randomly selected from three UK family practices, were invited to participate in a parallel two-arm cluster randomised trial; randomisation was by household. Two-hundred-ninety-eight people from 250 households were randomised between 2011 and 2012; 150 individuals to the intervention group, 148 to the usual care control group. Intervention participants received four primary care nurse physical activity (PA) consultations over 3 months, incorporating behaviour change techniques, pedometer step-count and accelerometer PA intensity feedback, and an individual PA diary and plan. Assessors were not blinded to group status, but statistical analyses were conducted blind. The primary outcome was change in accelerometry assessed average daily step-counts between baseline and 3 months, with change at 12 months a secondary outcome. Other secondary outcomes were change from baseline in time in MVPA weekly in ≥10-minute bouts, accelerometer counts, and counts/minute at 3 months and 12 months. Other outcomes were adverse events, anthropometric measures, mood, and pain. Qualitative evaluations of intervention participants and practice nurses assessed the intervention’s acceptability. At 3 months, eight participants had withdrawn or were lost to follow-up, 280 (94%) individuals provided primary outcome data. At 3 months changes in both average daily step-counts and weekly MVPA in ≥10-minute bouts were significantly higher in the intervention than control group: by 1,037 (95% CI 513–1,560) steps/day and 63 (95% CI 40–87) minutes/week, respectively. At 12 months corresponding differences were 609 (95% CI 104–1,115) steps/day and 40 (95% CI 17–63) minutes/week. Counts and counts/minute showed similar effects to steps and MVPA. Adverse events, anthropometry, mood, and pain were similar in the two groups. Participants and practice nurses found the intervention acceptable and enjoyable.
The PACE-Lift trial increased both step-counts and objectively measured MVPA in ≥10-minute bouts in 60–75 year olds at 3 and 12 months, with no effect on adverse events. To our knowledge, this is the first trial in this age group to demonstrate objective MVPA increases and highlights the value of individualised support incorporating objective PA assessment in a primary care setting.
Trial Registration ISRCTN42122561
In this cluster randomized controlled trial, Tess Harris and colleagues investigate whether a program delivered by primary care nurses to older adults can increase bouts of moderate to vigorous physical activity.
Editors’ Summary
Worldwide, people are becoming increasingly sedentary. They are sitting at desks instead of doing manual labor; they are driving to work instead of walking; and they are participating in fewer leisure time physical activities. But the human body needs regular exercise to stay healthy. Physical activity helps to maintain a healthy weight and prevents or delays heart disease, type 2 diabetes, and some cancers. Moreover, physically active people feel better and live longer than physically inactive people. The World Health Organization recommends that adults should be active daily and should do at least 150 minutes of moderate- to vigorous-intensity physical activity (MVPA) every week in bouts that each last at least 10 minutes. Moderate-intensity physical activities (for example, brisk walking) require a moderate amount of effort and noticeably increase the heart rate; vigorous-intensity physical activities (for example, running) require a large amount of effort and cause rapid breathing and a substantial heart rate increase.
Why Was This Study Done?
When physical activity is objectively measured using an accelerometer (a movement monitor that is usually worn on the waist; unlike pedometers, which simply count the number of steps a person takes, accelerometers record both step-counts and the intensity of physical activity), fewer than 5% of older people achieve the recommended weekly levels of MVPA. These levels could be reached by taking regular brisk walks but how can older people be persuaded to make such walks part of their daily lives? In this cluster randomized controlled trial—the PACE (Pedometer Accelerometer Consultation Evaluation)-Lift trial—the researchers assess whether an intervention to increase walking comprising pedometer and accelerometer feedback combined with physical activity consultations provided by practice nurses can lead to sustained increases in physical activity in 60–75 year olds. Cluster randomized trials compare outcomes in groups of people (here, husbands and wives living in one household) assigned through the play of chance to receive a test or a control intervention.
What Did the Researchers Do and Find?
The researchers assigned 298 people from 250 households to receive the intervention or usual care and determined the participants’ physical activity at baseline, 3 months, and 12 months by asking them to wear an accelerometer for 7 days. Intervention group participants received four physical activity consultations with a primary care nurse over 3 months. At the first consultation, the nurse gave each participant a pedometer to measure step-counts, a physical activity diary in which to record their goals and progress, and the PACE-Lift patient handbook. At each consultation, the nurse used behavior change techniques (for example, goal setting) to encourage the participant to walk regularly, gave the participant visual feedback from their accelerometer readings, and devised a personal walking plan. Control group participants received normal care only from the practice. At 3 months and 12 months, both the average daily step-count and the weekly MVPA level had decreased from baseline in the control group but increased in the intervention group. At 3 months, compared to the control group, the average step-count in the intervention group was 1,037 steps/day higher and the MVPA in bouts of more than 10 minutes in the intervention group was 63 minutes/week higher. At 12 months, the corresponding differences were 609 steps/day and 40 minutes/week. There were no significant differences in adverse events (for example, pain), body fat, or other measured health-related outcomes between the groups.
What Do These Findings Mean?
These findings show that the complex intervention tested in the PACE-Lift trial increased both step-counts and objectively measured MPVA among 60–75 year olds for at least 12 months. Importantly, all the participants and practice nurses were positive and enthusiastic about the intervention. Moreover, the observed increase in physical activity is estimated to reduce the participants’ risk of heart disease and type 2 diabetes by an estimated 5.5% and 9.1%, respectively. Further trials are needed to determine which aspects of the intervention were responsible for increasing physical activity, to determine whether the intervention’s effects will persist for longer than 12 months, and to test the intervention in socio-economically diverse populations (all the PACE-Lift participants came from an affluent, non-ethnically diverse area). However, these findings highlight the value of family practices providing older individuals with individualized support that incorporates objective assessment of physical activity to help them become more physically active.
Additional Information
Please access these websites via the online version of this summary at
The US Centers for Disease Control and Prevention provides information on all aspects of healthy living; its Physical Activity for Everyone web pages include guidelines for older people, instructional videos, and personal success stories (some information in English and Spanish)
The World Health Organization provides information about physical activity and health (in several languages); its Global Recommendations on Physical Activity for Health are available in several languages
The UK National Health Service information source Choices explains the benefits of regular physical activity, provides recommendations for older people, and includes tips for exercising and some personal stories
MedlinePlus has links to other resources about exercise and physical fitness (in English and Spanish)
More information about the PACE-Lift trial protocol is available
PMCID: PMC4331517  PMID: 25689364
16.  Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC)123456 
Background: The higher risk of death resulting from excess adiposity may be attenuated by physical activity (PA). However, the theoretical number of deaths reduced by eliminating physical inactivity compared with overall and abdominal obesity remains unclear.
Objective: We examined whether overall and abdominal adiposity modified the association between PA and all-cause mortality and estimated the population attributable fraction (PAF) and the years of life gained for these exposures.
Design: This was a cohort study in 334,161 European men and women. The mean follow-up time was 12.4 y, corresponding to 4,154,915 person-years. Height, weight, and waist circumference (WC) were measured in the clinic. PA was assessed with a validated self-report instrument. The combined associations between PA, BMI, and WC with mortality were examined with Cox proportional hazards models, stratified by center and age group, and adjusted for sex, education, smoking, and alcohol intake. Center-specific PAF associated with inactivity, body mass index (BMI; in kg/m2) (>30), and WC (≥102 cm for men, ≥88 cm for women) were calculated and combined in random-effects meta-analysis. Life-tables analyses were used to estimate gains in life expectancy for the exposures.
Results: Significant interactions (PA × BMI and PA × WC) were observed, so HRs were estimated within BMI and WC strata. The hazards of all-cause mortality were reduced by 16–30% in moderately inactive individuals compared with those categorized as inactive in different strata of BMI and WC. Avoiding all inactivity would theoretically reduce all-cause mortality by 7.35% (95% CI: 5.88%, 8.83%). Corresponding estimates for avoiding obesity (BMI >30) were 3.66% (95% CI: 2.30%, 5.01%). The estimates for avoiding high WC were similar to those for physical inactivity.
Conclusion: The greatest reductions in mortality risk were observed between the 2 lowest activity groups across levels of general and abdominal adiposity, which suggests that efforts to encourage even small increases in activity in inactive individuals may be beneficial to public health.
PMCID: PMC4340064  PMID: 25733647
cohort study; epidemiology; obesity; physical activity; exercise; mortality; population attributable fraction
17.  Towards the integration and development of a cross-European research network and infrastructure: the DEterminants of DIet and Physical ACtivity (DEDIPAC) Knowledge Hub 
To address major societal challenges and enhance cooperation in research across Europe, the European Commission has initiated and facilitated ‘joint programming’. Joint programming is a process by which Member States engage in defining, developing and implementing a common strategic research agenda, based on a shared vision of how to address major societal challenges that no Member State is capable of resolving independently. Setting up a Joint Programming Initiative (JPI) should also contribute to avoiding unnecessary overlap and repetition of research, and enable and enhance the development and use of standardised research methods, procedures and data management. The Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub (KH) is the first act of the European JPI ‘A Healthy Diet for a Healthy Life’. The objective of DEDIPAC is to contribute to improving understanding of the determinants of dietary, physical activity and sedentary behaviours. DEDIPAC KH is a multi-disciplinary consortium of 46 consortia and organisations supported by joint programming grants from 12 countries across Europe. The work is divided into three thematic areas: (I) assessment and harmonisation of methods for future research, surveillance and monitoring, and for evaluation of interventions and policies; (II) determinants of dietary, physical activity and sedentary behaviours across the life course and in vulnerable groups; and (III) evaluation and benchmarking of public health and policy interventions aimed at improving dietary, physical activity and sedentary behaviours. In the first three years, DEDIPAC KH will organise, develop, share and harmonise expertise, methods, measures, data and other infrastructure. This should further European research and improve the broad multi-disciplinary approach needed to study the interactions between multilevel determinants in influencing dietary, physical activity and sedentary behaviours. Insights will be translated into more effective interventions and policies for the promotion of healthier behaviours and more effective monitoring and evaluation of the impacts of such interventions.
Electronic supplementary material
The online version of this article (doi:10.1186/s12966-014-0143-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4245771  PMID: 25731079
Diet; Physical activity; Sedentary behaviour; Joint programming; Lifestyle; Prevention; Measurement; Determinants; Interventions; Policy
18.  Heritability of objectively assessed daily physical activity and sedentary behavior1234 
Background: Twin and family studies that estimated the heritability of daily physical activity have been limited by poor measurement quality and a small sample size.
Objective: We examined the heritability of daily physical activity and sedentary behavior assessed objectively by using combined heart rate and movement sensing in a large twin study.
Design: Physical activity traits were assessed in daily life for a mean (±SD) 6.7 ± 1.1 d in 1654 twins from 420 monozygotic and 352 dizygotic same-sex twin pairs aged 56.3 ± 10.4 y with body mass index (in kg/m2) of 26.1 ± 4.8. We estimated the average daily movement, physical activity energy expenditure, and time spent in moderate-to-vigorous intensity physical activity and sedentary behavior from heart rate and acceleration data. We used structural equation modeling to examine the contribution of additive genetic, shared environmental, and unique environmental factors to between-individual variation in traits.
Results: Additive genetic factors (ie, heritability) explained 47% of the variance in physical activity energy expenditure (95% CI: 23%, 53%) and time spent in moderate-to-vigorous intensity physical activity (95% CI: 29%, 54%), 35% of the variance in acceleration of the trunk (95% CI: 0%, 44%), and 31% of the variance in the time spent in sedentary behavior (95% CI: 9%, 51%). The remaining variance was predominantly explained by unique environmental factors and random error, whereas shared environmental factors played only a marginal role for all traits with a range of 0–15%.
Conclusions: The between-individual variation in daily physical activity and sedentary behavior is mainly a result of environmental influences. Nevertheless, genetic factors explain up to one-half of the variance, suggesting that innate biological processes may be driving some of our daily physical activity.
PMCID: PMC3798083  PMID: 24047914
19.  Physical activity levels in three Brazilian birth cohorts as assessed with raw triaxial wrist accelerometry 
Background: Data on objectively measured physical activity are lacking in low- and middle-income countries. The aim of this study was to describe objectively measured overall physical activity and time spent in moderate-to-vigorous physical activity (MVPA) in individuals from the Pelotas (Brazil) birth cohorts, according to weight status, socioeconomic status (SES) and sex.
Methods: All children born in 1982, 1993 and 2004 in hospitals in the city of Pelotas, Brazil, constitute the sampling frame; of these 99% agreed to participate. The most recent follow-ups were conducted between 2010 and 2013. In total, 8974 individuals provided valid data derived from raw triaxial wrist accelerometry. The average acceleration is presented in milli-g (1 mg = 0.001g), and time (min/d) spent in MVPA (>100 mg) is presented in 5- and 10-min bouts.
Results: Mean acceleration in the 1982 (mean age 30.2 years), 1993 (mean age 18.4 years) and 2004 (mean age 6.7 years) cohorts was 35 mg, 39 mg and 60 mg, respectively. Time spent in MVPA was 26 [95% confidence interval (CI) 25; 27], 43 (95% CI 42; 44) and 45 (95% CI 43; 46) min/d in the three cohorts, respectively, using 10-min bouts. Mean MVPA was on average 42% higher when using 5-min bouts. Males were more active than females and physical activity was inversely associated with age of the cohort and SES. Normal-weight individuals were more active than underweight, overweight and obese participants.
Conclusions: Overall physical activity and time spent in MVPA differed by cohort (age), sex, weight status and SES. Higher levels of activity in low SES groups may be explained by incidental physical activity.
PMCID: PMC4276065  PMID: 25361583
Activity monitor; cohort studies; motor activity; movement
20.  Independent and Combined Association of Muscle Strength and Cardiorespiratory Fitness in Youth With Insulin Resistance and β-Cell Function in Young Adulthood 
Diabetes Care  2013;36(9):2575-2581.
To examine the independent and combined association of isometric muscle strength of the abdomen and back and cardiorespiratory fitness (CRF) in youth with indices of glucose metabolism in young adulthood among boys and girls from the European Youth Heart Study.
We used data from a population-based prospective cohort study among youth followed up for up to 12 years (n = 317). In youth, maximal voluntary contractions during isometric back extension and abdominal flexion were determined using a strain-gauge dynamometer and CRF was obtained from a maximal cycle ergometer test. Insulin resistance (homeostasis model assessment of insulin resistance [HOMA-IR]) and β-cell function (homeostasis model assessment of β-cell function [HOMA-B]) were estimated from fasting serum insulin and glucose that were obtained in youth and at follow-up in young adulthood.
For each 1-SD difference in isometric muscle strength (0.16 N/kg) in youth, fasting insulin, HOMA-IR, and HOMA-B in young adulthood changed by −11.3% (95% CI −17.0 to −5.2), −12.2% (−18.2 to −5.7), and −8.9% (−14.4 to −3.0), respectively, in young adulthood after adjustment for CRF and personal lifestyle and demographic factors. Results for CRF were very similar in magnitude, and the magnitude of associations for both exposures was unchanged with additional adjustment for general or abdominal adiposity in youth. Combined associations of muscle strength and CRF with fasting insulin, HOMA-IR, and HOMA-B were additive, and adolescents in the highest sex-specific tertile for both isometric muscle strength and CRF had the lowest levels of these glucose metabolism outcomes.
Increasing muscle strength and CRF should be targets in youth primordial prevention strategies of insulin resistance and β-cell dysfunction.
PMCID: PMC3747926  PMID: 23579180
21.  Comparisons of intensity-duration patterns of physical activity in the US, Jamaica and 3 African countries 
BMC Public Health  2014;14:882.
This difference in how populations living in low-, middle or upper-income countries accumulate daily PA, i.e. patterns and intensity, is an important part in addressing the global PA movement. We sought to characterize objective PA in 2,500 participants spanning the epidemiologic transition. The Modeling the Epidemiologic Transition Study (METS) is a longitudinal study, in 5 countries. METS seeks to define the association between physical activity (PA), obesity and CVD risk in populations of African origin: Ghana (GH), South Africa (SA), Seychelles (SEY), Jamaica (JA) and the US (suburban Chicago).
Baseline measurements of objective PA, SES, anthropometrics and body composition, were completed on 2,500 men and women, aged 25–45 years. Moderate and vigorous PA (MVPA, min/d) on week and weekend days was explored ecologically, by adiposity status and manual labor.
Among the men, obesity prevalence reflected the level of economic transition and was lowest in GH (1.7%) and SA (4.8%) and highest in the US (41%). SA (55%) and US (65%) women had the highest levels of obesity, compared to only 16% in GH. More men and women in developing countries engaged in manual labor and this was reflected by an almost doubling of measured MPVA among the men in GH (45 min/d) and SA (47 min/d) compared to only 28 min/d in the US. Women in GH (25 min/d), SA (21 min/d), JA (20 min/d) and SEY (20 min/d) accumulated significantly more MPVA than women in the US (14 min/d), yet this difference was not reflected by differences in BMI between SA, JA, SEY and US. Moderate PA constituted the bulk of the PA, with no study populations except SA men accumulating > 5 min/d of vigorous PA. Among the women, no sites accumulated >2 min/d of vigorous PA. Overweight/obese men were 22% less likely to engage in manual occupations.
While there is some association for PA with obesity, this relationship is inconsistent across the epidemiologic transition and suggests that PA policy recommendations should be tailored for each environment.
PMCID: PMC4168059  PMID: 25160601
Physical activity patterns; Manual labor; Epidemiologic transition
22.  Sedentary Behavior and Incident Cancer: A Meta-Analysis of Prospective Studies 
PLoS ONE  2014;9(8):e105709.
Sedentary behavior is ubiquitous in modern adults' daily lives and it has been suggested to be associated with incident cancer. However, the results have been inconsistent. In this study, we performed a systematic review and meta-analysis of prospective cohort studies to clarify the association between sedentary behavior and incident cancer.
PubMed and Embase databases were searched up to March 2014. All prospective cohort studies on the association between sedentary behavior and incident cancer were included. The summary relative risks (RRs) with 95% confidence intervals (CIs) were estimated using random effect model.
A total of 17 prospective studies from 14 articles, including a total of 857,581 participants and 18,553 cases, were included in the analysis for sedentary behavior and risk of incident cancer. The overall meta-analysis suggested that sedentary behavior increased risk of cancer (RR = 1.20, 95%CI = 1.12–1.28), with no evidence of heterogeneity between studies (I2 = 7.3%, P = 0.368). Subgroup analyses demonstrated that there were statistical associations between sedentary behavior and some cancer types (endometrial cancer: RR = 1.28, 95% CI = 1.08–1.53; colorectal cancer: RR = 1.30, 95%CI = 1.12–1.49; breast cancer: RR = 1.17, 95%CI = 1.03–1.33; lung cancer: RR = 1.27, 95%CI = 1.06–1.52). However, there was no association of sedentary behavior with ovarian cancer (RR = 1.26, 95%CI = 0.87–1.82), renal cell carcinoma (RR = 1.11, 95%CI = 0.87–1.41) or non-Hodgkin lymphoid neoplasms (RR = 1.09, 95%CI = 0.82–1.43).
The present meta-analysis suggested that prolonged sedentary behavior was independently associated with an increased risk of incident endometrial, colorectal, breast, and lung cancers, but not with ovarian cancer, renal cell carcinoma or non-Hodgkin lymphoid neoplasms.
PMCID: PMC4143275  PMID: 25153314
23.  Identification of heart rate–associated loci and their effects on cardiac conduction and rhythm disorders 
den Hoed, Marcel | Eijgelsheim, Mark | Esko, Tõnu | Brundel, Bianca J J M | Peal, David S | Evans, David M | Nolte, Ilja M | Segrè, Ayellet V | Holm, Hilma | Handsaker, Robert E | Westra, Harm-Jan | Johnson, Toby | Isaacs, Aaron | Yang, Jian | Lundby, Alicia | Zhao, Jing Hua | Kim, Young Jin | Go, Min Jin | Almgren, Peter | Bochud, Murielle | Boucher, Gabrielle | Cornelis, Marilyn C | Gudbjartsson, Daniel | Hadley, David | Van Der Harst, Pim | Hayward, Caroline | Heijer, Martin Den | Igl, Wilmar | Jackson, Anne U | Kutalik, Zoltán | Luan, Jian’an | Kemp, John P | Kristiansson, Kati | Ladenvall, Claes | Lorentzon, Mattias | Montasser, May E | Njajou, Omer T | O’Reilly, Paul F | Padmanabhan, Sandosh | Pourcain, Beate St. | Rankinen, Tuomo | Salo, Perttu | Tanaka, Toshiko | Timpson, Nicholas J | Vitart, Veronique | Waite, Lindsay | Wheeler, William | Zhang, Weihua | Draisma, Harmen H M | Feitosa, Mary F | Kerr, Kathleen F | Lind, Penelope A | Mihailov, Evelin | Onland-Moret, N Charlotte | Song, Ci | Weedon, Michael N | Xie, Weijia | Yengo, Loic | Absher, Devin | Albert, Christine M | Alonso, Alvaro | Arking, Dan E | de Bakker, Paul I W | Balkau, Beverley | Barlassina, Cristina | Benaglio, Paola | Bis, Joshua C | Bouatia-Naji, Nabila | Brage, Søren | Chanock, Stephen J | Chines, Peter S | Chung, Mina | Darbar, Dawood | Dina, Christian | Dörr, Marcus | Elliott, Paul | Felix, Stephan B | Fischer, Krista | Fuchsberger, Christian | de Geus, Eco J C | Goyette, Philippe | Gudnason, Vilmundur | Harris, Tamara B | Hartikainen, Anna-liisa | Havulinna, Aki S | Heckbert, Susan R | Hicks, Andrew A | Hofman, Albert | Holewijn, Suzanne | Hoogstra-Berends, Femke | Hottenga, Jouke-Jan | Jensen, Majken K | Johansson, Åsa | Junttila, Juhani | Kääb, Stefan | Kanon, Bart | Ketkar, Shamika | Khaw, Kay-Tee | Knowles, Joshua W | Kooner, Angrad S | Kors, Jan A | Kumari, Meena | Milani, Lili | Laiho, Päivi | Lakatta, Edward G | Langenberg, Claudia | Leusink, Maarten | Liu, Yongmei | Luben, Robert N | Lunetta, Kathryn L | Lynch, Stacey N | Markus, Marcello R P | Marques-Vidal, Pedro | Leach, Irene Mateo | McArdle, Wendy L | McCarroll, Steven A | Medland, Sarah E | Miller, Kathryn A | Montgomery, Grant W | Morrison, Alanna C | Müller-Nurasyid, Martina | Navarro, Pau | Nelis, Mari | O’Connell, Jeffrey R | O’Donnell, Christopher J | Ong, Ken K | Newman, Anne B | Peters, Annette | Polasek, Ozren | Pouta, Anneli | Pramstaller, Peter P | Psaty, Bruce M | Rao, Dabeeru C | Ring, Susan M | Rossin, Elizabeth J | Rudan, Diana | Sanna, Serena | Scott, Robert A | Sehmi, Jaban S | Sharp, Stephen | Shin, Jordan T | Singleton, Andrew B | Smith, Albert V | Soranzo, Nicole | Spector, Tim D | Stewart, Chip | Stringham, Heather M | Tarasov, Kirill V | Uitterlinden, André G | Vandenput, Liesbeth | Hwang, Shih-Jen | Whitfield, John B | Wijmenga, Cisca | Wild, Sarah H | Willemsen, Gonneke | Wilson, James F | Witteman, Jacqueline C M | Wong, Andrew | Wong, Quenna | Jamshidi, Yalda | Zitting, Paavo | Boer, Jolanda M A | Boomsma, Dorret I | Borecki, Ingrid B | Van Duijn, Cornelia M | Ekelund, Ulf | Forouhi, Nita G | Froguel, Philippe | Hingorani, Aroon | Ingelsson, Erik | Kivimaki, Mika | Kronmal, Richard A | Kuh, Diana | Lind, Lars | Martin, Nicholas G | Oostra, Ben A | Pedersen, Nancy L | Quertermous, Thomas | Rotter, Jerome I | van der Schouw, Yvonne T | Verschuren, W M Monique | Walker, Mark | Albanes, Demetrius | Arnar, David O | Assimes, Themistocles L | Bandinelli, Stefania | Boehnke, Michael | de Boer, Rudolf A | Bouchard, Claude | Caulfield, W L Mark | Chambers, John C | Curhan, Gary | Cusi, Daniele | Eriksson, Johan | Ferrucci, Luigi | van Gilst, Wiek H | Glorioso, Nicola | de Graaf, Jacqueline | Groop, Leif | Gyllensten, Ulf | Hsueh, Wen-Chi | Hu, Frank B | Huikuri, Heikki V | Hunter, David J | Iribarren, Carlos | Isomaa, Bo | Jarvelin, Marjo-Riitta | Jula, Antti | Kähönen, Mika | Kiemeney, Lambertus A | van der Klauw, Melanie M | Kooner, Jaspal S | Kraft, Peter | Iacoviello, Licia | Lehtimäki, Terho | Lokki, Marja-Liisa L | Mitchell, Braxton D | Navis, Gerjan | Nieminen, Markku S | Ohlsson, Claes | Poulter, Neil R | Qi, Lu | Raitakari, Olli T | Rimm, Eric B | Rioux, John D | Rizzi, Federica | Rudan, Igor | Salomaa, Veikko | Sever, Peter S | Shields, Denis C | Shuldiner, Alan R | Sinisalo, Juha | Stanton, Alice V | Stolk, Ronald P | Strachan, David P | Tardif, Jean-Claude | Thorsteinsdottir, Unnur | Tuomilehto, Jaako | van Veldhuisen, Dirk J | Virtamo, Jarmo | Viikari, Jorma | Vollenweider, Peter | Waeber, Gérard | Widen, Elisabeth | Cho, Yoon Shin | Olsen, Jesper V | Visscher, Peter M | Willer, Cristen | Franke, Lude | Erdmann, Jeanette | Thompson, John R | Pfeufer, Arne | Sotoodehnia, Nona | Newton-Cheh, Christopher | Ellinor, Patrick T | Stricker, Bruno H Ch | Metspalu, Andres | Perola, Markus | Beckmann, Jacques S | Smith, George Davey | Stefansson, Kari | Wareham, Nicholas J | Munroe, Patricia B | Sibon, Ody C M | Milan, David J | Snieder, Harold | Samani, Nilesh J | Loos, Ruth J F
Nature genetics  2013;45(6):621-631.
Elevated resting heart rate is associated with greater risk of cardiovascular disease and mortality. In a 2-stage meta-analysis of genome-wide association studies in up to 181,171 individuals, we identified 14 new loci associated with heart rate and confirmed associations with all 7 previously established loci. Experimental downregulation of gene expression in Drosophila melanogaster and Danio rerio identified 20 genes at 11 loci that are relevant for heart rate regulation and highlight a role for genes involved in signal transmission, embryonic cardiac development and the pathophysiology of dilated cardiomyopathy, congenital heart failure and/or sudden cardiac death. In addition, genetic susceptibility to increased heart rate is associated with altered cardiac conduction and reduced risk of sick sinus syndrome, and both heart rate–increasing and heart rate–decreasing variants associate with risk of atrial fibrillation. Our findings provide fresh insights into the mechanisms regulating heart rate and identify new therapeutic targets.
PMCID: PMC3696959  PMID: 23583979
24.  Levels of physical activity among a nationally representative sample of people in early old age: results of objective and self-reported assessments 
Detailed assessment of physical activity (PA) in older adults is required to comprehensively describe habitual PA-levels in this growing population segment. Current evidence of population PA-levels is predominantly based on self-report.
We examined PA and sedentary behaviour in a nationally representative sample of British people aged 60–64, using individually-calibrated combined heart-rate and movement sensing and a validated questionnaire (EPAQ2), and the socio-demographic and behavioural factors that may explain between-individual variation in PA.
Between 2006–2010, 2224 participants completed EPAQ2 capturing the past year’s activity in four domains (leisure, work, transportation and domestic life) and 1787 participants provided 2–5 days of combined-sensing data. According to objective estimates, median(IQR) physical activity energy expenditure (PAEE) was 33.5 (25.3-42.2) and 35.5 (26.6- 47.3) kJ/kg/day for women and men, respectively. Median (IQR) time spent in moderate-to-vigorous PA (MVPA; >3MET), light-intensity PA (1.5-3 MET) and sedentary (<1.5 MET) was 26.0 (12.3-48.1) min/day, 5.4 (4.2-6.7) h/day and 18.0 (16.6-19.4) h/day, respectively, in women; and 41.0 (18.8-73.0) min/day, 5.2 (4.0-6.5) h/day and 17.9 (16.3-19.4) h/day in men. PAEE and time spent in MVPA were lower and sedentary time was greater in obese individuals, those with poor health, and those with lower educational attainment (women only). Questionnaire-derived PAEE and MVPA tended to have similar patterns of variation across socio-demographic strata. In the whole sample, domestic PA had the greatest relative contribution to total questionnaire-derived PAEE (58%), whereas occupational PA was the main driver among employed participants (54%). Only 2.2% of participants achieved an average of >30 min MVPA per day combined with >60 min strength-training per week.
The use of both self-report and objective monitoring to assess PA in early old age provides important information on the domains of PA, PAEE and time spent at different intensity levels. Our findings suggest PA levels are generally low and observed patterns of variation indicate specific subgroups who might benefit from targeted interventions to increase PA.
PMCID: PMC4038114  PMID: 24885497
Physical activity; Sedentary behaviour; Physical activity questionnaire; Combined sensing; Birth cohort; Old age
25.  A mixed ecologic-cohort comparison of physical activity & weight among young adults from five populations of African origin 
BMC Public Health  2014;14:397.
Examination of patterns and intensity of physical activity (PA) across cultures where obesity prevalence varies widely provides insight into one aspect of the ongoing epidemiologic transition. The primary hypothesis being addressed is whether low levels of PA are associated with excess weight and adiposity.
We recruited young adults from five countries (500 per country, 2500 total, ages 25–45 years), spanning the range of obesity prevalence. Men and women were recruited from a suburb of Chicago, Illinois, USA; urban Jamaica; rural Ghana; peri-urban South Africa; and the Seychelles. PA was measured using accelerometry and expressed as minutes per day of moderate-to-vigorous activity or sedentary behavior.
Obesity (BMI ≥ 30) prevalence ranged from 1.4% (Ghanaian men) to 63.8% (US women). South African men were the most active, followed by Ghanaian men. Relatively small differences were observed across sites among women; however, women in Ghana accumulated the most activity. Within site-gender sub-groups, the correlation of activity with BMI and other measures of adiposity was inconsistent; the combined correlation across sites was -0.17 for men and -0.11 for women. In the ecological analysis time spent in moderate-to-vigorous activity was inversely associated with BMI (r = -0.71).
These analyses suggest that persons with greater adiposity tend to engage in less PA, although the associations are weak and the direction of causality cannot be inferred because measurements are cross-sectional. Longitudinal data will be required to elucidate direction of association.
PMCID: PMC4031970  PMID: 24758286
Physical activity; Obesity; Epidemiologic transition

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