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1.  International Study of Objectively-measured Physical Activity and Sedentary Time with Body Mass Index and Obesity: IPEN Adult Study 
Physical activity (PA) has been consistently implicated in the etiology of obesity, while recent evidence on the importance of sedentary time remains inconsistent. Understanding of dose-response associations of PA and sedentary time with overweight and obesity in adults can be improved with large-scale studies using objective measures of PA and sedentary time. The purpose of this study was to examine the strength, direction and shape of dose-response associations of accelerometer-based PA and sedentary time with BMI and weight status in 10 countries, and the moderating effects of study site and gender.
Data from the International Physical activity and the Environment Network (IPEN) Adult study were used. IPEN Adult is an observational multi-country cross-sectional study, and 12 sites in 10 countries are included. Participants wore an accelerometer for seven consecutive days, completed a socio-demographic questionnaire and reported height and weight. In total, 5712 adults (18–65 years) were included in the analyses. Generalized additive mixed models, conducted in R, were used to estimate the strength and shape of the associations.
A curvilinear relationship of accelerometer-based moderate-to-vigorous PA and total counts/minute with BMI and the probability of being overweight/obese was identified. The associations were negative, but weakened at higher levels of moderate-to-vigorous PA (>50 min/day) and higher counts/minute. No associations between sedentary time and weight outcomes were found. Complex site- and gender-specific findings were revealed for BMI, but not for weight status.
Based on these results, the current Institute of Medicine recommendation of 60 minutes/day of moderate-to-vigorous PA to prevent weight gain in normal-weight adults was supported. No relationship between sedentary time and the weight outcomes was present, calling for further examination. If moderator findings are confirmed, the relationship between PA and BMI may be country- and gender-dependent, which could have important implications for country-specific health guidelines.
PMCID: PMC4282619  PMID: 24984753
obesity; accelerometers; exercise; sitting
2.  Perceived neighbourhood environmental attributes associated with adults’ recreational walking: IPEN Adult study in 12 countries 
Health & place  2014;28:22-30.
This study examined the strength and shape of associations between perceived environmental attributes and adults’ recreational walking, using data collected from 13,745 adult participants in 12 countries. Perceived residential density, land use mix, street connectivity, aesthetics, safety from crime, and proximity to parks were linearly associated with recreational walking, while curvilinear associations were found for residential density, land use mix, and aesthetics. The observed associations were consistent across countries, except for aesthetics. Using data collected from environmentally diverse countries, this study confirmed findings from prior single-country studies. Present findings suggest that similar environmental attributes are associated with recreational walking internationally.
PMCID: PMC4079701  PMID: 24721737
physical activity; exercise; leisure; built environment; urban design
3.  International study of perceived neighbourhood environmental attributes and Body Mass Index: IPEN Adult study in 12 countries 
Ecological models of health behaviour are an important conceptual framework to address the multiple correlates of obesity. Several single-country studies previously examined the relationship between the built environment and obesity in adults, but results are very diverse. An important reason for these mixed results is the limited variability in built environments in these single-country studies. Therefore, the aim of this study was to examine associations between perceived neighbourhood built environmental attributes and BMI/weight status in a multi-country study including 12 environmentally and culturally diverse countries.
A multi-site cross-sectional study was conducted in 17 cities (study sites) across 12 countries (Australia, Belgium, Brazil, China, Colombia, Czech Republic, Denmark, Mexico, New Zealand, Spain, the UK and USA). Participants (n = 14222, 18–66 years) self-reported perceived neighbourhood environmental attributes. Height and weight were self-reported in eight countries, and measured in person in four countries.
Three environmental attributes were associated with BMI or weight status in pooled data from 12 countries. Safety from traffic was the most robust correlate, suggesting that creating safe routes for walking/cycling by reducing the speed and volume of traffic might have a positive impact upon weight status/BMI across various geographical locations. Close proximity to several local destinations was associated with BMI across all countries, suggesting compact neighbourhoods with more places to walk related to lower BMI. Safety from crime showed a curvilinear relationship with BMI, with especially poor crime safety being related to higher BMI.
Environmental interventions involving these three attributes appear to have international relevance and focusing on these might have implications for tackling overweight/obesity.
PMCID: PMC4440250  PMID: 25982214
Weight status; Built environment; International; Pooled data
4.  Neighbourhood environment, sitting time and motorised transport in older adults: a cross-sectional study in Hong Kong 
BMJ Open  2015;5(4):e007557.
Sitting time is a public health concern. This study examined associations of objectively measured neighbourhood environmental attributes with non-transport sitting time and motorised transport in 484 Hong Kong older adults. Neighbourhood attributes encouraging walking may help older adults replace some sitting time at home and on motorised transport with light-to-moderate-intensity activities such as strolling around the neighbourhood or walking to/from neighbourhood destinations. Thus, we hypothesised environmental attributes found to be related to walking would show associations with non-transport sitting time and motorised transport opposite to those seen for walking.
Hong Kong, an ultradense urban environment.
484 ethnic Chinese Hong Kong residents aged 65+ recruited from membership lists of four Hong Kong Elderly Health Centres representing catchment areas of low and high transport-related walkability stratified by socioeconomic status (response rate: 78%).
Primary and secondary outcome measures
Attributes of participants’ neighbourhood environments were assessed by environmental audits, while non-transport sitting time and motorised transport were ascertained using the International Physical Activity Questionnaire—Long Form (Chinese version).
Daily non-transport sitting minutes were 283 (SD=128) and motorised transport 23 (SD=28). Prevalence of signs of crime/disorder, streetlights, public facilities (toilets and benches) and pedestrian safety were independently negatively related, and sloping streets positively related, to sitting outcomes. Places of worship in the neighbourhood were predictive of more, and prevalence of public transit points of less, non-transport sitting. Associations of either or both sitting outcomes with prevalence of food/grocery stores and presence of parks were moderated by path obstructions and signs of crime/disorder.
The findings suggest that access to specific destinations and relatively low-cost, minimal impact modifications to the urban form, such as street lighting, public toilets, benches and public transit points, could potentially reduce sitting time and associated negative health outcomes in Hong Kong older adults.
PMCID: PMC4420960  PMID: 25941186
Older adults; Sitting; Walkability; Neighbourhood; Hong Kong
5.  Park proximity, quality and recreational physical activity among mid-older aged adults: moderating effects of individual factors and area of residence 
The transition from active employment to retirement is a potentially critical period for promoting maintenance or development of recreational physical activity in older age. Park proximity and quality might be important correlates of recreational physical activity in this age group. However, research on park-physical activity relationships among mid-older aged adults is limited and inconclusive. Furthermore, while knowledge of individual moderators of park-physical activity relationships is crucial for tailoring interventions, this knowledge is also limited. We investigated relationships between perceived park proximity, park quality and recreational physical activity among mid-older aged adults. Additionally, we examined the potential moderating effects of gender, education level, retirement status, functional limitations and area of residence on these relationships.
Self-reported data on demographics, functional limitations, park proximity, park quality, recreational walking and other recreational moderate- to vigorous-intensity physical activity (MVPA) were collected among 2700 Australian adults (57–67 years) in 2012. Objective information on area of residence was collected. To examine associations of park-related variables with recreational walking and other recreational MVPA, zero-inflated negative binomial (ZINB) regression models were used.
Park proximity significantly interacted with retirement status; non-retired participants who reported living near a park were more likely to participate in recreational walking, whereas no relationship was observed in retired participants. Among those who walked for recreation, higher park quality was related to more weekly minutes of recreational walking. No significant relationships with other recreational MVPA and no moderating effects of gender, education level, functional limitations and area of residence were observed.
Parks may stimulate engagement in recreational walking among non-retirees and more walking among those who already walk. Future research should investigate which environmental factors relate to engagement in recreational walking among retirees and examine whether improvements in park quality actually lead to increases in mid-older aged adults’ recreational walking.
PMCID: PMC4391484  PMID: 25888885
Retirement; Physical environment; Public open spaces; Leisure
6.  The Dutch Obesity Intervention in Teenagers (DOiT) cluster controlled implementation trial: intervention effects and mediators and moderators of adiposity and energy balance-related behaviours 
The Dutch Obesity Intervention in Teenagers (DOiT) programme is an evidence-based obesity prevention programme tailored to adolescents attending the first two years of prevocational education in the Netherlands. The initial programme showed promising results during an effectiveness trial. The programme was adapted and prepared for nationwide dissemination. To gain more insight into the process of translating evidence-based approaches into ‘real world’ (i.e., ‘natural’) conditions, our research aims were to evaluate the impact of the DOiT-implementation programme on adolescents’ adiposity and energy balance-related behaviours during natural dissemination and to explore the mediating and moderating factors underlying the DOiT intervention effects.
We conducted a cluster-controlled implementation trial with 20 voluntary intervention schools (n=1002 adolescents) and 9 comparable control schools (n = 484 adolescents). We measured adolescents’ body height and weight, skinfold thicknesses, and waist circumference. We assessed adolescents’ dietary and physical activity behaviours by means of self-report. Data were collected at baseline and at 20-months follow-up. We used multivariable multilevel linear or logistic regression analyses to evaluate the intervention effects and to test the hypothesised behavioural mediating factors. We checked for potential effect modification by gender, ethnicity and education level.
We found no significant intervention effects on any of the adiposity measures or behavioural outcomes. Furthermore, we found no mediating effects by any of the hypothesised behavioural mediators. Stratified analyses for gender showed that the intervention was effective in reducing sugar-containing beverage consumption in girls (B = -188.2 ml/day; 95% CI = -344.0; -32.3). In boys, we found a significant positive intervention effect on breakfast frequency (B = 0.29 days/week; 95% CI = 0.01; 0.58). Stratified analyses for education level showed an adverse intervention effect (B = 0.09; 95% CI = 0.02; 0.16) on BMI z-scores for adolescents attending the vocational education track.
Although not successful in changing adolescents’ adiposity, the DOiT-implementation programme had some beneficial effects on specific obesity-related behaviours in subgroups. This study underlines the difficulty of translating intervention effectiveness in controlled settings to real world contexts. Adaptations to the implementation strategy are needed in order to promote implementation as intended by the teachers.
Trial registration
Current Controlled Trials ISRCTN92755979.
Electronic supplementary material
The online version of this article (doi:10.1186/s12966-014-0158-0) contains supplementary material, which is available to authorized users.
PMCID: PMC4304621  PMID: 25539582
Adolescents; Mediation; Intervention; Prevention; Energy balance; Implementation; Dissemination
7.  International variation in neighborhood walkability, transit, and recreation environments using geographic information systems: the IPEN adult study 
The World Health Organization recommends strategies to improve urban design, public transportation, and recreation facilities to facilitate physical activity for non-communicable disease prevention for an increasingly urbanized global population. Most evidence supporting environmental associations with physical activity comes from single countries or regions with limited variation in urban form. This paper documents variation in comparable built environment features across countries from diverse regions.
The International Physical Activity and the Environment Network (IPEN) study of adults aimed to measure the full range of variation in the built environment using geographic information systems (GIS) across 12 countries on 5 continents. Investigators in Australia, Belgium, Brazil, Colombia, the Czech Republic, Denmark, China, Mexico, New Zealand, Spain, the United Kingdom, and the United States followed a common research protocol to develop internationally comparable measures. Using detailed instructions, GIS-based measures included features such as walkability (i.e., residential density, street connectivity, mix of land uses), and access to public transit, parks, and private recreation facilities around each participant’s residential address using 1-km and 500-m street network buffers.
Eleven of 12 countries and 15 cities had objective GIS data on built environment features. We observed a 38-fold difference in median residential densities, a 5-fold difference in median intersection densities and an 18-fold difference in median park densities. Hong Kong had the highest and North Shore, New Zealand had the lowest median walkability index values, representing a difference of 9 standard deviations in GIS-measured walkability.
Results show that comparable measures can be created across a range of cultural settings revealing profound global differences in urban form relevant to physical activity. These measures allow cities to be ranked more precisely than previously possible. The highly variable measures of urban form will be used to explain individuals’ physical activity, sedentary behaviors, body mass index, and other health outcomes on an international basis. Present measures provide the ability to estimate dose–response relationships from projected changes to the built environment that would otherwise be impossible.
Electronic supplementary material
The online version of this article (doi:10.1186/1476-072X-13-43) contains supplementary material, which is available to authorized users.
PMCID: PMC4221715  PMID: 25343966
Walkability; Urban planning; Exercise; Built environment; International health; Transportation; Parks; Physical activity
8.  A commentary on current practice in mediating variable analyses in behavioural nutrition and physical activity 
Public health nutrition  2008;12(8):1182-1188.
To critique current practice in, and provide recommendations for, mediating variable analyses (MVA) of nutrition and physical activity behaviour change.
Theory-based behavioural nutrition and physical activity interventions aim at changing mediating variables that are hypothesized to be responsible for changes in the outcome of interest. MVA are useful because they help to identify the most promising theoretical approaches, mediators and intervention components for behaviour change. However, the current literature suggests that MVA are often inappropriately conducted, poorly understood and inadequately presented. Main problems encountered in the published literature are explained and suggestions for overcoming weaknesses of current practice are proposed.
The use of the most appropriate, currently available methods of MVA, and a correct, comprehensive presentation and interpretation of their findings, is of paramount importance for understanding how obesity can be treated and prevented.
PMCID: PMC4207270  PMID: 18778534
Mediation models; Logistic regression; Behaviour change
9.  Understanding Neighborhood Environment Related to Hong Kong Children’s Physical Activity: A Qualitative Study Using Nominal Group Technique 
PLoS ONE  2014;9(9):e106578.
Relationships between the neighborhood environment and children’s physical activity have been well documented in Western countries but are less investigated in ultra-dense Asian cities. The aim of this study was to identify the environmental facilitators and barriers of physical activity behaviors among Hong Kong Chinese children using nominal group technique.
Five nominal groups were conducted among 34 children aged 10–11 years from four types of neighborhoods varying in socio-economic status and walkability in Hong Kong. Environmental factors were generated by children in response to the question “What neighborhood environments do you think would increase or decrease your willingness to do physical activity?” Factors were prioritized in order of their importance to children’s physical activity.
Sixteen unique environmental factors, which were perceived as the most important to children’s physical activity, were identified. Factors perceived as physical activity-facilitators included “Sufficient lighting”, “Bridge or tunnel”, “Few cars on roads”, “Convenient transportation”, “Subway station”, “Recreation grounds”, “Shopping malls with air conditioning”, “Fresh air”, “Interesting animals”, and “Perfume shop”. Factors perceived as physical activity-barriers included “People who make me feel unsafe”, “Crimes nearby”, “Afraid of being taken or hurt at night”, “Hard to find toilet in shopping mall”, “Too much noise”, and “Too many people in recreation grounds”.
Specific physical activity-related environmental facilitators and barriers, which are unique in an ultra-dense city, were identified by Hong Kong children. These initial findings can inform future examinations of the physical activity-environment relationship among children in Hong Kong and similar Asian cities.
PMCID: PMC4154758  PMID: 25187960
10.  Development and reliability of a scale of physical-activity related informal social control for parents of Chinese pre-schoolers 
Parents’ perceived informal social control, defined as the informal ways residents intervene to create a safe and orderly neighbourhood environment, may influence young children’s physical activity (PA) in the neighbourhood. This study aimed to develop and test the reliability of a scale of PA-related informal social control relevant to Chinese parents/caregivers of pre-schoolers (children aged 3 to 5 years) living in Hong Kong.
Nominal Group Technique (NGT), a structured, multi-step brainstorming technique, was conducted with two groups of caregivers (mainly parents; n = 11) of Hong Kong pre-schoolers in June 2011. Items collected in the NGT sessions and those generated by a panel of experts were used to compile a list of items (n = 22) for a preliminary version of a questionnaire of informal social control. The newly-developed scale was tested with 20 Chinese-speaking parents/caregivers using cognitive interviews (August 2011). The modified scale, including all 22 original items of which a few were slightly reworded, was subsequently administered on two occasions, a week apart, to 61 Chinese parents/caregivers of Hong Kong pre-schoolers in early 2012. The test-retest reliability and internal consistency of the items and scale were examined using intraclass correlation coefficients (ICC), paired t-tests, relative percentages of shifts in responses to items, and Cronbach’s α coefficient.
Thirteen items generated by parents/caregivers and nine items generated by the panel of experts (total 22 items) were included in a first working version of the scale and classified into three subscales: “Personal involvement and general informal supervision”, “Civic engagement for the creation of a better neighbourhood environment” and “Educating and assisting neighbourhood children”. Twenty out of 22 items showed moderate to excellent test-test reliability (ICC range: 0.40-0.81). All three subscales of informal social control showed acceptable levels of internal consistency (Cronbach's α >0.70).
A reliable scale examining PA-related informal social control relevant to Chinese parents/caregivers of pre-schoolers living in Hong Kong was developed. Further studies should examine the factorial validity of the scale, its associations with Chinese children’s PA and its appropriateness for other populations of parents of young children.
PMCID: PMC4108234  PMID: 25030499
Nominal group technique; Health; Physical activity; Parental questionnaire; Reliability
11.  Understanding the relationships between the physical environment and physical activity in older adults: a systematic review of qualitative studies 
While physical activity (PA) provides many physical, social, and mental health benefits for older adults, they are the least physically active age group. Ecological models highlight the importance of the physical environment in promoting PA. However, results of previous quantitative research revealed inconsistencies in environmental correlates of older adults’ PA that may be explained by methodological issues. Qualitative studies can inform and complement quantitative research on environment-PA relationships by providing insight into how and why the environment influences participants’ PA behaviors. The current study aimed to provide a systematic review of qualitative studies exploring the potential impact of the physical environment on older adults’ PA behaviors.
A systematic search was conducted in databases of various disciplines, including: health, architecture and urban planning, transportation, and interdisciplinary databases. From 3,047 articles identified in the physical activity, initial search, 31 articles published from 1996 to 2012 met all inclusion criteria. An inductive content analysis was performed on the extracted findings to identify emerging environmental elements related to older adults’ PA. The identified environmental elements were then grouped by study methodologies [indoor interviews (individual or focus groups) vs spatial methods (photo-voice, observations, walk-along interviews)].
This review provides detailed information about environmental factors that potentially influence older adults’ PA behaviors. These factors were categorized into five themes: pedestrian infrastructure, safety, access to amenities, aesthetics, and environmental conditions. Environmental factors especially relevant to older adults (i.e., access to facilities, green open spaces and rest areas) tended to emerge more frequently in studies that combined interviews with spatial qualitative methods.
Findings showed that qualitative research can provide in-depth information on environmental elements that influence older adults’ PA. Future qualitative studies on the physical environment and older adults’ PA would benefit from combining interviews with more spatially-oriented methods. Multidisciplinary mixed-methods studies are recommended to establish quantitative relationships complemented with in-depth qualitative information.
PMCID: PMC4119420  PMID: 25034246
Physical environment; Physical activity; Older adults; Qualitative research; Systematic review
12.  Environmental and cultural correlates of physical activity parenting practices among Latino parents with preschool-aged children: Niños Activos 
BMC Public Health  2014;14:707.
Latino children are at high risk of becoming obese. Physical activity (PA) can help prevent obesity. Parents can influence children’s PA through parenting practices. This study aimed to examine the independent contributions of (1) sociodemographic, (2) cultural, (3) parent perceived environmental, and (4) objectively measured environmental factors, to PA parenting practices.
A cross-sectional sample of Latino parents (n = 240) from Harris County, TX in 2011–2012 completed validated questionnaires to assess PA parenting practices, acculturation, familism, perception of their neighborhood environment, and demographics. Home addresses were mapped and linked to Census block-level crime and traffic data. Distance to the closest park was mapped by GIS. Regression models were built in a hierarchical step-wise fashion.
Combined models showed R2 of 6.8% to 38.9% for different parenting practices. Significant correlations included sociodemographic variables with having outdoor toys available, psychological control, and promotion of inactivity. Cultural factors correlated with PA safety concern practices. Perceived environmental attributes correlated with five of seven parenting practices, while objectively-measured environmental attributes did not significantly correlate with PA parenting practices.
Interventions promoting PA among Latino preschoolers may need to address the social-ecological context in which families live to effectively promote PA parenting, especially parents’ perceptions of neighborhoods.
PMCID: PMC4226995  PMID: 25011669
Physical activity; Child; Parenting; Correlates; Environment; Neighborhood; Acculturation; Latino
13.  Repeatability of self-report measures of physical activity, sedentary and travel behaviour in Hong Kong adolescents for the iHealt(H) and IPEN – Adolescent studies 
BMC Pediatrics  2014;14:142.
Physical activity and sedentary behaviour are important contributors to adolescents’ health. These behaviours may be affected by the school and neighbourhood built environments. However, current evidence on such effects is mainly limited to Western countries. The International Physical Activity and the Environment Network (IPEN)–Adolescent study aims to examine associations of the built environment with adolescent physical activity and sedentary behaviour across five continents.
We report on the repeatability of measures of in-school and out-of school physical activity, plus measures of out-of-school sedentary and travel behaviours adopted by the IPEN – Adolescent study and adapted for Chinese-speaking Hong Kong adolescents participating in the international Healthy environments and active living in teenagers–(Hong Kong) [iHealt(H)] study, which is part of IPEN-Adolescent.
Items gauging in-school physical activity and out-of-school physical activity, and out-of-school sedentary and travel behaviours developed for the IPEN – Adolescent study were translated from English into Chinese, adapted, and pilot tested. Sixty-eight Chinese-speaking 12–17 year old secondary school students (36 boys; 32 girls) residing in areas of Hong Kong differing in transport-related walkability were recruited. They self-completed the survey items twice, 8–16 days apart. Test-retest reliability was assessed for the whole sample and by gender using one-way random effects intra-class correlation coefficients (ICC). Test-retest reliability of items with restricted variability was assessed using percentage agreement.
Overall test-retest reliability of items and scales was moderate to excellent (ICC = 0.47–0.92). Items with restricted variability in responses had a high percentage agreement (92%-100%). Test-retest reliability was similar in girls and boys, with the exception of daily hours of homework (reliability higher in girls) and number of school-based sports teams or after-school physical activity classes (reliability higher in boys).
The translated and adapted self-report measures of physical activity, sedentary and travel behaviours used in the iHealt(H) study are sufficiently reliable. Levels of reliability are comparable or slightly higher than those observed for the original measures.
PMCID: PMC4060092  PMID: 24903156
Adolescents; Physical activity; Sedentary behaviour; Self-reports; Repeatability; Multi-country study; China
14.  Built environment and physical activity in New Zealand adolescents: a protocol for a cross-sectional study 
BMJ Open  2014;4(4):e004475.
Built-environment interventions have the potential to provide population-wide effects and the means for a sustained effect on behaviour change. Population-wide effects for adult physical activity have been shown with selected built environment attributes; however, the association between the built environment and adolescent health behaviours is less clear. This New Zealand study is part of an international project across 10 countries (International Physical Activity and the Environment Network–adolescents) that aims to characterise the links between built environment and adolescent health outcomes.
Methods and analyses
An observational, cross-sectional study of the associations between measures of the built environment with physical activity, sedentary behaviour, body size and social connectedness in 1600 New Zealand adolescents aged 12–18 years will be conducted in 2013–2014. Walkability and neighbourhood destination accessibility indices will be objectively measured using Geographic Information Systems (GIS). Physical activity and sedentary behaviours will be objectively measured using accelerometers over seven consecutive days. Body mass index will be calculated as weight divided by squared height. Demographics, socioeconomic status, active commuting behaviours and perceived neighbourhood walkability will be assessed using the Neighbourhood Environment Walkability Scale for Youth and psychosocial indicators. A web-based computer-assisted personal interview tool Visualisation and Evaluation of Route Itineraries, Travel Destinations, and Activity Spaces (VERITAS) and Global Positioning System (GPS) receivers will be used in a subsample of 300 participants. A qualitative research component will explore barriers and facilitators for physical activity in adolescents with respect to the built and social environment in a subsample of 80 participants.
Ethics and dissemination
The study received ethical approval from the Auckland University of Technology Ethics Committee (12/161). Data will be entered and stored into a secure (password protected) database. Only the named researchers will have access to the data. Data will be stored for 10 years and permanently destroyed thereafter. The results papers will be submitted for publication in peer-reviewed journals.
PMCID: PMC4010838  PMID: 24736036
Preventive Medicine; Epidemiology; Public Health
15.  Walking for Recreation and Perceptions of the Neighborhood Environment in Older Chinese Urban Dwellers 
Engagement in walking for recreation can contribute to healthy aging. Although there is growing evidence that the neighborhood environment can influence walking for recreation, the amount of such evidence in relation to older adults is scarce and limited to Western low-density urban locations. Asian urban environments are typified by distinctive environmental and cultural characteristics that may yield different patterns to those observed in Western countries. Therefore, the main aim of this study was to examine associations of perceived environmental attributes with overall and within-neighborhood walking for recreation in Chinese elders (65+ years) residing in Hong Kong, an ultradense Asian metropolis. A sample of 484 elders was recruited from 32 neighborhoods stratified by socio-economic status and walkability (dwelling and intersection densities). Validated questionnaires measuring perceived neighborhood environment and weekly minutes of overall and within-neighborhood walking for recreation were interviewer administered. Results showed that the level of recreational walking was twice to four times higher than that reported in Western adults and elders. While overall walking for recreation showed a general lack of associations with perceived environmental attributes, within-neighborhood recreational walking was positively related with proximity of recreational facilities, infrastructure for walking, indoor places for walking, and presence of bridge/overpasses connecting to services. Age and educational attainment moderated the associations with several perceived environmental attributes with older and less-educated participants showing stronger associations. Traditional cultural views on the benefits of physical activity and the high accessibility of facilities and pedestrian infrastructure of Hong Kong may explain the high levels of walking. Although specific neighborhood attributes, or their perception, may influence recreational walking within the neighborhood, the compactness and public transport affordability of ultradense metropolises such as Hong Kong may make it easy for elders to compensate for the lack of favorable neighborhood attributes by walking outside the neighborhood.
PMCID: PMC3579303  PMID: 22678651
Walking for recreation; Older adults; Perceived environment; Moderators
16.  Psychometrics of the preschooler physical activity parenting practices instrument among a Latino sample 
Latino preschoolers (3-5 year old children) have among the highest rates of obesity. Low levels of physical activity (PA) are a risk factor for obesity. Characterizing what Latino parents do to encourage or discourage their preschooler to be physically active can help inform interventions to increase their PA. The objective was therefore to develop and assess the psychometrics of a new instrument: the Preschooler Physical Activity Parenting Practices (PPAPP) among a Latino sample, to assess parenting practices used to encourage or discourage PA among preschool-aged children.
Cross-sectional study of 240 Latino parents who reported the frequency of using PA parenting practices. 95% of respondents were mothers; 42% had more than a high school education. Child mean age was 4.5 (±0.9) years (52% male). Test-retest reliability was assessed in 20%, 2 weeks later. We assessed the fit of a priori models using Confirmatory factor analyses (CFA). In a separate sub-sample (35%), preschool-aged children wore accelerometers to assess associations with their PA and PPAPP subscales.
The a-priori models showed poor fit to the data. A modified factor structure for encouraging PPAPP had one multiple-item scale: engagement (15 items), and two single-items (have outdoor toys; not enroll in sport-reverse coded). The final factor structure for discouraging PPAPP had 4 subscales: promote inactive transport (3 items), promote screen time (3 items), psychological control (4 items) and restricting for safety (4 items). Test-retest reliability (ICC) for the two scales ranged from 0.56-0.85. Cronbach’s alphas ranged from 0.5-0.9. Several sub-factors correlated in the expected direction with children’s objectively measured PA.
The final models for encouraging and discouraging PPAPP had moderate to good fit, with moderate to excellent test-retest reliabilities. The PPAPP should be further evaluated to better assess its associations with children’s PA and offers a new tool for measuring PPAPP among Latino families with preschool-aged children.
PMCID: PMC3903032  PMID: 24428935
Physical activity; Parenting practices; Latino; Hispanic; Preschool child; Confirmatory factor analysis
17.  Research priorities for child and adolescent physical activity and sedentary behaviours: an international perspective using a twin-panel Delphi procedure 
The quantity and quality of studies in child and adolescent physical activity and sedentary behaviour have rapidly increased, but research directions are often pursued in a reactive and uncoordinated manner.
To arrive at an international consensus on research priorities in the area of child and adolescent physical activity and sedentary behaviour.
Two independent panels, each consisting of 12 experts, undertook three rounds of a Delphi methodology. The Delphi methodology required experts to anonymously answer questions put forward by the researchers with feedback provided between each round.
The primary outcome of the study was a ranked set of 29 research priorities that aimed to be applicable for the next 10 years. The top three ranked priorities were: developing effective and sustainable interventions to increase children’s physical activity long-term; policy and/or environmental change and their influence on children’s physical activity and sedentary behaviour; and prospective, longitudinal studies of the independent effects of physical activity and sedentary behaviour on health.
These research priorities can help to guide decisions on future research directions.
PMCID: PMC3853883  PMID: 24228891
Physical activity; Sedentary behaviour; Research priorities; Children; Adolescents
18.  What Hispanic parents do to encourage and discourage 3-5 year old children to be active: a qualitative study using nominal group technique 
Hispanic preschoolers are less active than their non-Hispanic peers. As part of a feasibility study to assess environmental and parenting influences on preschooler physical activity (PA) (Niños Activos), the aim of this study was to identify what parents do to encourage or discourage PA among Hispanic 3-5 year old children to inform the development of a new PA parenting practice instrument and future interventions to increase PA among Hispanic youth.
Nominal Group Technique (NGT), a structured multi-step group procedure, was used to elicit and prioritize responses from 10 groups of Hispanic parents regarding what parents do to encourage (5 groups) or discourage (5 groups) preschool aged children to be active. Five groups consisted of parents with low education (less than high school) and 5 with high education (high school or greater) distributed between the two NGT questions.
Ten NGT groups (n = 74, range 4-11/group) generated 20-46 and 42-69 responses/group for practices that encourage or discourage PA respectively. Eight to 18 responses/group were elected as the most likely to encourage or discourage PA. Parental engagement in child activities, modeling PA, and feeding the child well were identified as parenting practices that encourage child PA. Allowing TV and videogame use, psychological control, physical or emotional abuse, and lack of parental engagement emerged as parenting practices that discourage children from being active. There were few differences in the pattern of responses by education level.
Parents identified ways they encourage and discourage 3-5 year-olds from PA, suggesting both are important targets for interventions. These will inform the development of a new PA parenting practice scale to be further evaluated. Further research should explore the role parents play in discouraging child PA, especially in using psychological control or submitting children to abuse, which were new findings in this study.
PMCID: PMC3750326  PMID: 23919301
Physical activity; Parenting practices; Hispanic; Preschool child; Qualitative research; Nominal group technique
19.  Walking for transportation in Hong Kong Chinese urban elders: a cross-sectional study on what destinations matter and when 
Walking for transport can contribute to the accrual of health-enhancing levels of physical activity in elders. Identifying destinations and environmental conditions that facilitate this type of walking has public health significance. However, most findings are limited to Western, low-density locations, while a larger proportion of the global population resides in ultra-dense Asian metropolises. We investigated relationships of within-neighborhood objectively-measured destination categories and environmental attributes with walking for transport in 484 elders from an ultra-dense metropolis (Hong Kong).
We estimated relationships of diversity (number of different types) and prevalence of within-neighborhood destination categories (environmental audits of 400 m buffers surrounding residential addresses) with transport-related walking (interviewer–administered questionnaire) in 484 Chinese-speaking elders able to walk unassisted and living in 32 neighborhoods stratified by socio-economic status and transport-related walkability. We examined the moderating effects of safety and pedestrian infrastructure-related neighborhood attributes on destination-walking associations.
Participants reported on average 569 and 254 min/week of overall and within-neighborhood walking for transport, respectively. The prevalence of public transit points and diversity of recreational destinations were positively related to overall walking for transport. The presence of a health clinic/service and place of worship, higher diversity in recreational destinations, and greater prevalence of non-food retails and services, food/grocery stores, and restaurants in the neighborhood were predictive of more within-neighborhood walking for transport. Neighborhood safety-related aspects moderated the relationship of overall walking for transport with the prevalence of public transit points, this being positive only in safe locations. Similar moderating effects of safety-related attributes were observed for the relationships of within-neighborhood walking for transport with diversity of recreational and entertainment destinations. Pedestrian-infrastructure attributes acted as moderators of associations of within-neighborhood walking for transport with prevalence of commercial destination categories. Composite destinations indices consisting of destination categories related to the specific measures of walking were positively associated with walking for transport.
The availability of both non-commercial and commercial destinations may promote within-neighborhood walking for transport, while recreational facilities and public transit points may facilitate overall walking for transport. However, destination-rich areas need to also provide adequate levels of personal safety and a physically-unchallenging pedestrian network.
PMCID: PMC3689599  PMID: 23782627
Utilitarian walking; Elders; China; Environmental audit; Neighborhood; Destinations
20.  Examination of mid-intervention mediating effects on objectively assessed sedentary time among children in the Transform-Us! cluster-randomized controlled trial 
The optimal targets and strategies for effectively reducing sedentary behavior among young people are unknown. Intervention research that explores changes in mediated effects as well as in outcome behaviors is needed to help inform more effective interventions. Therefore, the purpose of this study was to examine the mid-intervention mediating effects on children’s objectively assessed classroom and total weekday sedentary time in the Transform-Us! intervention.
The results are based on 293 children, aged 7- to 9-years-old at baseline, from 20 schools in Melbourne, Australia. Each school was randomly allocated to one of four groups, which targeted reducing sedentary time in the school and family settings (SB; n = 74), increasing or maintaining moderate- to vigorous-intensity physical activity in the school and family settings (PA; n = 75), combined SB and PA (SB + PA; n = 80), or the current practice control (C; n = 64). Baseline and mid-intervention data (5–9 months) were collected in 2010 and analyzed in 2012. Classroom and total weekday sedentary time was objectively assessed using ActiGraph accelerometers. The hypothesized mediators including, child enjoyment, parent and teacher outcome expectancies, and child perceived access to standing opportunities in the classroom environment, were assessed by questionnaire.
The SB + PA group spent 13.3 min/day less in weekday sedentary time at mid-intervention compared to the control group. At mid-intervention, children in the SB group had higher enjoyment of standing in class (0.9 units; 5-unit scale) and all intervention groups had more positive perceptions of access to standing opportunities in the classroom environment (0.3-0.4 units; 3-unit scale), compared to the control group. However, none of the hypothesized mediator variables had an effect on sedentary time; thus, no mediating effects were observed.
While beneficial intervention effects were observed on some hypothesized mediating variables and total weekday sedentary time at mid-intervention, no significant mediating effects were found. Given the dearth of existing information, future intervention research is needed that explores mediated effects. More work is also needed on the development of reliable mediator measures that are sensitive to change overtime.
Trial registration
PMCID: PMC3681598  PMID: 23688180
Sedentary behavior; Intervention; Mediators; Children
21.  Study protocol for “Moving Bright, Eating Smart”– A phase 2 clinical trial on the acceptability and feasibility of a diet and physical activity intervention to prevent recurrence in colorectal cancer survivors 
BMC Public Health  2013;13:487.
Colorectal cancer is the second most common cancer and cancer-killer in Hong Kong with an alarming increasing incidence in recent years. The latest World Cancer Research Fund report concluded that foods low in fibre, and high in red and processed meat cause colorectal cancer whereas physical activity protects against colon cancer. Yet, the influence of these lifestyle factors on cancer outcome is largely unknown even though cancer survivors are eager for lifestyle modifications. Observational studies suggested that low intake of a Western-pattern diet and high physical activity level reduced colorectal cancer mortality. The Theory of Planned Behaviour and the Health Action Process Approach have guided the design of intervention models targeting a wide range of health-related behaviours.
We aim to demonstrate the feasibility of two behavioural interventions intended to improve colorectal cancer outcome and which are designed to increase physical activity level and reduce consumption of a Western-pattern diet. This three year study will be a multicentre, randomised controlled trial in a 2x2 factorial design comparing the “Moving Bright, Eating Smart” (physical activity and diet) programme against usual care. Subjects will be recruited over a 12-month period, undertake intervention for 12 months and followed up for a further 12 months. Baseline, interim and three post-intervention assessments will be conducted.
Two hundred and twenty-two colorectal cancer patients who completed curative treatment without evidence of recurrence will be recruited into the study. Primary outcome measure will be whether physical activity and dietary targets are met at the end of the 12-month intervention. Secondary outcome measures include the magnitude and mechanism of behavioural change, the degree and determinants of compliance, and the additional health benefits and side effects of the intervention.
The results of this study will establish the feasibility of targeting the two behaviours (diet and physical activity) and demonstrate the magnitude of behaviour change. The information will facilitate the design of a further larger phase III randomised controlled trial with colorectal cancer outcome as the study endpoint to determine whether this intervention model would reduce colorectal cancer recurrence and mortality.
Trial registration No: NCT01708824
PMCID: PMC3716902  PMID: 23688320
Colorectal cancer; Cancer survivor; Diet; Meat; Grains; Physical activity; Behavioural intervention; Feasibility; Acceptability; Randomised
22.  Can social dancing prevent falls in older adults? a protocol of the Dance, Aging, Cognition, Economics (DAnCE) fall prevention randomised controlled trial 
BMC Public Health  2013;13:477.
Falls are one of the most common health problems among older people and pose a major economic burden on health care systems. Exercise is an accepted stand-alone fall prevention strategy particularly if it is balance training or regular participation in Tai chi. Dance shares the ‘holistic’ approach of practices such as Tai chi. It is a complex sensorimotor rhythmic activity integrating multiple physical, cognitive and social elements. Small-scale randomised controlled trials have indicated that diverse dance styles can improve measures of balance and mobility in older people, but none of these studies has examined the effect of dance on falls or cognition. This study aims to determine whether participation in social dancing: i) reduces the number of falls; and ii) improves cognitive functions associated with fall risk in older people.
A single-blind, cluster randomised controlled trial of 12 months duration will be conducted. Approximately 450 participants will be recruited from 24 self-care retirement villages that house at least 60 residents each in Sydney, Australia. Village residents without cognitive impairment and obtain medical clearance will be eligible. After comprehensive baseline measurements including physiological and cognitive tests and self-completed questionnaires, villages will be randomised to intervention sites (ballroom or folk dance) or to a wait-listed control using a computer randomisation method that minimises imbalances between villages based on two baseline fall risk measures. Main outcome measures are falls, prospectively measured, and the Trail Making cognitive function test. Cost-effectiveness and cost-utility analyses will be performed.
This study offers a novel approach to balance training for older people. As a community-based approach to fall prevention, dance offers older people an opportunity for greater social engagement, thereby making a major contribution to healthy ageing. Providing diversity in exercise programs targeting seniors recognises the heterogeneity of multicultural populations and may further increase the number of taking part in exercise.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12612000889853
The trial is now in progress with 12 villages already have been randomised.
PMCID: PMC3691670  PMID: 23675705
23.  Associations between perceived neighborhood environmental attributes and adults’ sedentary behavior: Findings from the USA, Australia and Belgium 
Social science & medicine (1982)  2012;74(9):1375-1384.
Sedentary behaviors are associated with multiple health problems, independently of physical activity. Neighborhood environment attributes might influence sedentary behaviors, but few studies have investigated these relationships. Moreover, all previous studies have been conducted within single countries, limiting environmental variability. We investigated the shape of associations between perceived neighborhood environment attributes and sedentary behavior in three countries; and whether these associations differed by country and gender. Data from USA (Seattle and Baltimore regions), Australia (Adelaide) and Belgium (Ghent) were pooled. Data collection took place between 2002 and 2008. In total, 6,014 adults (20–65 years, 55.7% women) were recruited in high-/low-walkability and high-/low-income neighborhoods. All participants completed the International Physical Activity Questionnaire (domain-specific physical activity, transport-related sitting and overall time spent sitting) and the Neighborhood Environmental Walkability Scale (environmental perceptions). The number of destinations within a 20 minute walk from home, perceiving few cul-de-sacs, good walking and cycling facilities, and traffic safety were included in an index of motorized transport correlates. This index was linearly negatively associated with motorized transport time, so the higher the scores on the index (more activity-friendliness), the lower the amount of motorized transport. No gender- or country-differences were identified. Perceived aesthetics and proximity of destinations were included in an index of overall sitting time correlates. A linear negative relationship with overall sitting time was found, but associations were stronger for men and not significant in Belgian adults. In conclusion, consistent and expected correlates were found for motorized transport in the three countries, but results were less clear for overall sitting time. Future studies should include even more countries to maximize environmental variability, but present findings suggest that neighborhoods may be designed to improve health through supporting more active and less sedentary transportation, which can be expected to have health benefits.
PMCID: PMC3321105  PMID: 22405686
sitting; NEWS; built environment; dose-response; pooled analyses; USA, Australia; Belgium
24.  Breaking Up Prolonged Sitting Reduces Postprandial Glucose and Insulin Responses 
Diabetes Care  2012;35(5):976-983.
Observational studies show breaking up prolonged sitting has beneficial associations with cardiometabolic risk markers, but intervention studies are required to investigate causality. We examined the acute effects on postprandial glucose and insulin levels of uninterrupted sitting compared with sitting interrupted by brief bouts of light- or moderate-intensity walking.
Overweight/obese adults (n = 19), aged 45–65 years, were recruited for a randomized three-period, three-treatment acute crossover trial: 1) uninterrupted sitting; 2) seated with 2-min bouts of light-intensity walking every 20 min; and 3) seated with 2-min bouts of moderate-intensity walking every 20 min. A standardized test drink was provided after an initial 2-h period of uninterrupted sitting. The positive incremental area under curves (iAUC) for glucose and insulin (mean [95% CI]) for the 5 h after the test drink (75 g glucose, 50 g fat) were calculated for the respective treatments.
The glucose iAUC (mmol/L) ⋅ h after both activity-break conditions was reduced (light: 5.2 [4.1–6.6]; moderate: 4.9 [3.8–6.1]; both P < 0.01) compared with uninterrupted sitting (6.9 [5.5–8.7]). Insulin iAUC (pmol/L) ⋅ h was also reduced with both activity-break conditions (light: 633.6 [552.4–727.1]; moderate: 637.6 [555.5–731.9], P < 0.0001) compared with uninterrupted sitting (828.6 [722.0–950.9]).
Interrupting sitting time with short bouts of light- or moderate-intensity walking lowers postprandial glucose and insulin levels in overweight/obese adults. This may improve glucose metabolism and potentially be an important public health and clinical intervention strategy for reducing cardiovascular risk.
PMCID: PMC3329818  PMID: 22374636
25.  Sharing good NEWS across the world: developing comparable scores across 12 countries for the neighborhood environment walkability scale (NEWS) 
BMC Public Health  2013;13:309.
The IPEN (International Physical Activity and Environment Network) Adult project seeks to conduct pooled analyses of associations of perceived neighborhood environment, as measured by the Neighborhood Environment Walkability Scale (NEWS) and its abbreviated version (NEWS-A), with physical activity using data from 12 countries. As IPEN countries used adapted versions of the NEWS/NEWS-A, this paper aimed to develop scoring protocols that maximize cross-country comparability in responses. This information is also highly relevant to non-IPEN studies employing the NEWS/NEWS-A, which is one of the most popular measures of perceived environment globally.
The following countries participated in the IPEN Adult study: Australia, Belgium, Brazil, Colombia, Czech Republic, Denmark, Hong Kong, Mexico, New Zealand, Spain, the United Kingdom, and the United States. Participants (N = 14,305) were recruited from neighborhoods varying in walkability and socio-economic status. Countries collected data on the perceived environment using a self- or interviewer-administered version of the NEWS/NEWS-A. Confirmatory Factor Analysis (CFA) was used to derive comparable country-specific measurement models of the NEWS/NEWS-A. The level of correspondence between standard and alternative versions of the NEWS/NEWS-A factor-analyzable subscales was determined by estimating the correlations and mean standardized difference (Cohen’s d) between them using data from countries that had included items from both standard and alternative versions of the subscales.
Final country-specific measurement models of the NEWS/NEWS-A provided acceptable levels of fit to the data and shared the same factorial structure with six latent factors and two single items. The correspondence between the standard and alternative versions of subscales of Land use mix – access, Infrastructure and safety for walking/cycling, and Aesthetics was high. The Brazilian version of the Traffic safety subscale was highly, while the Australian and Belgian versions were marginally, comparable to the standard version. Single-item versions of the Street connectivity subscale used in Australia and Belgium showed marginally acceptable correspondence to the standard version.
We have proposed country-specific modifications to the original scoring protocol of the NEWS/NEWS-A that enhance inter-country comparability. These modifications have yielded sufficiently equivalent measurement models of the NEWS/NEWS-A. Some inter-country discrepancies remain. These need to be considered when interpreting findings from different countries.
PMCID: PMC3642009  PMID: 23566032
Built environment; Questionnaire; Global; Confirmatory factor analysis; Pooled analyses

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