Carme Martin-Borràs

Effectiveness of a primary care-based intervention to reduce sitting time in overweight and obese patients (SEDESTACTIV): a randomized controlled trial; rationale and study design

BackgroundThere is growing evidence suggesting that prolonged sitting has negative effects on people’s weight, chronic diseases and mortality. Interventions to reduce sedentary time can be an effective strategy to increase daily energy expenditure. The purpose of this study is to evaluate the effectiveness of a six-month primary care intervention to reduce daily of sitting time in overweight and mild obese sedentary patients.Method/DesignThe study is a randomized controlled trial (RCT). Professionals from thirteen primary health care centers (PHC) will randomly invite to participate mild obese or overweight patients of both gender, aged between 25 and 65 years old, who spend 6 hours at least daily sitting. A total of 232 subjects will be randomly allocated to an intervention (IG) and control group (CG) (116 individuals each group). In addition, 50 subjects with fibromyalgia will be included.Primary outcome is: (1) sitting time using the activPAL device and the Marshall questionnaire. The following parameters will be also assessed: (2) sitting time in work place (Occupational Sitting and Physical Activity Questionnaire), (3) health-related quality of life (EQ-5D), (4) evolution of stage of change (Prochaska and DiClementes Stages of Change Model), (5) physical inactivity (catalan version of Brief Physical Activity Assessment Tool), (6) number of steps walked (pedometer and activPAL), (7) control based on analysis (triglycerides, total cholesterol, HDL, LDL, glycemia and, glycated haemoglobin in diabetic patients) and (8) blood pressure and anthropometric variables. All parameters will be assessed pre and post intervention and there will be a follow up three, six and twelve months after the intervention. A descriptive analysis of all variables and a multivariate analysis to assess differences among groups will be undertaken. Multivariate analysis will be carried out to assess time changes of dependent variables. All the analysis will be done under the intention to treat principle.DiscussionIf the SEDESTACTIV intervention shows its effectiveness in reducing sitting time, health professionals would have a low-cost intervention tool for sedentary overweight and obese patients management.Trial registrationA service of the U.S. National Institutes of Health. Developed by the National Library of Medicine. ClinicalTrials.gov NCT01729936

Prolonged Sitting Time: Barriers, Facilitators and Views on Change among Primary Healthcare Patients Who Are Overweight or Moderately Obese

Background and Objectives Prolonged sitting time has negative consequences on health, although the population is not well aware of these harmful effects. We explored opinions expressed by primary care patients diagnosed as overweight or moderately obese concerning their time spent sitting, willingness to change, and barriers, facilitators, goals and expectations related to limiting this behaviour. Methods A descriptive-interpretive qualitative study was carried out at three healthcare centres in Barcelona, Spain, and included 23 patients with overweight or moderate obesity, aged 25 to 65 years, who reported sitting for at least 6 hours a day. Exclusion criteria were inability to sit down or stand up from a chair without help and language barriers that precluded interview participation. Ten in-depth, semi-structured interviews (5 group, 5 individual) were audio recorded from January to July 2012 and transcribed. The interview script included questions about time spent sitting, willingness to change, barriers and facilitators, and the prospect of assistance from primary healthcare professionals. An analysis of thematic content was made using ATLAS.Ti and triangulation of analysts. Results The most frequent sedentary activities were computer use, watching television, and motorized journeys. There was a lack of awareness of the amount of time spent sitting and its negative consequences on health. Barriers to reducing sedentary time included work and family routines, lack of time and willpower, age and sociocultural limitations. Facilitators identified were sociocultural change, free time and active work, and family surroundings. Participants recognized the abilities of health professionals to provide help and advice, and reported a preference for patient-centred or group interventions. Conclusions Findings from this study have implications for reducing sedentary behaviour. Patient insights were used to design an intervention to reduce sitting time within the frame of the SEDESTACTIV clinical trial.

The Effect of a Physical Activity Program on the Total Number of Primary Care Visits in Inactive Patients: A 15-Month Randomized Controlled Trial

Background Effective promotion of exercise could result in substantial savings in healthcare cost expenses in terms of direct medical costs, such as the number of medical appointments. However, this is hampered by our limited knowledge of how to achieve sustained increases in physical activity. Objectives To assess the effectiveness of a Primary Health Care (PHC) based physical activity program in reducing the total number of visits to the healthcare center among inactive patients, over a 15-month period. Research Design Randomized controlled trial. Subjects Three hundred and sixty-two (n = 362) inactive patients suffering from at least one chronic condition were included. One hundred and eighty-three patients (n = 183; mean (SD); 68.3 (8.8) years; 118 women) were randomly allocated to the physical activity program (IG). One hundred and seventy-nine patients (n = 179; 67.2 (9.1) years; 106 women) were allocated to the control group (CG). The IG went through a three-month standardized physical activity program led by physical activity specialists and linked to community resources. Measures The total number of medical appointments to the PHC, during twelve months before and after the program, was registered. Self-reported health status (SF-12 version 2) was assessed at baseline (month 0), at the end of the intervention (month 3), and at 12 months follow-up after the end of the intervention (month 15). Results The IG had a significantly reduced number of visits during the 12 months after the intervention: 14.8 (8.5). The CG remained about the same: 18.2 (11.1) (P = .002). Conclusions Our findings indicate that a 3-month physical activity program linked to community resources is a short-duration, effective and sustainable intervention in inactive patients to decrease rates of PHC visits. Trial Registration ClinicalTrials.gov NCT00714831

Relationship between Physical Activity and Plasma Fibrinogen Concentrations in Adults without Chronic Diseases

Objective To analyze the relationship between regular physical activity, as assessed by accelerometer and 7-day physical activity recall (PAR), and plasma fibrinogen concentrations. Methods A cross-sectional study in a previously established cohort of healthy subjects was performed. This study analyzed 1284 subjects who were included in the EVIDENT study (mean age 55.0±13.6 years; 60.90% women). Fibrinogen concentrations were measured in blood plasma. Physical activity was assessed with a 7-day PAR (metabolic equivalents (METs)/hour/week) and GT3X ActiGraph accelerometer (counts/minute) for 7 days. Results Physical exercise, which was evaluated with both an accelerometer (Median: 237.28 counts/minute) and 7-day PAR (Median: 8 METs/hour/week). Physical activity was negatively correlated with plasma fibrinogen concentrations, which was evaluated by counts/min (r = −0.100; p<0.001) and METs/hour/week (r = −0.162; p<0.001). In a multiple linear regression analysis, fibrinogen concentrations of the subjects who performed more physical activity (third tertile of count/minute and METs/hour/week) respect to subjects who performed less (first tertile), maintained statistical significance after adjustments for age and others confounders (β = −0.03; p = 0.046 and β = −0.06; p<0.001, respectively). Conclusions Physical activity, as assessed by accelerometer and 7-day PAR, was negatively associated with plasma fibrinogen concentrations. This relation is maintained in subjects who performed more exercise even after adjusting for age and other confounders.

Programa de Promoción de Actividad Física (PPAF) en los centros de atención primaria. Estudio piloto

Sr. Director: Se ha diseñado un estudio piloto con el objetivo de evaluar la efectividad del Programa de Promoción de Actividad Física (PPAF) en los centros de atención primaria (CAP) a partir de la creación del hábito de realizar actividad física de forma regular, de la socialización de los participantes y de la disminución de la presión asistencial. Se trata de un estudio longitudinal preintervención y postintervención. Se ha realizado en 5 CAP de la ciudad de Barcelona escogidos de forma aleatoria buscando la representación de los 4 servicios de atención primaria (SAP) de esta ciudad. Se incluyó a 66 pacientes que aceptaron participar (n = 66, 5 varones y 61 mujeres) con una edad media de 63,18 ± 6,98 años; una frecuencia cardíaca basal de 72,99 ± 8,79 lat/min, y un índice de masa corporal (IMC) de 31,6 ± 3,89 kg/m2. Los criterios de inclusión fueron los siguientes: a) pacientes adultos; b) sedentarios (versión reducida del cuestionario internacional de actividad física, IPAQ); c) dispuestos a realizar un programa con las características del PPAF (fig. 1), con una asistencia mínima de un 80%,y d) con una aptitud física mínima para seguir el programa. Los criterios de exclusión se definieron a partir de las contraindicaciones absolutas y relativas a realizar actividad física1. Desde el Área de Actividad Física y Salud del Ámbito de Atención Primaria de Barcelona Ciudad del Institut Català de la Salut (ICS), se ha contactado con 2 profesionales voluntarios de cada CAP, que han centralizado la captación de pacientes. Desde sus consultas ofrecían la posibilidad de participar en el PPAF a todos los pacientes que cumplían con los criterios de inclusión. Si el paciente aceptaba participar en el programa, se le entregaba el consentimiento informado, que debía devolver firmado, y una hoja informativa del programa. Si el paciente no quería participar, se le hacía una recomendación del tipo de actividad física más adecuado según su enfermedad, basándose en la guía de prescripción de actividad física elaborada desde la misma área2. Los 5 grupos de intervención (un grupo por cada CAP piloto) se cerraron con las primeras 10-15 personas que aceptaron participar. En la primera y en la última sesiones se cumplimentaron los cuestionarios y se llevaron a cabo las pruebas exploratorias. Al finalizar el programa se le facilitó a cada participante una prescripción individualizada de actividad física por escrito y un listado de recursos disponibles en el distrito donde poder continuar con dicha práctica. Al mes de la finalización del programa se citó a todos los participantes a una sesión de seguimiento. Pasados 3 meses, se registró el número total de visitas al CAP, comparándolo con la suma total de visitas durante los 3 meses previos al PPAF. Se aplicaron los siguientes cuestionarios y pruebas de condición física: a) preguntas de la encuesta de salud de Barcelona; b) viñetas COOP/WONCA; c) «6 minutes walking test», y d) prueba ACEMFEI (evaluación de la coordinación, el equilibrio, la marcha y la fuerza de las extremidades inferiores para la prevención de caídas). Se han registrado también: a) peso y talla; b) frecuencia cardíaca basal, y c) presión arterial. El 74,19% del total de participantes del PPAF continúa practicando algún tipo de actividad física de forma regular después de un mes de la finalización del programa. En el 78,26% de los casos los participantes se han reunido con compañeros que conocieron durante el programa. Respecto a la influencia del programa en la presión asistencial, el 76,92% de los participantes ha disminuido el número total de visitas. Tras la experiencia del pilotaje del PPAF, se puede afirmar que un programa de actividad física de 3 meses realizado en los CAP es suficiente para causar cambios en el estilo de vida a partir de un aumento del nivel de actividad física, que persiste pasado un mes de la finalización de éste. No bastan las intervenciones basadas en consejos generales3. Resulta más motivador y eficaz para el cambio de conducta una intervención como el PPAF, que incluya la participación en un programa de actividad física con estrategias de enseñanza-aprendizaje, y que sea super-

Patterns of sedentary behavior in overweight and moderately obese users of the Catalan primary-health care system

Background and objectives Prolonged sitting time (ST) has negative consequences on health. Changing this behavior is paramount in overweight/obese individuals because they are more sedentary than those with normal weight. The aim of the study was to establish the pattern of sedentary behavior and its relationship to health, socio-demographics, occupation, and education level in Catalan overweight/obese individuals. Methods A descriptive study was performed at 25 healthcare centers in Catalonia (Spain) with 464 overweight/moderately obese patients, aged25 to 65 years. Exclusion criteria were chronic diseases which contraindicated physical activity and language barriers. Face-to-face interviews were conducted to collect data on age, gender, educational level, social class, and marital status. Main outcome was ‘sitting time’ (collected by the Marshall questionnaire); chronic diseases and anthropometric measurements were registered. Results 464 patients, 58.4% women, mean age 51.9 years (SD 10.1), 76.1% married, 60% manual workers, and 48.7% had finished secondary education. Daily sitting time was 6.2 hours on working days (374 minutes/day, SD: 190), and about 6 hours on non-working ones (357 minutes/day, SD: 170). 50% of participants were sedentary ≥6 hours. The most frequent sedentary activities were: working/academic activities around 2 hours (128 minutes, SD: 183), followed by watching television, computer use, and commuting. Men sat longer than women (64 minutes more on working days and 54 minutes on non-working days), and individuals with office jobs (91 minutes),those with higher levels of education (42 minutes), and younger subjects (25 to 35 years) spent more time sitting. Conclusions In our study performed in overweight/moderately obese patients the mean sitting time was around 6 hours which was mainly spent doing work/academic activities and watching television. Men, office workers, individuals with higher education, and younger subjects had longer sitting time. Our results may help design interventions targeted at these sedentary patients to decrease sitting time.

A new model of exercise referral scheme in primary care: is the effect on adherence to physical activity sustainable in the long term? A 15-month randomised controlled trial

Introduction Studies had not yet overcome the most relevant barriers to physical activity (PA) adherence. An exercise referral scheme (ERS) with mechanisms to promote social support might enhance adherence to PA in the long term. Setting A randomised controlled trial in 10 primary care centres in Spain. Objective To assess the effectiveness of a primary care-based ERS linked to municipal resources and enhancing social support and social participation in establishing adherence to PA among adults over a 15-month period. Participants 422 insufficiently active participants suffering from at least one chronic condition were included. 220 patients (69.5 (8.4) years; 136 women) were randomly allocated to the intervention group (IG) and 202 (68.2 (8.9) years; 121 women) to the control group (CG). Interventions The IG went through a 12-week standardised ERS linked to community resources and with inclusion of mechanisms to enhance social support. The CG received usual care from their primary care practice. Outcomes The main outcome measure was self-report PA with the International Physical Activity Questionnaire and secondary outcomes included stages of change and social support to PA practice. Data collection Participant-level data were collected via questionnaires at baseline, and at months 3, 9 and 15. Blinding The study statistician and research assessors were blinded to group allocation. Results Compared with usual care, follow-up data at month 15 for the ERS group showed a significant increase of self-reported PA (IG: 1373±1845 metabolic equivalents (MET) min/week, n=195; CG: 919±1454 MET min/week, n=144; P=0.009). Higher adherence (in terms of a more active stage of change) was associated with higher PA level at baseline and with social support. Conclusions Prescription from ordinary primary care centres staff yielded adherence to PA practice in the long term. An innovative ERS linked to community resources and enhancing social support had shown to be sustainable in the long term. Trial registration number NCT00714831; Results.