Maria Giné-Garriga

Physical Exercise Interventions for Improving Performance-Based Measures of Physical Function in Community-Dwelling, Frail Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVE To conduct a systematic review to determine the efficacy of exercise-based interventions on improving performance-based measures of physical function and markers of physical frailty in community-dwelling, frail older people. DATA SOURCES Comprehensive bibliographic searches in MEDLINE, the Cochrane Library, PEDro, and CINAHL databases were conducted (April 2013). STUDY SELECTION Randomized controlled trials of community-dwelling older adults, defined as frail according to physical function and physical difficulties in activities of daily living (ADL). Included trials had to compare an exercise intervention with a control or another exercise intervention, and assess performance-based measures of physical function such as mobility and gait, or disability in ADL. DATA EXTRACTION Two review authors independently screened the search results and performed data extraction and risk of bias assessment. Nineteen trials were included, 12 of them comparing exercise with an inactive control. Most exercise programs were multicomponent. DATA SYNTHESIS Meta-analysis was performed for the comparison of exercise versus control with the inverse variance method under the random-effects models. When compared with control interventions, exercise was shown to improve normal gait speed (mean difference [MD]=.07m/s; 95% confidence interval [CI], .04-.09), fast gait speed (MD=.08m/s; 95% CI, .02-.14), and the Short Physical Performance Battery (MD=2.18; 95% CI, 1.56-2.80). Results are inconclusive for endurance outcomes, and no consistent effect was observed on balance and the ADL functional mobility. The evidence comparing different modalities of exercise is scarce and heterogeneous. CONCLUSIONS Exercise has some benefits in frail older people, although uncertainty still exists with regard to which exercise characteristics (type, frequency, duration) are most effective.

Patterns of Impact Resulting from a ‘Sit Less, Move More’ Web-Based Program in Sedentary Office Employees

Purpose Encouraging office workers to ‘sit less and move more’ encompasses two public health priorities. However, there is little evidence on the effectiveness of workplace interventions for reducing sitting, even less about the longer term effects of such interventions and still less on dual-focused interventions. This study assessed the short and mid-term impacts of a workplace web-based intervention (Walk@WorkSpain, W@WS; 2010-11) on self-reported sitting time, step counts and physical risk factors (waist circumference, BMI, blood pressure) for chronic disease. Methods Employees at six Spanish university campuses (n=264; 42±10 years; 171 female) were randomly assigned by worksite and campus to an Intervention (used W@WS; n=129; 87 female) or a Comparison group (maintained normal behavior; n=135; 84 female). This phased, 19-week program aimed to decrease occupational sitting time through increased incidental movement and short walks. A linear mixed model assessed changes in outcome measures between the baseline, ramping (8 weeks), maintenance (11 weeks) and follow-up (two months) phases for Intervention versus Comparison groups. Results A significant 2 (group) × 2 (program phases) interaction was found for self-reported occupational sitting (F[3]=7.97, p=0.046), daily step counts (F[3]=15.68, p=0.0013) and waist circumference (F[3]=11.67, p=0.0086). The Intervention group decreased minutes of daily occupational sitting while also increasing step counts from baseline (446±126; 8,862±2,475) through ramping (+425±120; 9,345±2,435), maintenance (+422±123; 9,638±3,131) and follow-up (+414±129; 9,786±3,205). In the Comparison group, compared to baseline (404±106), sitting time remained unchanged through ramping and maintenance, but decreased at follow-up (-388±120), while step counts diminished across all phases. The Intervention group significantly reduced waist circumference by 2.1cms from baseline to follow-up while the Comparison group reduced waist circumference by 1.3cms over the same period. Conclusions W@WS is a feasible and effective evidence-based intervention that can be successfully deployed with sedentary employees to elicit sustained changes on “sitting less and moving more”.

Self-reported sitting time and physical activity: interactive associations with mental well-being and productivity in office employees

BackgroundLittle is known about how sitting time, alone or in combination with markers of physical activity (PA), influences mental well-being and work productivity. Given the need to develop workplace PA interventions that target employees’ health related efficiency outcomes; this study examined the associations between self-reported sitting time, PA, mental well-being and work productivity in office employees.MethodsDescriptive cross-sectional study. Spanish university office employees (n = 557) completed a survey measuring socio-demographics, total and domain specific (work and travel) self-reported sitting time, PA (International Physical Activity Questionnaire short version), mental well-being (Warwick-Edinburg Mental Well-Being Scale) and work productivity (Work Limitations Questionnaire). Multivariate linear regression analyses determined associations between the main variables adjusted for gender, age, body mass index and occupation. PA levels (low, moderate and high) were introduced into the model to examine interactive associations.ResultsHigher volumes of PA were related to higher mental well-being, work productivity and spending less time sitting at work, throughout the working day and travelling during the week, including the weekends (p < 0.05). Greater levels of sitting during weekends was associated with lower mental well-being (p < 0.05). Similarly, more sitting while travelling at weekends was linked to lower work productivity (p < 0.05). In highly active employees, higher sitting times on work days and occupational sitting were associated with decreased mental well-being (p < 0.05). Higher sitting times while travelling on weekend days was also linked to lower work productivity in the highly active (p < 0.05). No significant associations were observed in low active employees.ConclusionsEmployees’ PA levels exerts different influences on the associations between sitting time, mental well-being and work productivity. The specific associations and the broad sweep of evidence in the current study suggest that workplace PA strategies to improve the mental well-being and productivity of all employees should focus on reducing sitting time alongside efforts to increase PA.

Biomarkers associated with sedentary behaviour in older adults: A systematic review

OBJECTIVE Pathomechanisms of sedentary behaviour (SB) are unclear. We conducted a systematic review to investigate the associations between SB and various biomarkers in older adults. METHODS Electronic databases were searched (MEDLINE, EMBASE, CINAHL, AMED) up to July 2015 to identify studies with objective or subjective measures of SB, sample size ≥50, mean age ≥60years and accelerometer wear time ≥3days. Methodological quality was appraised with the CASP tool. The protocol was pre-specified (PROSPERO CRD42015023731). RESULTS 12701 abstracts were retrieved, 275 full text articles further explored, from which 249 were excluded. In the final sample (26 articles) a total of 63 biomarkers were detected. Most investigated markers were: body mass index (BMI, n=15), waist circumference (WC, n=15), blood pressure (n=11), triglycerides (n=12) and high density lipoprotein (HDL, n=15). Some inflammation markers were identified such as interleukin-6, C-reactive protein or tumor necrosis factor alpha. There was a lack of renal, muscle or bone biomarkers. Randomized controlled trials found a positive correlation for SB with BMI, neck circumference, fat mass, HbA1C, cholesterol and insulin levels, cohort studies additionally for WC, leptin, C-peptide, ApoA1 and Low density lipoprotein and a negative correlation for HDL. CONCLUSION Most studied biomarkers associated with SB were of cardiovascular or metabolic origin. There is a suggestion of a negative impact of SB on biomarkers but still a paucity of high quality investigations exist. Longitudinal studies with objectively measured SB are needed to further elucidate the pathophysiological pathways and possible associations of unexplored biomarkers.

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.

Development of a New Index of Balance in Adults with Intellectual and Developmental Disabilities

Purposes The first objective was to propose a new model representing the balance level of adults with intellectual and developmental disabilities (IDD) using Principal Components Analysis (PCA); and the second objective was to use the results from the PCA recorded by regression method to construct and validate summative scales of the standardized values of the index, which may be useful to facilitate a balance assessment in adults with IDD. Methods A total of 801 individuals with IDD (509 males) mean 33.1±8.5 years old, were recruited from Special Olympic Games in Spain 2009 to 2012. The participants performed the following tests: the timed-stand test, the single leg stance test with open and closed eyes, the Functional Reach Test, the Expanded Timed-Get-up-and-Go Test. Data was analyzed using principal components analysis (PCA) with Oblimin rotation and Kaiser normalization. We examined the construct validity of our proposed two-factor model underlying balance for adults with IDD. The scores from PCA were recorded by regression method and were standardized. Results The Component Plot and Rotated Space indicated that a two-factor solution (Dynamic and Static Balance components) was optimal. The PCA with direct Oblimin rotation revealed a satisfactory percentage of total variance explained by the two factors: 51.6 and 21.4%, respectively. The median score standardized for component dynamic and static of the balance index for adults with IDD is shown how references values. Conclusions Our study may lead to improvements in the understanding and assessment of balance in adults with IDD. First, it confirms that a two-factor model may underlie the balance construct, and second, it provides an index that may be useful for identifying the balance level for adults with IDD.

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

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-

Combined Effects of Diet and Exercise or Diet Alone to Improve Physical Function in Community-Dwelling Older Adults: A Systematic Review of the Literature

This systematic review and meta-analysis examines the effectiveness of combined diet (not limited to caloric restriction) and exercise interventions, and diet interventions alone to improve physical function in community-dwelling older adults. Randomized clinical trials and observational population-based studies of community-dwelling older adults were selected through comprehensive bibliographic searches in Medline (up to September 2014). Included trials had to assess performance-based measures of physical function such as strength, balance, mobility and gait, and diet measured as diet indexes or food intake. Seven studies were included. Meta-analysis was performed with the inverse variance method under the random effects models. Combined exercise and diet interventions, when compared with control or diet interventions alone, were shown to improve walking speed and performance on the Short Physical Performance Battery (SPPB), although SPPB results failed to show clinical significance. No consistent effect was observed for balance outcomes. Although exercise interventions are known to improve physical function outcomes, based on current data, it is not possible to affirm that a combination of diet and exercise interventions can further improve physical function. The evidence comparing different patterns of diet is scarce, and it is not possible to pinpoint which diet intervention is the most effective.