1
|
Eckhardt H, Quentin W, Silzle J, Busse R, Rombey T. Cost-effectiveness of prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO) versus usual care - Protocol for a health economic evaluation alongside a randomized controlled trial. BMC Geriatr 2024; 24:231. [PMID: 38448804 PMCID: PMC10916129 DOI: 10.1186/s12877-024-04833-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 02/21/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Prehabilitation aims to improve patients' functional capacity before surgery to reduce perioperative complications, promote recovery and decrease probability of disability. The planned economic evaluation is performed alongside a large German multi-centre pragmatic, two-arm parallel-group, randomized controlled trial on prehabilitation for frail elderly patients before elective surgery compared to standard care (PRAEP-GO RCT). The aim is to determine the cost-effectiveness and cost-utility of prehabilitation for frail elderly before an elective surgery. METHODS The planned health economic evaluation comprises cost-effectiveness, and cost-utility analyses. Analyses are conducted in the German context from different perspectives including the payer perspective, i.e. the statutory health insurance, the societal perspective and the health care provider perspective. Data on outcomes and costs, are collected alongside the ongoing PRAEP-GO RCT. The trial population includes frail or pre-frail patients aged ≥70 years with planned elective surgery. The intervention consists of frailty screening (Fried phenotype), a shared decision-making conference determining modality (physiotherapy and unsupervised physical exercises, nutrition counselling, etc.) and setting (inpatient, day care, outpatient etc.) of a 3-week individual multimodal prehabilitation prior to surgery. The control group receives standard preoperative care. Costs include the intervention costs, the costs of the index hospital stay for surgery, and health care resources consumed during a 12-month follow-up. Clinical effectiveness outcomes included in the economic evaluation are the level of care dependency, the degree of disability as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality-adjusted life years (QALY) derived from the EQ-5D-5L and the German utility set, and complications occurring during the index hospital stay. Each adopted perspective considers different types of costs and outcomes as outlined in the protocol. All analyses will feature Intention-To-Treat analysis. To explore methodological and parametric uncertainties, we will conduct probabilistic and deterministic sensitivity analyses. Subgroup analyses will be performed as secondary analyses. DISCUSSION The health economic evaluation will provide insights into the cost-effectiveness of prehabilitation in older frail populations, informing decision-making processes and contributing to the evidence base in this field. Potential limitation includes a highly heterogeneous trial population. TRIAL REGISTRATION PRAEP-GO RCT: NCT04418271; economic evaluation: OSF ( https://osf.io/ecm74 ).
Collapse
Affiliation(s)
- Helene Eckhardt
- Department of Health Care Management, Institute of Technology and Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany.
| | - Wilm Quentin
- Department of Health Care Management, Institute of Technology and Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany
- Planetary & Public Health, University of Bayreuth, Universitätsstraße 30, 95447, Bayreuth, Germany
| | - Julia Silzle
- Department of Health Care Management, Institute of Technology and Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Institute of Technology and Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Institute of Technology and Management, Technische Universität Berlin, Straße des 17. Juni 135, 10623, Berlin, Germany
| |
Collapse
|
2
|
Nagata CDA, Garcia PA, Hamu TCDDS, Caetano MBD, Costa RR, Leal JC, Bastos JAI, Cadore EL, Durigan JLQ. Are dose-response relationships of resistance training reliable to improve functional performance in frail and pre-frail older adults? A systematic review with meta-analysis and meta-regression of randomized controlled trials. Ageing Res Rev 2023; 91:102079. [PMID: 37774931 DOI: 10.1016/j.arr.2023.102079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/11/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
This systematic review with meta-analyses investigates the impact of resistance training (RT), using meta-regressions, on functional performance in frail and pre-frail adults aged ≥ 65 years to determine the key variables of RT. Ten randomized controlled trials involving 1303 participants were analyzed. Five studies assessed habitual walking speed (HWS), three studies evaluated performance in the timed-up-and-go test (TUG), three studies evaluated performance in the Short Physical Performance Battery (SPPB), and three studies assessed performance in the sit-to-stand test (STS). RT alone improved STS time and SPPB scores in frail and pre-frail older adults. RT improved STS performance (Effect Size (ES):- 0.536; 95% CI - 0.874 to - 0.199; p = .002) and led to a 2.261-point increase in SPPB performance (ES:1.682; 95% CI 0.579-2.786; p = .003). At least two weekly training sessions are required to increase SPPB scores, and three sessions seem to optimize the improvements. Higher training volume per exercise and volume per session reduce the gains in SPPB performance. We did not observe any association between different doses of RT and STS time improvements. RT alone positively influenced TUG performance only in community-dwelling older frail and pre-frail adults but not in institutionalized older individuals. RT alone did not improve the HWS compared to the non-active control group.
Collapse
Affiliation(s)
| | - Patrícia Azevedo Garcia
- Universidade de Brasília, Programa de Pós-Graduação em Ciências da Reabilitação, Brasília, DF, Brazil.
| | | | | | | | - Josevan Cerqueira Leal
- Universidade de Brasília, Programa de Pós-Graduação em Ciências da Reabilitação, Brasília, DF, Brazil.
| | - Júlia Aguillar Ivo Bastos
- Universidade de Brasília, Programa de Pós-Graduação em Ciências da Reabilitação, Brasília, DF, Brazil.
| | - Eduardo Lusa Cadore
- Exercise Research Laboratory (LAPEX), School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - João Luiz Quagliotti Durigan
- Universidade de Brasília, Laboratory of Muscle and Tendon Plasticity, Programa de Pós-Graduação em Educação Física, Brasília, DF, Brazil.
| |
Collapse
|
3
|
Ruiz-Cárdenas JD, Montemurro A, Del Mar Martínez-García M, Rodríguez-Juan JJ. Concurrent and discriminant validity and reliability of an Android App to assess time, velocity and power during sit-to-stand test in community-dwelling older adults. Aging Clin Exp Res 2023:10.1007/s40520-023-02451-6. [PMID: 37306926 DOI: 10.1007/s40520-023-02451-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/21/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Nowadays, smartphones are equipped with the most sophisticated hardware which provides the opportunity to develop specific smartphone apps to analyze kinetic and kinematic parameters during sit-to-stand test in a clinical setting. The aims were to ascertain whether a new Android video-analysis based-App is comparable to the previously validated Apple-App for measuring time, velocity and power during sit-to-stand test, to determine its reliability and discriminant validity. METHODS One-hundred sixty-one older adults (61-86 years) were recruited from an elderly social center. Sit-to-stand variables were simultaneously recorded through the Android and Apple-App. Their validity and inter-rater, intra-rater, and test-retest reliability was tested using an intraclass correlation coefficient (ICC2-1). Low gait speed (< 1.0 m/s), low physical performance (Short Physical Performance Battery < 10 points), and sarcopenia (EWGSOP2 guideline) were used to determine discriminant validity which was reported as the area under the curves (AUC) and their effect sizes (Hedges' g) for independent sample t-test. RESULTS Excellent reproducibility (ICC2-1 > 0.85) and strong agreement (ICC2-1 > 0.90) between operating systems for sit-to-stand variables derived from the App was found. Older adults classified as sarcopenic (11.2%), low physical performance (15.5%), or reduced gait speed (14.3%) showed worse sit-to-stand time, velocity and power with large effect sizes (Hedges' g: > 0.8) compared to their respective counterpart. These variables showed the acceptable-to-excellent ability to identify low gait speed, low physical performance, and sarcopenic older adults (AUC-range: 0.73-0.82). CONCLUSION The new Sit-to-Stand App running on the Android operating system is comparable to the previously validated Apple App. Excellent reproducibility and acceptable-to-excellent discriminant validity were found.
Collapse
Affiliation(s)
- Juan D Ruiz-Cárdenas
- Physiotherapy Department, Faculty of Physiotherapy, Podiatry and Occupational Therapy, Universidad Católica de Murcia, Av. de los Jerónimos, 135, Guadalupe de Maciascoque, 30107, Murcia, Spain.
| | - Alessio Montemurro
- Physiotherapy Department, Faculty of Physiotherapy, Podiatry and Occupational Therapy, Universidad Católica de Murcia, Av. de los Jerónimos, 135, Guadalupe de Maciascoque, 30107, Murcia, Spain
| | - María Del Mar Martínez-García
- Physiotherapy Department, Faculty of Physiotherapy, Podiatry and Occupational Therapy, Universidad Católica de Murcia, Av. de los Jerónimos, 135, Guadalupe de Maciascoque, 30107, Murcia, Spain
- Cystic Fibrosis Association of Murcia, Av. de Las Palmeras, 37, 30120, Murcia, Spain
| | - Juan J Rodríguez-Juan
- Physiotherapy Department, Facultad de Medicina, Universidad de Murcia, Campus de Ciencias de La Salud, 30120, Murcia, Spain
| |
Collapse
|
4
|
Bartolomé Martín I, Esteve Arríen A, Neira Álvarez M, Cristofori G, Cedeno-Veloz BA, Esbrí Víctor M, Pérez Pena B, González Ramírez A, Caballero-Mora MÁ. Specialized Care Resources for Diagnosis and Management of Patients Who Have Suffered Falls: Results of a National Survey in Geriatric Units. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5975. [PMID: 37297579 PMCID: PMC10252905 DOI: 10.3390/ijerph20115975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Clinical guidelines recommend comprehensive multifactorial assessment and intervention to prevent falls and fractures in older populations. METHODS A descriptive study was conducted by the Falls Study Group of the Spanish Geriatric Medicine Society (SEMEG) to outline which types of healthcare-specific resources were assigned for fall assessment in Spanish geriatric departments. A self-reported seven-item questionnaire was delivered from February 2019 to February 2020. Where geriatric medicine departments were not available, we tried to contact geriatricians working in those areas. RESULTS Information was obtained regarding 91 participant centers from 15 autonomous communities, 35.1% being from Catalonia and 20.8% from Madrid. A total of 21.6% reported a multidisciplinary falls unit, half of them in geriatric day hospitals. Half of them reported fall assessment as part of a general geriatric assessment in general geriatric outpatient clinics (49.5%) and, in 74.7% of cases, the assessment was based on functional tests. A total of 18.7% reported the use of biomechanical tools, such as posturography, gait-rides or accelerometers, for gait and balance analysis, and 5.5% used dual X-ray absorptiometry. A total of 34% reported research activity focused on falls or related areas. Regarding intervention strategies, 59% reported in-hospital exercise programs focused on gait and balance improvement and 79% were aware of community programs or the pathways to refer patients to these resources. CONCLUSIONS This study provides a necessary starting point for a future deep analysis. Although this study was carried out in Spain, it highlights the need to improve public health in the field of fall prevention, as well as the need, when implementing public health measures, to verify that these measures are implemented homogeneously throughout the territory. Therefore, although this analysis was at the local level, it could be useful for other countries to reproduce the model.
Collapse
Affiliation(s)
| | | | - Marta Neira Álvarez
- Geriatrician Department, Hospital Universitario Infanta Leonor, Universidad Complutense, 28031 Madrid, Spain;
| | - Giovanna Cristofori
- Geriatrician Department, Hospital Universitario Central de la Cruz Roja, 28003 Madrid, Spain;
| | | | - Mariano Esbrí Víctor
- Geriatrician Department, Hospital Perpetuo Socorro Albacete, 02006 Albacete, Spain;
| | - Bárbara Pérez Pena
- Geriatrician Department, Hospital Universitario Marqués de Valdecilla Santander, 39008 Santander, Spain;
| | | | | | | |
Collapse
|
5
|
Marques DL, Neiva HP, Marinho DA, Marques MC. Manipulating the Resistance Training Volume in Middle-Aged and Older Adults: A Systematic Review with Meta-Analysis of the Effects on Muscle Strength and Size, Muscle Quality, and Functional Capacity. Sports Med 2023; 53:503-518. [PMID: 36307745 DOI: 10.1007/s40279-022-01769-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Effective manipulation of the acute variables of resistance training is critical to optimizing muscle and functional adaptations in middle-aged and older adults. However, the ideal volume prescription (e.g., number of sets performed per exercise) in middle-aged and older adults remains inconclusive in the literature. OBJECTIVE The effects of single versus multiple sets per exercise on muscle strength and size, muscle quality, and functional capacity in middle-aged and older adults were compared. Moreover, the effects of single versus multiple sets per exercise on muscular and functional gains were also examined, considering the influence of training duration. METHODS Randomized controlled trials and non-randomized controlled trials comparing single versus multiple sets per exercise on muscle strength, muscle size, muscle quality, or functional capacity in middle-aged and older adults (aged ≥ 50 years) in the PubMed/MEDLINE, Web of Science, and Scopus databases (01/09/2021, updated on 15/05/2022) were identified. A random-effects meta-analysis was used. RESULTS Fifteen studies were included (430 participants; 93% women; age 57.9-70.1 years). Multiple sets per exercise produced a greater effect than single sets on lower-limb strength (standardized mean difference [SMD] = 0.29; 95% confidence interval [CI] 0.07-0.51; mean difference [MD] = 1.91 kg; 95% CI 0.50-3.33) and muscle quality (SMD = 0.40; 95% CI 0.05-0.75) gains. There were no differences between single versus multiple sets per exercise for upper-limb strength (SMD = 0.13; 95% CI - 0.14 to 0.40; MD = 0.11 kg; 95% CI - 0.52 to 0.75), muscle size (SMD = 0.15; 95% CI - 0.07 to 0.37), and functional capacity (SMD = 0.01; 95% CI - 0.47 to 0.50) gains. In addition, there were no differences between single versus multiple sets on muscle strength and size gains for training durations ≤ 12 weeks or > 12 weeks. CONCLUSIONS Multiple sets per exercise produced greater lower-limb strength and muscle quality gains than single sets in middle-aged and older adults, although the magnitude of the difference was small. In contrast, single sets per exercise were sufficient to improve upper-limb strength, muscle size, and functional capacity in these populations. Despite these findings, researchers should conduct future high-quality, pre-registered, and blinded randomized controlled trials to strengthen the scientific evidence on this topic.
Collapse
Affiliation(s)
- Diogo Luís Marques
- Department of Sport Sciences, University of Beira Interior, Covilhã, Portugal.
| | - Henrique Pereira Neiva
- Department of Sport Sciences, University of Beira Interior, Covilhã, Portugal
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Covilhã, Portugal
| | - Daniel Almeida Marinho
- Department of Sport Sciences, University of Beira Interior, Covilhã, Portugal
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Covilhã, Portugal
| | - Mário Cardoso Marques
- Department of Sport Sciences, University of Beira Interior, Covilhã, Portugal
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Covilhã, Portugal
| |
Collapse
|
6
|
Timmons JF, Hone M, Duffy O, Egan B. When Matched for Relative Leg Strength at Baseline, Male and Female Older Adults Respond Similarly to Concurrent Aerobic and Resistance Exercise Training. J Strength Cond Res 2022; 36:2927-2933. [PMID: 36135036 DOI: 10.1519/jsc.0000000000003987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Affiliation(s)
- James F Timmons
- Institute for Sport and Health, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin, Ireland
| | - Michelle Hone
- School of Health and Human Performance, Dublin City University, Glasnevin, Dublin, Ireland
| | - Orlaith Duffy
- Medfit Proactive Healthcare, Blackrock, Co. Dublin, Ireland
| | - Brendan Egan
- School of Health and Human Performance, Dublin City University, Glasnevin, Dublin, Ireland
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin, Ireland ; and
- Florida Institute for Human and Machine Cognition, Pensacola, Florida
| |
Collapse
|
7
|
Effects of Strength Exercises Combined with Other Training on Physical Performance in Frail Older Adults: A Systematic Review and Meta-analysis. Arch Gerontol Geriatr 2022; 102:104757. [DOI: 10.1016/j.archger.2022.104757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 11/17/2022]
|
8
|
Cheng IF, Kuo LC, Tsai YJ, Su FC. The Comparisons of Physical Functional Performances between Older Adults with and without Regular Physical Activity in Two Different Living Settings. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073561. [PMID: 33808083 PMCID: PMC8036914 DOI: 10.3390/ijerph18073561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 01/07/2023]
Abstract
We compared the physical function performances of community-dwelling and day care center older adults with and without regular physical activity (PA). A total of 163 Taiwanese older adults living in rural communities participated. PA habits and physical functional performances were assessed. The participants were divided into community-dwelling (CD) and senior day care (DC) center groups that were further classified into regular physical activity (RPA) and non-physical activity (NPA) subgroups. Comparison took place between subgroups. In the CD group, only the grip strength, pinch strength, and box and blocks test scored significantly better for the participants with regular PA. Muscle strength, flexibility, and three items of functional ability of participants with regular PA were significantly better in the DC group. An active lifestyle contributes to a good old-age life. The effective amount of PA and the reduction of sedentary time should be advocated to prevent frailty and disability in older adults.
Collapse
Affiliation(s)
- I-Fang Cheng
- Department of Biomedical Engineering, National Cheng Kung University, Tainan 701, Taiwan;
| | - Li-Chieh Kuo
- Department of Occupational Therapy, National Cheng Kung University, Tainan 701, Taiwan;
| | - Yi-Jung Tsai
- Department of Medical Research, E-Da Hospital, Kaohsiung 824, Taiwan;
- Medical College, I-Shou University, Kaohsiung 840, Taiwan
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan 701, Taiwan;
- Medical Device Innovation Center, National Cheng Kung University, Tainan 701, Taiwan
- Correspondence: ; Tel.: +886-6-2760665
| |
Collapse
|
9
|
Izquierdo M, Merchant RA, Morley JE, Anker SD, Aprahamian I, Arai H, Aubertin-Leheudre M, Bernabei R, Cadore EL, Cesari M, Chen LK, de Souto Barreto P, Duque G, Ferrucci L, Fielding RA, García-Hermoso A, Gutiérrez-Robledo LM, Harridge SDR, Kirk B, Kritchevsky S, Landi F, Lazarus N, Martin FC, Marzetti E, Pahor M, Ramírez-Vélez R, Rodriguez-Mañas L, Rolland Y, Ruiz JG, Theou O, Villareal DT, Waters DL, Won Won C, Woo J, Vellas B, Fiatarone Singh M. International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr Health Aging 2021; 25:824-853. [PMID: 34409961 DOI: 10.1007/s12603-021-1665-8] [Citation(s) in RCA: 331] [Impact Index Per Article: 110.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.
Collapse
Affiliation(s)
- M Izquierdo
- Mikel Izquierdo, PhD, Department of Health Sciences, Public University of Navarra, Av. De Barañain s/n 31008 Pamplona (Navarra) Spain, Tel + 34 948 417876
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Angulo J, El Assar M, Álvarez-Bustos A, Rodríguez-Mañas L. Physical activity and exercise: Strategies to manage frailty. Redox Biol 2020; 35:101513. [PMID: 32234291 PMCID: PMC7284931 DOI: 10.1016/j.redox.2020.101513] [Citation(s) in RCA: 201] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/13/2020] [Accepted: 03/17/2020] [Indexed: 12/25/2022] Open
Abstract
Frailty, a consequence of the interaction of the aging process and certain chronic diseases, compromises functional outcomes in the elderly and substantially increases their risk for developing disabilities and other adverse outcomes. Frailty follows from the combination of several impaired physiological mechanisms affecting multiple organs and systems. And, though frailty and sarcopenia are related, they are two different conditions. Thus, strategies to preserve or improve functional status should consider systemic function in addition to muscle conditioning. Physical activity/exercise is considered one of the main strategies to counteract frailty-related physical impairment in the elderly. Exercise reduces age-related oxidative damage and chronic inflammation, increases autophagy, and improves mitochondrial function, myokine profile, insulin-like growth factor-1 (IGF-1) signaling pathway, and insulin sensitivity. Exercise interventions target resistance (strength and power), aerobic, balance, and flexibility work. Each type improves different aspects of physical functioning, though they could be combined according to need and prescribed as a multicomponent intervention. Therefore, exercise intervention programs should be prescribed based on an individual's physical functioning and adapted to the ensuing response.
Collapse
Affiliation(s)
- Javier Angulo
- Servicio de Histología-Investigación, Unidad de Investigación Traslacional en Cardiología (IRYCIS-UFV), Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - Mariam El Assar
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain; Fundación para la Investigación Biomédica del Hospital Universitario de Getafe, Getafe, Spain
| | | | - Leocadio Rodríguez-Mañas
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Geriatría, Hospital Universitario de Getafe, Getafe, Spain.
| |
Collapse
|
11
|
Makizako H, Nakai Y, Tomioka K, Taniguchi Y, Sato N, Wada A, Kiyama R, Tsutsumimoto K, Ohishi M, Kiuchi Y, Kubozono T, Takenaka T. Effects of a Multicomponent Exercise Program in Physical Function and Muscle Mass in Sarcopenic/Pre-Sarcopenic Adults. J Clin Med 2020; 9:jcm9051386. [PMID: 32397192 PMCID: PMC7291119 DOI: 10.3390/jcm9051386] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 12/13/2022] Open
Abstract
This study aimed to assess the effects of a multicomponent exercise program on physical function and muscle mass in older adults with sarcopenia or pre-sarcopenia. Moreover, we aim to standardize the exercise program for easy incorporation in the daily life of community-dwelling older adults as a secondary outcome. A single-blind randomized controlled trial was conducted with individuals (≥60 years) who had sarcopenia or pre-sarcopenia (n = 72). Participants were randomly assigned to the exercise and control groups. The exercise program consisted of 12 weekly 60-min sessions that included resistance, balance, flexibility, and aerobic training. Outcome measures were physical function and muscle mass. Assessments were conducted before and immediately after the intervention. Among the 72 participants (mean age: 75.0 ± 6.9 years; 70.8% women), 67 (93.1%) completed the trial. Group-by-time interactions on the chair stand (p = 0.02) and timed “up and go” (p = 0.01) tests increased significantly in the exercise group. Although the exercise group showed a tendency to prevent loss of muscle mass, no significant interaction effects were observed for cross-sectional muscle area and muscle volume. The 12-week exercise program improved physical function in the intervention group. Although it is unclear whether the program is effective in increasing muscle mass, a multicomponent exercise program would be an effective treatment for physical function among older adults with sarcopenia.
Collapse
Affiliation(s)
- Hyuma Makizako
- Department of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, Kagoshima 890-8544, Japan; (Y.N.); (R.K.)
- Correspondence: ; Tel.: +81-99-275-5111; Fax: +81-99-275-6804
| | - Yuki Nakai
- Department of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, Kagoshima 890-8544, Japan; (Y.N.); (R.K.)
| | - Kazutoshi Tomioka
- Graduate School of Health Sciences, Kagoshima University, Kagoshima 890-8544, Japan; (K.T.); (Y.T.); (N.S.); (A.W.); (Y.K.)
- Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Kagoshima 891-2124, Japan;
| | - Yoshiaki Taniguchi
- Graduate School of Health Sciences, Kagoshima University, Kagoshima 890-8544, Japan; (K.T.); (Y.T.); (N.S.); (A.W.); (Y.K.)
- Department of Physical Therapy, Kagoshima Medical Professional College, Kagoshima 891-0133, Japan
| | - Nana Sato
- Graduate School of Health Sciences, Kagoshima University, Kagoshima 890-8544, Japan; (K.T.); (Y.T.); (N.S.); (A.W.); (Y.K.)
- Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Kagoshima 891-2124, Japan;
| | - Ayumi Wada
- Graduate School of Health Sciences, Kagoshima University, Kagoshima 890-8544, Japan; (K.T.); (Y.T.); (N.S.); (A.W.); (Y.K.)
- Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Kagoshima 891-2124, Japan;
| | - Ryoji Kiyama
- Department of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, Kagoshima 890-8544, Japan; (Y.N.); (R.K.)
| | - Kota Tsutsumimoto
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu 474-5811, Japan;
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan; (M.O.); (T.K.)
| | - Yuto Kiuchi
- Graduate School of Health Sciences, Kagoshima University, Kagoshima 890-8544, Japan; (K.T.); (Y.T.); (N.S.); (A.W.); (Y.K.)
| | - Takuro Kubozono
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima 890-8520, Japan; (M.O.); (T.K.)
| | - Toshihiro Takenaka
- Tarumizu Municipal Medical Center Tarumizu Chuo Hospital, Kagoshima 891-2124, Japan;
| |
Collapse
|
12
|
Mierzwicki JT, Fox MA, Griffith KR, Harrison KM, Holstay DK, Singley NM. Comparison of High-Intensity Resistance and Power Training Programs in Pre-Frail and Frail Older Adults. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2020. [DOI: 10.1080/02703181.2020.1748161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Justin T. Mierzwicki
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, USA
| | - Madelyn A. Fox
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, USA
| | - Kevin R. Griffith
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, USA
| | - Kelsey M. Harrison
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, USA
| | - Daryl K. Holstay
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, USA
| | - Nikki M. Singley
- Department of Physical Therapy, Lebanon Valley College, Annville, Pennsylvania, USA
| |
Collapse
|
13
|
Silva-Grigoletto MED, Resende-Neto AGD, Teixeira CVLS. Treinamento funcional: uma atualização conceitual. ACTA ACUST UNITED AC 2020. [DOI: 10.1590/1980-0037.2020v22e72646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Resumo O treinamento funcional (TF) tem crescido em popularidade, porém tal crescimento ainda ocorre de forma desorganizada e multifacetada. Assim, uma atualização conceitual se faz necessário, especialmente, baseado na maneira como o TF tem sido aplicado na maioria das pesquisas. Nesse contexto, o TF tem sido compreendido como aquele que objetiva o aprimoramento sinérgico, integrado e equilibrado de diferentes capacidades físicas para garantir eficiência e segurança durante o desempenho de tarefas cotidianas, sendo baseado nos princípios do treinamento, sobretudo, no princípio da especificidade. As sessões de TF devem focar no aprimoramento de padrões básicos de movimento, estimular adequadamente a força em diversas situações, a potência muscular e a capacidade cardiorrespiratória, ativar frequentemente músculos estabilizadores e incluir atividades complexas, respeitando critérios de segurança e eficácia.
Collapse
|
14
|
Higueras-Fresnillo S, de la Cámara MÁ, Cabanas-Sánchez V, Martínez-Gómez D. Associations of Frailty and Physical Function with a Daily Activities Measured by a Pattern-Recognition Activity Monitor: An Isotemporal Substitution Analysis in the IMPACT65+ Study. J Nutr Health Aging 2020; 24:55-62. [PMID: 31886809 DOI: 10.1007/s12603-019-1296-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aims of this study were (i) to examine the independent associations of the time spent in daily activities measured by multi-sensor pattern-recognition with frailty and physical functioning (PF); and (ii) to analyze how relocating time between these daily activities is associated with frailty and PF in a sample of older adults. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS The study sample consists of 436 (287 women) high-functioning community-dwelling older adults, aged 65 to 92 years, who participated in the IMPACT65+ Study. MEASUREMENTS Frailty was calculated as a continuous measure; based on the five widely recognized Fried's criteria. PF was assessed using the SF-12 questionnaire. The time in daily activities was assessed by the Intelligent Device for Energy expenditure and Activity (IDEEA). Independent associations of daily activities with frailty and PF were examined using linear regression models adjusting for potential confounders. The isotemporal substitution models for estimate the effect of replacing time in one activity with the same amount of time in another activity while holding wake time constant. RESULTS Time spent lying was directly associated, while time in walk at average and brisk pace was inversely associated with frailty. The independent associations for PF were similar to lying, walk at average pace and walk at brisk pace. Isotemporal substitution analyses revealed a clear beneficial effect of hypothetically replacing 30 min/day of sedentary behaviors or light physical activity by the same amount of moderate-to-vigorous physical activity for frailty and PF. CONCLUSION This is the first study examining the activity-specific and isotemporal association of daily activities with frailty and PF in older adults. Isotemporal substitution analyses showed that replacing sedentary behaviors (lie, recline, passive sit) by light-intensity activities (active sit, stand and walk at slow pace), as well as light-intensity activities by activities at MVPA such as walk at brisk pace, may produce theoretical improvements in frailty and PF. These findings are important for the development of effective interventions focused on reducing age-related frailty and declines in PF.
Collapse
Affiliation(s)
- S Higueras-Fresnillo
- Sara Higueras-Fresnillo. Department of Physical Education, Sport and Human Movement. Facultad de Formación de Profesorado y Educación. Universidad Autónoma de Madrid. Ctra. de Colmenar Km 11. E-28049. Madrid (Spain). E-mail:
| | | | | | | |
Collapse
|
15
|
Courel-Ibáñez J, Pallarés JG. Effects of β-hydroxy-β-methylbutyrate (HMB) supplementation in addition to multicomponent exercise in adults older than 70 years living in nursing homes, a cluster randomized placebo-controlled trial: the HEAL study protocol. BMC Geriatr 2019; 19:188. [PMID: 31277595 PMCID: PMC6612176 DOI: 10.1186/s12877-019-1200-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 06/30/2019] [Indexed: 01/06/2023] Open
Abstract
Background Evidence supports the fact that multicomponent exercise and HMB supplementation are, separately, effective in improving older adult’s health and palliate functional metabolic diseases in older people. However, the true effect of HMB supplementation combined with a tailored exercise program in frail older adults is still unknown. Thus, the aim of the HEAL (HMB + Exercise = Adults Living longer) study is to assess the effects of the combination of a daily multicomponent exercise and resistance training (VIVIFRAIL program) intervention in addition to HMB supplementation on older adults’ health. Methods/design A 24-week cluster randomized, double-blind, placebo-controlled study will be conducted on 104 adults ≥70 years. Nursing homes will be randomized to either of four groups: Ex-HMB (exercise intervention with HMB), Ex-Plac (exercise intervention with placebo), NoEx-HMB (no exercise intervention with HMB), and Controls (No exercise and no HMB). Intervention groups which include exercise will complete the individualized multicomponent (strength, balance and cardiovascular exercises) training program VIVIFRAIL. Intervention groups which include HMB supplementation will receive a 3 g/daily dose of free acid HMB in powder form. The primary outcome measure is the functional capacity. Secondary outcome measures are muscle strength and power, frailty and fall risk, body composition, biochemical analyses and cardiometabolic risk factor, disability and comorbidity, cognitive function and depression. Discussion The findings of the HEAL study will help professionals from public health systems to identify cost-effective and innovative actions to improve older people’s health and quality of life, and endorse exercise practice in older adults and people living in nursing homes. Trial registration NCT03827499; Date of registration: 01/02/2019.
Collapse
Affiliation(s)
- Javier Courel-Ibáñez
- Human Performance and Sports Science Laboratory, Faculty of Sport Sciences, University of Murcia, Calle Argentina, 19, 30720, San Javier, Murcia, Spain.
| | - J G Pallarés
- Human Performance and Sports Science Laboratory, Faculty of Sport Sciences, University of Murcia, Calle Argentina, 19, 30720, San Javier, Murcia, Spain
| | | |
Collapse
|
16
|
DiPietro L, Campbell WW, Buchner DM, Erickson KI, Powell KE, Bloodgood B, Hughes T, Day KR, Piercy KL, Vaux-Bjerke A, Olson RD. Physical Activity, Injurious Falls, and Physical Function in Aging: An Umbrella Review. Med Sci Sports Exerc 2019; 51:1303-1313. [PMID: 31095087 PMCID: PMC6527126 DOI: 10.1249/mss.0000000000001942] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To review and update the evidence of the relationship between physical activity, risk of fall-related injury, and physical function in community-dwelling older people that was presented in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report (PAGAC Report). METHODS Duplicate independent screenings of 1415 systematic reviews and meta-analyses published between 2006 and 2016 identified from PubMed®, Cochrane Library, and CINAHL databases yielded 111 articles used for the PAGAC Report. The PAGAC Aging Subcommittee members graded scientific evidence strength based upon a five-criteria rubric and assigned one of four grades: strong, moderate, limited, or not assignable. An updated search of 368 articles published between January 2017 and March 2018 yielded 35 additional pertinent articles. RESULTS Strong evidence demonstrated that physical activity reduced the risk of fall-related injuries by 32% to 40%, including severe falls requiring medical care or hospitalization. Strong evidence also supported that physical activity improved physical function and reduced the risk of age-related loss of physical function in an inverse graded manner among the general aging population, and improved physical function in older people with frailty and with Parkinson's disease. Aerobic, muscle-strengthening, and/or multicomponent physical activity programs elicited the largest improvements in physical function in these same populations. Moderate evidence indicated that for older adults who sustained a hip fracture or stroke, extended exercise programs and mobility-oriented physical activity improved physical function. CONCLUSIONS Regular physical activity effectively helps older adults improve or delay the loss of physical function and mobility while reducing the risk of fall-related injuries. These important public health benefits underscore the importance of physical activity among older adults, especially those living with declining physical function and chronic health conditions.
Collapse
Affiliation(s)
- Loretta DiPietro
- Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Wayne W. Campbell
- Department of Nutrition Science, Purdue University, West Lafayette, IN
| | | | | | | | | | - Timothy Hughes
- Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Kelsey R. Day
- Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Katrina L. Piercy
- Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Rockville, MD
| | - Alison Vaux-Bjerke
- Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Rockville, MD
| | - Richard D. Olson
- Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Rockville, MD
| |
Collapse
|
17
|
Cadore EL, Sáez de Asteasu ML, Izquierdo M. Multicomponent exercise and the hallmarks of frailty: Considerations on cognitive impairment and acute hospitalization. Exp Gerontol 2019; 122:10-14. [PMID: 30995516 DOI: 10.1016/j.exger.2019.04.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/10/2019] [Accepted: 04/13/2019] [Indexed: 10/27/2022]
Abstract
Frailty syndrome encompasses several physical hallmarks such as loss of muscle strength, power output and mass, which leads to poor gait ability, fatigue, falls and overall difficulty to perform activities of daily living. On the other hand, physical exercise interventions induce marked improvements in frailty physical hallmarks (e.g., gait ability, muscle strength, balance and falls). In addition, because cognitive impairment is closely related to frailty syndrome, exercise is an effective intervention to counteract the physical consequences of mild cognitive impairment and dementia. Moreover, exercise and early rehabilitation programs are among the interventions through which functional decline is prevented in older patients during acute hospitalization. This narrative review provides a summary of the effectiveness of different exercise interventions in the hallmarks of frailty. Furthermore, this review addresses special considerations on exercise in frail older with cognitive impairment. Also, we review the role of exercise interventions in acute hospitalized older patients. There is strong evidence that exercise training is an effective intervention for improving muscle strength, muscle mass, incidence of falls, and gait ability in frail older adults. In addition, it seems that multicomponent exercise intervention programs including resistance, gait and balance training is the best strategy for improving the frailty hallmarks, as well as for reducing the rate of falls in frail individuals, and so maintaining their functional capacity during aging. This training modality also proved to be safe and effective to revert the functional decline and cognitive impairment in acutely hospitalized older adults of advanced age. Based on the association between muscle power output and physical function, explosive resistance training should be included in the exercise intervention in order to optimize the functional outcomes in frail older adults.
Collapse
Affiliation(s)
- Eduardo Lusa Cadore
- School of Physical Education, Physiotherapy and Dance, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Mikel L Sáez de Asteasu
- Department of Health Sciences, Navarrabiomed, IdiSNA, CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Public University of Navarra, Pamplona, Navarra, Spain
| | - Mikel Izquierdo
- Department of Health Sciences, Navarrabiomed, IdiSNA, CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Public University of Navarra, Pamplona, Navarra, Spain.
| |
Collapse
|
18
|
Higueras-Fresnillo S, Cabanas-Sánchez V, Lopez-Garcia E, Esteban-Cornejo I, Banegas JR, Sadarangani KP, Rodríguez-Artalejo F, Martinez-Gomez D. Physical Activity and Association Between Frailty and All-Cause and Cardiovascular Mortality in Older Adults: Population-Based Prospective Cohort Study. J Am Geriatr Soc 2018; 66:2097-2103. [DOI: 10.1111/jgs.15542] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Sara Higueras-Fresnillo
- Department of Physical Education, Sport and Human Movement; Autonomous University of Madrid; Madrid Spain
| | - Verónica Cabanas-Sánchez
- Department of Physical Education, Sport and Human Movement; Autonomous University of Madrid; Madrid Spain
| | - Esther Lopez-Garcia
- Department of Preventive Medicine and Public Health, School of Medicine; Autonomous University of Madrid / Instituto de Investigación Hospital Universitario La Paz, Biomedical Research Center Network of Epidemiology and Public Health; Madrid Spain
- Madrid Institute of Advanced Studies Food Institute, Campus of International Excellence; Universidad Autónoma de Madrid, Consejo Superior de Investigaciones Científicas; Madrid Spain
| | - Irene Esteban-Cornejo
- Center for Cognitive and Brain Health, Department of Psychology; Northeastern University; Boston Massachusetts
- “PROmoting FITness and Health through physical activity” Research Group, Department of Physical Education and Sports, Faculty of Sport Sciences; University of Granada; Granada Spain
| | - José R. Banegas
- Department of Preventive Medicine and Public Health, School of Medicine; Autonomous University of Madrid / Instituto de Investigación Hospital Universitario La Paz, Biomedical Research Center Network of Epidemiology and Public Health; Madrid Spain
| | - Kabir P. Sadarangani
- School of Physiotherapy, Faculty of Health Sciences; Universidad San Sebastián; Santiago Chile
- Escuela de Kinesiología, Facultad de Salud y Odontología; Universidad Diego Portales; Santiago Chile
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine; Autonomous University of Madrid / Instituto de Investigación Hospital Universitario La Paz, Biomedical Research Center Network of Epidemiology and Public Health; Madrid Spain
- Madrid Institute of Advanced Studies Food Institute, Campus of International Excellence; Universidad Autónoma de Madrid, Consejo Superior de Investigaciones Científicas; Madrid Spain
| | - David Martinez-Gomez
- Department of Physical Education, Sport and Human Movement; Autonomous University of Madrid; Madrid Spain
- Madrid Institute of Advanced Studies Food Institute, Campus of International Excellence; Universidad Autónoma de Madrid, Consejo Superior de Investigaciones Científicas; Madrid Spain
| |
Collapse
|