Physical Activity Levels, Correlates, and All-Cause Mortality Risk in People Living With Different Health Conditions

BACKGROUND

To better understand physical activity behavior and its health benefits in people living with health conditions, we studied people with and without 20 different self-reported health conditions with regard to (1) their physical activity levels, (2) factors correlated with these physical activity levels, and (3) the association between physical activity and all-cause mortality.

METHODS

We used a subsample (n = 88,659) of the Lifelines cohort study from the Netherlands. For people living with and without 20 different self-reported health conditions, we studied the aforementioned factors in relation to physical activity. Physical activity was assessed with the Short Questionnaire to Assess Health-Enhancing Physical Activity Questionnaire, and mortality data were obtained from the Dutch death register.

RESULTS

People with a reported health condition were less likely to meet physical activity guidelines than people without a reported health condition (odds ratios ranging from 0.55 to 0.89). Higher body mass index and sitting time, and lower self-rated health, physical functioning, and education levels were associated with lower odds of meeting physical activity guidelines across most health conditions. Finally, we found a protective association between physical activity and all-cause mortality in both people living with and without different health conditions.

CONCLUSION

People living with different health conditions are generally less physically active compared with people living without a health condition. Both people living with and without self-reported health conditions share a number of key factors associated with physical activity levels. We also observed the expected protective association between physical activity and all-cause mortality.

Stability of clustering of lifestyle risk factors in the Dutch adult population and the association with mental health

BACKGROUND

Lifestyle factors often co-occur in clusters. This study examines whether clusters of lifestyle risk factors, such as smoking, alcohol use, physical inactivity, poor diet, sexual risk behaviour, cannabis and other drug use, change over time in a representative sample of Dutch adults. Additionally, the association between mental health and self-reported depression of lifestyle clusters was examined.

METHODS

Each year cross-sectional data of approximately 7500 individuals of 18 years and older from the annual Dutch Health Survey of 2014-2019 were used. Clusters were determined by a two-step cluster analysis. Furthermore, regression analyses determined the association between clusters of lifestyle risk factors and mental health.

RESULTS

Results show six clusters composed of one, multiple or no lifestyle risk factors. The clusters remained relatively stable over time: in some clusters, the number of people slightly changed between 2014 and 2019. More specifically, clusters that increased in size were the cluster with no lifestyle risk factors and the cluster with multiple lifestyle risk factors. Furthermore, results show that clusters with none to a few lifestyle risk factors were associated with better mental health and a lower prevalence of self-reported depression compared with clusters with multiple lifestyle risk factors.

CONCLUSIONS

The clustering of lifestyle risk factors remained stable over time. People with multiple lifestyle risk factors had poorer mental health than those without risk factors. These findings may emphasize the need for intervention strategies targeting this subgroup with multiple lifestyle risk factors.

P09-06 Getting a grip on sitting behaviour

Background

Sedentary time (sitting) has been associated with adverse cardio-metabolic consequences. The general recommendation is to interrupt long periods of sitting. In order to successfully develop interventions and policies to decrease sedentary behaviour, high-risk groups as well as the context of sitting should be identified. The aim of this study was to investigate sedentary behaviour among (subgroups of) the Dutch population and to identify in which domains most sedentary time was spent.

Methods

Data from the 2017 Dutch national Health Interview Survey was used, which includes a nationally representative sample of 8,441 Dutch citizens aged 4 years and older. Sedentary time on an average day was assessed using an adjusted version of the Marshall questionnaire. Sitting domains were defined as: 1) traveling, 2) at work, 3) at school or studying 4) watching television, 5) using a computer/smartphone at home, and 6) otherwise. Total sedentary time was analysed stratified by age, sex and level of education with ANOVA and Bonferroni correction.

Results

On average the Dutch population accumulates 9,0 hours/day of sedentary time. Overall, participants accumulated most sedentary time while watching television (2.2 hours/day) followed by sitting at work and other activities (both 1.7 hour/day). Significant differences (p > 0.001) were found by sex, age group and level of education. Men reported slightly more sedentary hours than women (9.2 vs. 8.8 hours/day). With respect to age groups, adolescents (12-17 years old) reported the highest, whereas children (4-11 years old) reported the lowest sedentary hours (10.1 vs. 7.3 hours/day). Finally, sedentary hours were high for higher educated people (9.7 vs. 8.2 hours/day in lower educated people). Adolescents accumulated most sedentary time at school or during studying (4.0 hours/day), higher educated people accumulated most sedentary time at work (3.4 hours/day).

Conclusions

Our study showed that in general Dutch people spend a lot of time sedentarily, especially adolescents and higher educated people. Most sedentary times was spent while watching television, at school or during studying, and at work. Therefore interventions aiming to decrease sedentary behaviour in the home environment, the occupational as well as the educational setting are of importance to implement.

P06-09 Data processing with the short questionnaire to assess health enhancing physical activity (SQUASH): an update

Background

The Short Questionnaire to Assess Health Enhancing Physical Activity (SQUASH) is a widely used questionnaire, and used for monitoring prevalence rates of physical activity(PA) in the Netherlands. To provide a standardized protocol for data processing and analysis of the SQUASH, an analysis guide was published in 2004. However, since then, the compendium of Metabolic Equivalent (MET) values of PA has been updated, and new PA guidelines have been developed. The new PA guidelines differ from the old ones in terms of the appropriate amount of active time (150 minutes/week versus 5 days/week 30 minutes), decrease in cut-off point for moderate intensity (adults 18-54 years of age) and adding a bone- and muscle strengthening component. Therefore, the protocol for data processing and analysis of the SQUASH needs to be updated. In this study, results from the old and new protocol demonstrate the differences in adherence rates between the two sets of guidelines in the Netherlands for the adult population.

Methods

Data of a nationally representative sample of 6942 participants aged 18 years and older were used to calculate adherence to the old and the new PA guidelines by using the original and the updated protocol. In the new protocol, the MET-values of the activities including sports were adjusted according to the 2011 Compendium. Moderate intense activity was defined as ≥ 3.0 MET irrespective of age and the bone and muscle strengthening component was added.

Results

Adherence to the old Dutch PA guidelines is 48.1% among adults aged 18-54 years, and 74.4% among adults 55 years and older. For the new PA guidelines the adherence is 48.4% and 38.1% respectively. The large difference for adults 55 years and older is due to changes in the cut-off values for moderate-to-vigorous intensity PA and the addition of bone and muscle strengthening exercises.

Conclusions

The updated protocol for data processing and analysis of the SQUASH describes the steps to calculate the new PA guidelines in a structured way and gives researchers the opportunity to work with the data from the SQUASH in a uniform way. The SPSS syntax for data processing is available at: www.sportenbewegenincijfers.nl/methoden.

P01-12 The Netherlands united by sport: implementtion and monitoring of the national sports agreement in 2019

Issue/problem

The favorable international position of the Netherlands in terms of sport an physical activity is no reason for those involved in policy to lean back. The motor skills of our children are decreasing, some population groups never engage in sports, respectful behavior in sports needs our attention and the traditional sports clubs are under pressure due to declining numbers of members and volunteers. To tackle these issues, for the first time in history, the Netherlands have a National Sports Agreement (NSA) involving a numerous set of stakeholders besides the national government.

Description of the problem

Through the NSA, we want to make sport enjoyable for everyone. Now and in the future, without any restrictions and in a safe and healthy environment. The sports infrastructure will be strengthened at every level: locally, regionally and nationally. Policy makers want to involve communities of practice and knowledge from monitoring and science in order to be able to adjust policy on the short term and create a ‘self-learning' policy process.

Results

Local and regional stakeholders were invited to strengthen and start collaboration and compose local and regional sports agreements in line with the NSA which has six main ambitions: inclusive sport, sustainable sports facilities, vital providers, positive sports culture, enjoying exercise from an early age and elite sport inspires. As registered on 08-11-2019, 339 out of the 355 municipalities in the Netherlands have started work on a local sports agreement. Thirty nine local agreements were already in place covering 45 municipalities. From the national level, vouchers are made available for local stakeholders to facilitate implementation of particular interventions within a certain ambition on the local level. A consortium of national knowledge institutes provided local policy makers with training sessions facilitating them to incorporate local data, facts and figures in the local sports agreements. Twice a year, National Parliament is informed about the efforts taken and results obtained. On a continuous basis, for every ambition, a set of indicators is disseminated through the website www.sportenbewegenincijfers.nl

O6-6 The added value of using the HEPA PAT for physical activity policy monitoring: A four-country comparison

Background

Public policy is increasingly recognized as an important component of physical activity (PA) promotion, as policy actions to address lifestyle behaviours have the potential to in?uence the health and well-being of an entire population. However, our knowledge about the current status, implementation and effectiveness of PA policies in individual countries is still very limited, and there is consequently no clear guidance on which policies governments should preferably use in different settings or under various preconditions. In order to improve the evidence-base, we conducted a detailed assessment of existing PA policies in four EU Member States using WHO's HEPA Policy Audit Tool (PAT) in the context of the Policy Evaluation Network (PEN).

Methods

We employed a six-step process to administer the HEPA PAT Version 2 in Ireland, the Netherlands, Germany, and Poland. This involved identifying stakeholders, pre-filling parts of the tool using existing survey data and desk-research, approaching select institutions to verify details, and obtaining expert opinion via workshops, interviews, and/or questionnaires. Based on the four completed PATs, we performed a comparative analysis to identify similarities and differences between countries and with previous studies using the tool.

Results

In all four countries, the health and sport sector were found to be most active in PA promotion, followed by education, transport, and environment/urban planning. All countries have national systems to monitor population PA levels, and three out of four already have national PA recommendations. The study also showed that policy context (e.g. ministry portfolios, importance of subnational governments) varies substantially between countries. This influences policy implementation and made it necessary to employ a bespoke approach in each country to obtain the required information.

Conclusions

Our findings largely confirm results of previous studies using the PAT in other countries. They also indicate that using the tool in combination with other policy monitoring tools, e.g. the EU Monitoring Framework for HEPA across Sectors, may provide added value and help countries monitor policy progress more consistently. Our experience also confirms some known limitations of the PAT, e.g. regarding subnational policies and a high level of dependence on cooperation from key policy actors.

An inventory of national surveillance systems assessing physical activity, sedentary behaviour and sport participation of adults in the European Union

Background

Physical inactivity has been recognised as a global public health problem that requires concerted action. This calls for systematic physical activity (PA) surveillance as a mechanism for assessing the problem and evaluating the effectiveness of related policies. Because countries tend to design their policy measures based on national surveillance data, here we present an inventory of existing national surveillance systems on PA, sedentary behaviour (SB) and sport participation (SP) among adult population in all European Union (EU) Member States.

Methods

As a part of the European Physical Activity and Sports Monitoring System (EUPASMOS) project, a questionnaire was constructed in the form of an on-line survey to collect detailed information on existing national surveillance systems on either PA, SB, or SP. National HEPA focal points from all 27 EU Member States were invited to answer the on-line questionnaire and data collection took part in the period May 2018–September 2019.

Results

National monitoring of PA or SB or SP for adults has been established in 16/27 EU Member States, that host 33 different PA/SB/SP monitoring systems. Apart from 3 countries that are using accelerometers (Finland, Ireland and Portugal), surveillance is typically based on questionnaires. In most Member States these questionnaires have not been validated in the particular language and cultural setting. Next, specific domains and dimensions of PA, SB and SP assessed vary a lot across countries. Only 3 countries (the Netherlands, Portugal and Slovenia) are monitoring all three behaviours while covering most of the domains and dimensions of PA/SB/SP. Lastly, as half of the existing surveillance systems set an upper age limit, in 9/16 countries that are monitoring PA/SB/SP, no data for people older than 80 years are available.

Conclusions

Systematic surveillance of PA is lacking among 11/27 EU countries, with even few monitoring SB and SP. Besides, existing surveillance systems typically fail to assess all dimensions and domains of PA/SB/SP with only three countries maintaining monitoring systems that encompass all three behaviours while covering most of the domains and dimensions of PA/SB/SP. Hence, additional efforts in advocacy of systematic PA surveillance in the EU are called for.

Development of national physical activity recommendations in 18 EU member states: a comparison of methodologies and the use of evidence

OBJECTIVES

The aim of the study is to compare how member states of the European Union (EU) develop their national physical activity (PA) recommendations and to provide an overview of the methodologies they apply in doing so. Information was collected directly from the physical activity focal points of EU member states in 2018. Five countries were chosen for detailed case study analysis of development processes.

DESIGN

Cross-sectional survey.

PARTICIPANTS

The representatives of the 28 EU member state governments to the EU physical activity Focal Point Network.

OUTCOME MEASURES

From national documents we extracted data on (1) the participants of the development process, (2) the different methods used during development, and (3) on which sources national PA recommendations were based. An additional survey for case study countries provided details on (1) anonymised information on the participants of development process, (2) methods employed and rationale for choosing them, (3) development process and timeline, and (4) main source documents used for recommendation development.

RESULTS

Eighteen national documents on PA recommendations contained information about development process. The results showed that countries used different approaches to develop national recommendations. The main strategies were (1) adoption of WHO 2010 recommendations or (2) a combination of analysis and adoption of other national and international recommendations and literature review. All of the five case study countries relied on review processes rather than directly adopting WHO recommendations.

CONCLUSIONS

While there are arguments for the use of particular strategies for PA recommendation development, there is currently no evidence for the general superiority of a specific approach. Instead, our findings highlight the broad spectrum of potential development methods, resources utilisation and final recommendations design currently available to national governments. These results may be a source of inspiration for other countries currently planning the development or update of national PA recommendations.

The added value of using the HEPA PAT for physical activity policy monitoring: a four-country comparison

BACKGROUND

Public policy is increasingly recognized as an important component of physical activity promotion. This paper reports on the current status of physical activity policy development and implementation in four European countries based on the Health-Enhancing Physical Activity Policy Audit Tool (HEPA PAT) developed by WHO. It compares the findings to previous studies and discusses the general utility of this tool and its unique features in relation to other instruments.

METHODS

The study was conducted as part of the Policy Evaluation Network ( www.jpi-pen.eu ) in Germany, Ireland, the Netherlands and Poland. Data collection built upon information obtained via the EU Physical Activity Monitoring Framework survey, additional desk research and expert opinion. Data analysis employed Howlett's policy cycle framework to map and compare national physical activity policies in the four countries.

RESULTS

In all countries under study, policy agenda-setting is influenced by prevalence data from national health monitoring systems, and the sport and/or health sector takes the lead in policy formulation. Key policy documents were located mainly in the health sector but also in sport, urban design and transport. Physical activity programmes implemented to meet policy objectives usually cover a broad range of target groups, but currently only a small selection of major policies are evaluated for effectiveness. National experts made several suggestions to other countries wishing to establish physical activity policies, e.g. regarding cross-sectoral support and coordination, comprehensive national action plans, and monitoring/surveillance.

CONCLUSIONS

This study provides a detailed overview of physical activity policies in the four countries. Results show that national governments are already very active in the field but that there is room for improvement in a number of areas, e.g. regarding the contribution of sectors beyond sport and health. Using the HEPA PAT simultaneously in four countries also showed that procedures and timelines have to be adapted to national contexts. Overall, the instrument can make an important contribution to understanding and informing physical activity policy, especially when used as an add-on to regular monitoring tools like the EU HEPA Monitoring Framework.

Results from the Netherlands' 2018 Report Card and Report Card+ on physical activity for children and youth with and without chronic medical condition

OBJECTIVE

The objective of this study was to summarize the results of the 2018 the Netherlands' Physical Activity Report Card (PARC) for children and youth as well as for children and youth with a chronic medical condition (CMC; PARC⁺).

STUDY DESIGN

This study is a survey.

METHODS

A total of 12 indicators were graded using the Active Healthy Kids Global Alliance PARC development process, which includes a synthesis of the best available research, surveillance, policy and practice findings and expert consensus. Grades were based on the best available evidence and ranged from grade A (>80% of the children succeed) to grade F (less than 20% succeed) or incomplete (INC). Sources included national surveys, peer-reviewed literature and grey literature such as government and non-government reports and online content.

RESULTS

Grades assigned for PARC/PARC⁺ were as follows: Overall Physical Activity: C-/D+; Organized Sports Participation: B/B-; Active Play: D/D; Active Transportation: A-/B+; Sedentary Behaviour: D/D; Physical Fitness: INC /INC; Family and Peers: C/INC; School: C+/A-; Community and Environment: INC /INC; Government: INC /INC; Sleep: A-/B+ and Weight Status: A-/A-, respectively.

CONCLUSIONS

The report shows that the Netherlands' youth scores well on (organized) participation in sports and active transport to and from school. However, they do not participate enough in overall physical activity. Despite the fact that outdoor play is the most important exercise activity for children, outdoor play scores an insufficient score for both healthy children and children with a CMC. Sports participation also contributed significantly to daily physical activity. However, sports participation alone is not enough to comply with the national activity guidelines.

Exploring mechanisms underlying the relationship between the natural outdoor environment and health and well-being - Results from the PHENOTYPE project

BACKGROUND

Despite the large number of studies on beneficial effects of the natural outdoor environment (NOE) on health, the underlying mechanisms are not fully understood.

OBJECTIVE

This study explored the relations between amount, quality, use and experience of the NOE; and physical activity, social contacts and mental well-being.

METHODS

In this cross-sectional study, data on GIS-derived measures of residential surrounding greenness (NDVI), NOE within 300 m, and audit data on quality of the streetscape were combined with questionnaire data from 3947 adults in four European cities. These included time spent in NOE (use); and perceived greenness, and satisfaction with and importance given to the NOE (experience). Physical activity, social contacts and mental health were selected as key outcome indicators. Descriptive and multilevel analyses were conducted both on pooled data and for individual cities.

RESULTS

More minutes spent in the NOE were associated with more minutes of physical activity, a higher frequency of social contacts with neighbors, and better mental well-being. Perceived greenness, satisfaction with and importance of the NOE, were other strong predictors of the outcomes, while GIS measures of NOE and streetscape quality were not. We found clear differences between the four cities.

CONCLUSIONS

Use and experience of the natural outdoor environment are important predictors for beneficial effects of the natural outdoor environment and health. Future research should focus more on these aspects to further increase our understanding of these mechanisms, and needs to take the local context into account.

Chronically ill patients' preferences for a financial incentive in a lifestyle intervention. Results of a discrete choice experiment

BACKGROUND

The preferences of diabetes type 2 patients and cardiovascular disease patients for a financial incentive added to a specified combined lifestyle intervention were investigated.

METHODS

A discrete choice experiment questionnaire was filled out by 290 diabetes type 2 patients (response rate 29.9%). Panel-mixed-logit models were used to estimate the preferences for a financial incentive. Potential uptake rates of different financial incentives and relative importance scores of the included attributes were estimated. Included attributes and levels were: form of the incentive (cash money and different types of vouchers), value of the incentive (ranging from 15 to 100 euros), moment the incentive is received (start, halfway, after finishing the intervention) and prerequisite for receiving the incentive (registration, attendance or results at group or individual level).

RESULTS

Prerequisites for receiving the financial incentive were the most important attribute, according to the respondents. Potential uptake rates for different financial incentives ranged between 37.9% and 58.8%. The latter uptake rate was associated with a financial incentive consisting of cash money with a value of €100 that is handed out after completing the lifestyle program with the prerequisite that the participant attended at least 75% of the scheduled meetings.

CONCLUSIONS

The potential uptake of the different financial incentives varied between 37.9% and 58.8%. The value of the incentive does not significantly influence the potential uptake. However, the potential uptake and associated potential effect of the financial incentive is influenced by the type of financial incentive. The preferred type of incentive is €100 in cash money, awarded after completing the lifestyle program if the participant attended at least 75% of the scheduled meetings.

Dog ownership, the natural outdoor environment and health: a cross-sectional study

OBJECTIVES

Dog owners walking their dog in natural outdoor environments (NOE) may benefit from the physical activity facilitated by dog walking and from time spent in nature. However, it is unclear whether dog owners receive additional health benefits associated with having access to NOE above the physical activity benefit of walking with their dog. We investigated associations between dog ownership, walking, time spent in NOE and health and whether these associations differed among those with good and poor access to NOE and those living in green and less green areas.

DESIGN

Cross-sectional study.

SETTING

The Positive Health Effects of the Natural Outdoor Environment in Typical Populations in Different Regions in Europe project.

PARTICIPANTS

n=3586 adults from Barcelona (Spain), Doetinchem (the Netherlands), Kaunas (Lithuania) and Stoke-on-Trent (UK).

DATA COLLECTION AND ANALYSIS

We calculated access to NOE with land maps and residential surrounding greenness with satellite data. Leisure time walking, time spent in NOE and general and mental health status were measured using validated questionnaires. Associations were estimated using multilevel analysis with a random intercept defined at the neighbourhood level.

RESULTS

Dog ownership was associated with higher rates of leisure time walking and time spending in NOE (OR 2.17, 95% CI 1.86 to 2.54 and 2.37, 95% CI 2.02 to 2.79, respectively). These associations were stronger in those living within 300 m of a NOE and in greener areas. No consistent associations were found between dog ownership and perceived general or mental health status.

CONCLUSIONS

Compared with non-dog owners, dog owners walked more and spent more time in NOE, especially those living within 300 m of a NOE and in greener areas. The health implications of these relationships should be further investigated. In a largely physically inactive society, dog walking in NOE may be a simple way of promoting physical activity and health.

Greener living environment healthier people?: Exploring green space, physical activity and health in the Doetinchem Cohort Study

BACKGROUND

Evidence is emerging that more green space in the living environment is associated with better health, partly via the pathway of physical activity.

OBJECTIVES

We explored the cross-sectional and longitudinal associations between green space and physical activity and several health indicators in the Doetinchem Cohort Study.

METHODS

A random sample of men and women aged 20-59years at baseline was measured max 5 times with 5year-intervals in the period 1987-2012. Data of round 3-5 were used. Measurements were based on examinations (height, weight, blood pressure) or questionnaires (physical activity, perceived health, depressive symptoms, chronic conditions). The percentage of green space (mainly urban and agricultural green) around the home address (125m and 1km) was calculated using satellite data.

RESULTS

More agricultural green was associated with less time spent on bicycling (β1km=-0.15, 95%CL -0.13; -0.04) and sports (β1km=-0.04, 95%CL -0.07; -0.01) and more time spent on gardening (β1km=0.16, 95%CL 0.12; 0.19) and odd jobs (β1km=0.10, 95%CL 0.05; 0.15), and this was in the other direction for urban green. For only a few of the many health indicators a positive association with green was found, and mainly for total green within 1km radius. Longstanding green or a transition to more green did not show more pronounced associations with health.

CONCLUSIONS

For the green space range of the Doetinchem area the findings do not strongly support the hypothesis that the percentage of green in the living environment affects health positively. The distinction by type of green may, however, be relevant for physical activity.

Health in All Policies? The case of policies to promote bicycle use in the Netherlands

To gather insight on how Health in All Policies (HiAP) is applied in practice, we carried out a case study on transport policies intended to stimulate a shift from car use to bicycling. We reviewed 3 years (2010, 2011, and 2012) of national budgets and policy documents in the Netherlands, followed by two focus group sessions and a second round of document analysis. We found to our surprise, given the country's history of bicycle promotion, that no HiAP approaches for bicycle promotion remain in place in national transport policies. The Netherlands may face serious challenges in the near future for facilitating bicycle use. Inclusion of health goals requires that the health sector work towards acquiring a better understanding of core values in other sector's policies.

Transport choice when travelling to a sports facility: the role of perceived route features - Results from a cross-sectional study in the Netherlands

Background

Physical activity and sedentary behaviour are independently associated with health outcomes, where physical activity (PA) is associated with health benefits and sedentary behaviour is associated with health risks. One possible strategy to counteract sedentary behaviour is to stimulate active transport use. As monitoring studies in the Netherlands have shown that among sedentary people the proportion of adults who engage in sports (hereafter: sports practitioners) is 62.3%, sports practitioners seem a feasible target group for this strategy. Previous studies have generally reported associations between neighbourhood characteristics and active transport use. However, the neighbourhood covers only part of the route to a certain destination. Therefore, we examined the association between perceived route features and transport choice when travelling up to 7.5 kilometres to a sports facility among sports practitioners.

Methods

For 1118 Dutch sports practitioners – who indicated that they practice a sport and travel to a sports facility – age 18 and older, data on transport choice and perceived features of the route to a sports facility were gathered. Participants were classified into one of three transport groups based on their transport choice: car users, cyclists and walkers. Participants were asked whether perceived route features influenced their transport choice. Logistic regression was used to model the odds of cycling versus car use and walking versus car use in the association with perceived route features, adjusted for potential confounders.

Results

Perceived traffic safety was associated with lower odds of cycling (OR: 0.36, 95% CI: 0.15-0.86). Perceived route duration was associated with lower odds of both cycling (OR: 0.54, 95%CI: 0.39-0.75) and walking (OR: 0.60, 95%CI: 0.36-1.00). Perceived distance to a sports facility and having to make a detour when using other transport modes than the chosen transport mode were associated with higher odds of both cycling and walking (OR_range: 1.82-5.21). What and who people encountered during their trip (i.e. visual aspects) was associated with higher odds of both cycling and walking (OR_range: 2.40-3.69).

Conclusions

Perceived traffic safety, duration, distance, detour, and visual aspects, when travelling to a sports facility were associated with transport choice. Therefore, the perception of route features should be considered when stimulating active transport use among sports practitioners.

Electronic supplementary material

The online version of this article (doi:10.1186/s13102-015-0009-6) contains supplementary material, which is available to authorized users.

Cross-sectional associations of objectively measured physical activity, cardiorespiratory fitness and anthropometry in European adults

OBJECTIVE

To quantify the independent associations between objectively measured physical activity (PA), cardiorespiratory fitness (CRF), and anthropometry in European men and women.

METHODS

2,056 volunteers from 12 centers across Europe were fitted with a heart rate and movement sensor at 2 visits 4 months apart for a total of 8 days. CRF (ml/kg/min) was estimated from an 8 minute ramped step test. A cross-sectional analysis of the independent associations between objectively measured PA (m/s(2)/d), moderate and vigorous physical activity (MVPA) (%time/d), sedentary time (%time/d), CRF, and anthropometry using sex stratified multiple linear regression was performed.

RESULTS

In mutually adjusted models, CRF, PA, and MVPA were inversely associated with all anthropometric markers in women. In men, CRF, PA, and MVPA were inversely associated with BMI, whereas only CRF was significantly associated with the other anthropometric markers. Sedentary time was positively associated with all anthropometric markers, however, after adjustment for CRF significant in women only.

CONCLUSION

CRF, PA, MVPA, and sedentary time are differently associated with anthropometric markers in men and women. CRF appears to attenuate associations between PA, MVPA, and sedentary time. These observations may have implications for prevention of obesity.

Positive health effects of the natural outdoor environment in typical populations in different regions in Europe (PHENOTYPE): a study programme protocol

INTRODUCTION

Growing evidence suggests that close contact with nature brings benefits to human health and well-being, but the proposed mechanisms are still not well understood and the associations with health remain uncertain. The Positive Health Effects of the Natural Outdoor environment in Typical Populations in different regions in Europe (PHENOTYPE) project investigates the interconnections between natural outdoor environments and better human health and well-being.

AIMS AND METHODS

The PHENOTYPE project explores the proposed underlying mechanisms at work (stress reduction/restorative function, physical activity, social interaction, exposure to environmental hazards) and examines the associations with health outcomes for different population groups. It implements conventional and new innovative high-tech methods to characterise the natural environment in terms of quality and quantity. Preventive as well as therapeutic effects of contact with the natural environment are being covered. PHENOTYPE further addresses implications for land-use planning and green space management. The main innovative part of the study is the evaluation of possible short-term and long-term associations of green space and health and the possible underlying mechanisms in four different countries (each with quite a different type of green space and a different use), using the same methodology, in one research programme. This type of holistic approach has not been undertaken before. Furthermore there are technological innovations such as the use of remote sensing and smartphones in the assessment of green space.

CONCLUSIONS

The project will produce a more robust evidence base on links between exposure to natural outdoor environment and human health and well-being, in addition to a better integration of human health needs into land-use planning and green space management in rural as well as urban areas.

Personal and environmental characteristics associated with choice of active transport modes versus car use for different trip purposes of trips up to 7.5 kilometers in The Netherlands

INTRODUCTION

This explorative study examines personal and neighbourhood characteristics associated with short-distance trips made by car, bicycle or walking in order to identify target groups for future interventions.

METHODS

Data were derived from 'Mobility Research Netherlands (2004-2009; MON)', a dataset including information regarding trips made by household members (n = ±53,000 respondents annually). Using postal codes of household addresses, MON data were enriched with data on neighbourhood typologies. Multilevel logistic modelling was used to calculate odds ratio (OR) of active transport versus car use associated with four different trip purposes (shopping (reference), commuting, taking or bringing persons or sports). A total of 277,292 short distance trips made by 102,885 persons were included in analyses.

RESULTS

Compared to women shopping, women less often take active transport to sports clubs (OR = 0.88) and men less often take active transport for shopping (OR = 0.92), or for bringing or taking persons (OR = 0.76). Those aged 25-34 years (OR = 0.83) and 35-44 years (OR = 0.96) were more likely to use active transport for taking or bringing persons than persons belonging to the other age groups (relative to trips made for shopping by those 65 years or over). A higher use of active transport modes by persons with an university or college degree was found and particularly persons living in urban-centre neighbourhoods were likely to use active transport modes.

CONCLUSION

IN DEVELOPING POLICIES PROMOTING A MODE SHIFT SPECIAL ATTENTION SHOULD BE GIVEN TO THE FOLLOWING GROUPS: a) men making short distance trips for taking or bringing persons, b) women making short distance trips to sport facilities, c) persons belonging to the age groups of 25-44 years of age, d) Persons with a primary school or lower general secondary education degree and persons with a high school or secondary school degree and e) persons living in rural or urban-green neighbourhoods.

The SQUASH was a more valid tool than the OBiN for categorizing adults according to the Dutch physical activity and the combined guideline

OBJECTIVE

To examine whether the "Short QUestionnaire to ASsess Health-enhancing physical activity" (SQUASH) and the "Injuries and Physical Activity in the Netherlands" questionnaire ("Ongevallen en Bewegen in Nederland," OBiN) were valid in assessing adherence to physical activity (PA) guidelines.

STUDY DESIGN AND SETTING

Participants (N=187) aged 20-69 years were categorized as "inactive," "semiactive," or "norm-active" according to the Dutch PA, the American College of Sports Medicine (ACSM), and the combined guideline (adhering to either or both of two other guidelines) by the questionnaires and a combined heart rate monitor and accelerometer (Actiheart). Percentage of exact agreement and maximum disagreement (difference of two categories) for the categorization between questionnaires and Actiheart was calculated.

RESULTS

The SQUASH had a significant higher agreement than the OBiN for the Dutch PA (SQUASH: 78%, OBiN: 46%; P<0.01) and combined guideline (SQUASH: 84%, OBiN: 55%; P<0.01). Both questionnaires had a low agreement regarding the ACSM guideline (SQUASH: 37%, OBiN: 34%; P=0.45). The SQUASH had a significant higher maximum disagreement than the OBiN for this guideline (SQUASH: 19.8%, OBiN 8%; P<0.01).

CONCLUSION

The SQUASH was a more valid measure than the OBiN for categorizing adults according to the Dutch PA and the combined guideline. Both questionnaires failed to correctly categorize adults according to the ACSM guideline.

Environmental determinants of outdoor play in children: a large-scale cross-sectional study

BACKGROUND

Outdoor play is a cheap and natural way for children to be physically active.

PURPOSE

This study aims to identify physical as well as social correlates of outdoor play in the home and neighborhood environment among children of different age groups.

METHODS

Cross-sectional data were derived from 6470 parents of children from 42 primary schools in four Dutch cities by means of questionnaires (2007-2008). Multivariate sequential Poisson GEE analyses were conducted (2010) to quantify the correlation between physical and social home and neighborhood characteristics and outdoor play among boys and girls aged 4-6 years, 7-9 years, and 10-12 years.

RESULTS

This study showed that next to proximal (home) environmental characteristics such as parental education (RR=0.93-0.97); the importance parents pay to outdoor play (RR=1.32-1.75); and the presence of electronic devices in the child's own room (RR=1.04-1.15), several neighborhood characteristics were significantly associated with children's outdoor play. Neighborhood social cohesion was related to outdoor play in five of six subgroups (RR=1.01-1.02), whereas physical neighborhood characteristics (e.g., green neighborhood type, presence of water, diversity of routes) were associated with outdoor play in specific subgroups only.

CONCLUSIONS

Neighborhood social cohesion was related to outdoor play among children of different age and gender, which makes it a promising point of action for policy development. Policies aimed at improving physical neighborhood characteristics in relation to outdoor play should take into account age and gender of the target population.

The association of neighbourhood psychosocial stressors and self-rated health in Amsterdam, The Netherlands

OBJECTIVE

To investigate associations between neighbourhood-level psychosocial stressors (i.e. experience of crime, nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with the quality of green space) and self-rated health in Amsterdam, the Netherlands.

PARTICIPANTS

A random sample of 2914 subjects aged > or = 18 years from 75 neighbourhoods in the city of Amsterdam, the Netherlands.

DESIGN

Individual data from the Social State of Amsterdam Survey 2004 were linked to data on neighbourhood-level attributes from the Amsterdam Living and Security Survey 2003. Multilevel logistic regression was used to estimate odds ratios and neighbourhood-level variance.

RESULTS

Fair to poor self-rated health was significantly associated with neighbourhood-level psychosocial stressors: nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with green space. In addition, when all the neighbourhood-level psychosocial stressors were combined, individuals from neighbourhoods with a high score of psychosocial stressors were more likely than those from neighbourhoods with a low score to report fair to poor health. These associations remained after adjustments for individual-level factors (i.e. age, sex, educational level, income and ethnicity). The neighbourhood-level variance showed significant differences in self-rated health between neighbourhoods independent of individual-level demographic and socioeconomic factors.

CONCLUSION

Our findings show that neighbourhood-level psychosocial stressors are associated with self-rated health. Strategies that target these factors might prove a promising way to improve public health.

The costs, effects and cost-effectiveness of counteracting overweight on a population level. A scientific base for policy targets for the Dutch national plan for action

OBJECTIVES

To gain insight in realistic policy targets for overweight at a population level and the accompanying costs. Therefore, the effect on overweight prevalence was estimated of large scale implementation of a community intervention (applied to 90% of general population) and an intensive lifestyle program (applied to 10% of overweight adults), and costs and cost-effectiveness were assessed.

METHODS

Costs and effects were based on two Dutch projects and verified by similar international projects. A markov-type simulation model estimated long-term health benefits, health care costs and cost-effectiveness.

RESULTS

Combined implementation of the interventions--at the above mentioned scale--reduces prevalence rates of overweight by approximately 3 percentage points and of physical inactivity by 2 percentage points after 5 years, at a cost of 7 euros per adult capita per year. The cost-effectiveness ratio of combined implementation amounts to euro 6000 per life-year gained and euro 5700 per QALY gained (including costs of unrelated diseases in life years gained). Sensitivity analyses showed that these ratios are quite robust.

CONCLUSIONS

A realistic policy target is a decrease in overweight prevalence of three percentage points, compared to a situation with no interventions. In reality, large scale implementation of the interventions may not counteract the expected upward trends in The Netherlands completely. Nonetheless, implementation of the interventions is cost-effective.

Potential environmental determinants of physical activity in adults: a systematic review

The objective of this systematic review of observational studies was to gain insight into potential determinants of various types and intensities of physical activity among adult men and women. Studies were retrieved from Medline, PsycInfo, Embase and Social scisearch. The ANGELO framework was used to classify environmental factors. In total, 47 publications were identified. Social support and having a companion for physical activity were found to be convincingly associated with different types of physical activity [(neighbourhood) walking, bicycling, vigorous physical activity/sports, active commuting, leisure-time physical activity in general, sedentary lifestyle, moderately intense physical activity and a combination of moderately intense and vigorous activity]. Availability of physical activity equipment was convincingly associated with vigorous physical activity/sports and connectivity of trails with active commuting. Other possible, but less consistent correlates of physical activity were availability, accessibility and convenience of recreational facilities. No evidence was found for differences between men and women. In conclusion, supportive evidence was found for only very few presumed environmental determinants. However, most studies used cross-sectional designs and non-validated measures of environments and/or behaviour. Therefore, no strong conclusions can be drawn and more research of better quality is clearly needed.

Ethnic differences in the effect of environmental stressors on blood pressure and hypertension in the Netherlands

BACKGROUND

Evidence strongly suggests that the neighbourhood in which people live influences their health. Despite this, investigations of ethnic differences in cardiovascular risk factors have focused mainly on individual-level characteristics. The main purpose of this study was to investigate associations between neighbourhood-level environmental stressors (crime, housing density, nuisance from alcohol and drug misuse, quality of green space and social participation), and blood pressure (BP) and hypertension among different ethnic groups.

METHODS

Individual data from the Amsterdam Health Survey 2004 were linked to data on neighbourhood stressors creating a multilevel design for data analysis. The study sample consisted of 517 Dutch, 404 Turkish and 365 Moroccans living in 15 neighbourhoods in Amsterdam, the Netherlands.

RESULTS

Amongst Moroccans, high density housing and nuisance from drug misuse were associated with a higher systolic BP, while high quality of green space and social participation were associated with a lower systolic BP. High level of nuisance from drug misuse was associated with a higher diastolic BP. High quality of green space was associated with lower odds of hypertension. Amongst Turkish, high level of crime and nuisance from motor traffic were associated with a higher diastolic BP. Similar associations were observed among the Dutch group but none of the differences were statistically significant.

CONCLUSION

The study findings show that neighbourhood-level stressors are associated with BP in ethnic minority groups but were less evident in the Dutch group. These findings might imply that the higher BP levels found in some ethnic minority groups might be partly due to their greater susceptibility to the adverse neighbourhood environment in which many ethnic minority people live. Primary prevention measures targeting these neighbourhood stressors may have an impact in reducing high BP related morbidity and mortality among ethnic minority groups.

A systematic review of environmental correlates of obesity-related dietary behaviors in youth

There is increasing interest in the role the environment plays in shaping the dietary behavior of youth, particularly in the context of obesity prevention. An overview of environmental factors associated with obesity-related dietary behaviors among youth is needed to inform the development of interventions. A systematic review of observational studies on environmental correlates of energy, fat, fruit/vegetable, snack/fast food and soft drink intakes in children (4-12 years) and adolescents (13-18 years) was conducted. The results were summarized using the analysis grid for environments linked to obesity. The 58 papers reviewed mostly focused on sociocultural and economical-environmental factors at the household level. The most consistent associations were found between parental intake and children's fat, fruit/vegetable intakes, parent and sibling intake with adolescent's energy and fat intakes and parental education with adolescent's fruit/vegetable intake. A less consistent but positive association was found for availability and accessibility on children's fruit/vegetable intake. Environmental factors are predominantly studied at the household level and focus on sociocultural and economic aspects. Most consistent associations were found for parental influences (parental intake and education). More studies examining environmental factors using longitudinal study designs and validated measures are needed for solid evidence to inform interventions.

Environmental correlates of physical activity in youth - a review and update

Obesogenic environments are thought to underlie the increased obesity prevalence observed in youth during the past decades. Understanding the environmental factors that are associated with physical activity (PA) in youth is needed to better inform the development of effective intervention strategies attempting to halt the obesity epidemic. We conducted a systematic semi-quantitative review of 150 studies on environmental correlates of youth PA published in the past 25 years. The ANalysis Grid for Environments Linked to Obesity (ANGELO) framework was used to classify the environmental correlates studied. Most studies retrieved used cross-sectional designs and subjective measures of environmental factors and PA. Variables of the home and school environments were especially associated with children's PA. Most consistent positive correlates of PA were father's PA, time spent outdoors and school PA-related policies (in children), and support from significant others, mother's education level, family income, and non-vocational school attendance (in adolescents). Low crime incidence (in adolescents) was characteristic of the neighbourhood environment associated with higher PA. Convincing evidence of an important role for many other environmental factors was, however, not found. Further research should aim at longitudinal and intervention studies, and use more objective measures of PA and its potential (environmental) determinants.

Environmental determinants of fruit and vegetable consumption among adults: a systematic review

The current ecological approach in health behaviour research recognises that health behaviour needs to be understood in a broad environmental context. This has led to an exponential increase in the number of studies on this topic. It is the aim of this systematic review to summarise the existing empirical evidence pertaining to environmental influences on fruit and vegetable (FV) consumption. The environment was defined as 'all factors external to the individual'. Scientific databases and reference lists of selected papers were systematically searched for observational studies among adults (18-60 years old), published in English between 1 January 1980 and 31 December 2004, with environmental factor(s) as independent factor(s), and fruit intake, vegetable intake or FV intake combined as one outcome measure as dependent factor(s). Findings showed there was a great diversity in the environmental factors studied, but that the number of replicated studies for each determinant was limited. Most evidence was found for household income, as people with lower household incomes consistently had a lower FV consumption. Married people had higher intakes than those who were single, whereas having children showed mixed results. Good local availability (e.g. access to one's own vegetable garden, having low food insecurity) seemed to exert a positive influence on intake. Regarding the development of interventions, improved opportunities for sufficient FV consumption among low-income households are likely to lead to improved intakes. For all other environmental factors, more replicated studies are required to examine their influence on FV intake.

Environmental determinants of fruit and vegetable consumption among adults: a systematic review

The current ecological approach in health behaviour research recognises that health behaviour needs to be understood in a broad environmental context. This has led to an exponential increase in the number of studies on this topic. It is the aim of this systematic review to summarise the existing empirical evidence pertaining to environmental influences on fruit and vegetable (FV) consumption. The environment was defined as 'all factors external to the individual'. Scientific databases and reference lists of selected papers were systematically searched for observational studies among adults (18-60 years old), published in English between 1 January 1980 and 31 December 2004, with environmental factor(s) as independent factor(s), and fruit intake, vegetable intake or FV intake combined as one outcome measure as dependent factor(s). Findings showed there was a great diversity in the environmental factors studied, but that the number of replicated studies for each determinant was limited. Most evidence was found for household income, as people with lower household incomes consistently had a lower FV consumption. Married people had higher intakes than those who were single, whereas having children showed mixed results. Good local availability (e.g. access to one's own vegetable garden, having low food insecurity) seemed to exert a positive influence on intake. Regarding the development of interventions, improved opportunities for sufficient FV consumption among low-income households are likely to lead to improved intakes. For all other environmental factors, more replicated studies are required to examine their influence on FV intake.