All-cause mortality risks among participants in mass-participation sporting events

OBJECTIVES

Exercise transiently increases the risk for sudden death, whereas long-term exercise promotes longevity. This study assessed acute and intermediate-term mortality risks of participants in mass-participation sporting events.

METHODS

Data of participants in Dutch running, cycling and walking events were collected between 1995 and 2017. Survival status was obtained from the Dutch Population Register. A time-stratified, case-crossover design examined if deceased participants more frequently participated in mass-participation sporting events 0-7 days before death compared with the reference period (14-21 days before death). Mortality risks during follow-up were compared between participants and non-participants from the general population using Cox regression.

RESULTS

546 876 participants (median (IQR) age 41 (31-50) years, 56% male, 72% runners) and 211 592 non-participants (41 (31-50) years, 67% male) were included. In total, 4625 participants died of which more participants had partaken in a sporting event 0-7 days before death (n=23) compared with the reference period (n=12), and the mortality risk associated with acute exercise was greater but did not reach statistical significance (OR 1.92; 95% CI 0.95 to 3.85). During 3.3 (1.1-7.4) years of follow-up, participants had a 30% lower risk of death (HR 0.70; 95% CI 0.67 to 0.74) compared with non-participants after adjustment for age and sex. Runners (HR 0.65; 95% CI 0.62 to 0.69) and cyclists (HR 0.70; 95% CI 0.64 to 0.77) had the best survival during follow-up followed by walkers (HR 0.88; 95% CI 0.80 to 0.94).

CONCLUSION

Participating in mass-participation sporting events was associated with a non-significant increased odds (1.92) of mortality and a low absolute event rate (4.2/100 000 participants) within 7 days post-event, whereas a 30% lower risk of death was observed compared with non-participants during 3.3 years of follow-up. These results suggest that the health benefits of mass sporting event participation outweigh potential risks.

Associations between muscular strength and mental health in cognitively normal older adults: a cross-sectional study from the AGUEDA trial

Objective

To examine the associations between muscular strength and mental health.

Design

We used baseline data of 91 cognitively healthy older adults (71.69 ± 3.91 years old, 57 % women) participating in the AGUEDA randomized controlled trial.

Methods

Muscular strength was assessed using both objective (i.e., handgrip strength, biceps curl, squats, and isokinetic test) and perceived (i.e., International Fitness Scale) indicators. Psychological ill-being indicators: anxiety, depression, stress, and loneliness; and psychological well-being indicators: satisfaction with life, self-esteem, and emotional well-being) were assessed using a set of valid and reliable self-reported questionnaires. Linear regression analyses were performed adjusting for sex, age, years of education, body mass index , alcohol, diet, and smoking (model 1), and additionally by cardiorespiratory fitness (model 2).

Results

Elbow extension was positively associated with stress in model 1 (β = 0.252, 95 % Confidence Interval [95 % CI] = 0.007 to 0.497, p = 0.044), and even after further adjustment for cardiorespiratory fitness (β = 0.282, 95 % CI = 0.032 to 0.532, p = 0.028). Perceived strength was negatively associated with depressive symptoms in model 1 (β = -0.271, 95 % CI = -0.491 to -0.049, p = 0.017) and model 2 reported associations tending towards significant (β = -0.220, 95 % CI = -0.445 to 0.005, p = 0.055). Handgrip strength was positively associated with self-esteem in model 1 (β = 0.558, 95 % CI = 0.168 to 0.949, p = 0.006) and model 2 (β = 0.546, 95 % CI = 0.135 to 0.956, p = 0.010). No further associations were found among other muscular strength and mental health variables.

Conclusion

Handgrip had a moderate association with self-esteem and there was a small association between perceived strength with depressive symptoms and elbow extension with stress. No other associations were observed between muscular strength and mental health outcomes in cognitively normal older adults.

Relationship of Daily Step Counts to All-Cause Mortality and Cardiovascular Events

BACKGROUND

The minimal and optimal daily step counts for health improvements remain unclear.

OBJECTIVES

A meta-analysis was performed to quantify dose-response associations of objectively measured step count metrics in the general population.

METHODS

Electronic databases were searched from inception to October 2022. Primary outcomes included all-cause mortality and incident cardiovascular disease (CVD). Study results were analyzed using generalized least squares and random-effects models.

RESULTS

In total, 111,309 individuals from 12 studies were included. Significant risk reductions were observed at 2,517 steps/d for all-cause mortality (adjusted HR [aHR]: 0.92; 95% CI: 0.84-0.999) and 2,735 steps/d for incident CVD (aHR: 0.89; 95% CI: 0.79-0.999) compared with 2,000 steps/d (reference). Additional steps resulted in nonlinear risk reductions of all-cause mortality and incident CVD with an optimal dose at 8,763 (aHR: 0.40; 95% CI: 0.38-0.43) and 7,126 steps/d (aHR: 0.49; 95% CI: 0.45-0.55), respectively. Increments from a low to an intermediate or a high cadence were independently associated with risk reductions of all-cause mortality. Sex did not influence the dose-response associations, but after stratification for assessment device and wear location, pronounced risk reductions were observed for hip-worn accelerometers compared with pedometers and wrist-worn accelerometers.

CONCLUSIONS

As few as about 2,600 and about 2,800 steps/d yield significant mortality and CVD benefits, with progressive risk reductions up to about 8,800 and about 7,200 steps/d, respectively. Additional mortality benefits were found at a moderate to high vs a low step cadence. These findings can extend contemporary physical activity prescriptions given the easy-to-understand concept of step count. (Dose-Response Relationship Between Daily Step Count and Health Outcomes: A Systematic Review and Meta-Analyses; CRD42021244747).

Central and local arterial stiffness in White Europeans compared to age-, sex-, and BMI-matched South Asians

BACKGROUND

Ethnicity impacts cardiovascular disease (CVD) risk, and South Asians demonstrate a higher risk than White Europeans. Arterial stiffness is known to contribute to CVD, and differences in arterial stiffness between ethnicities could explain the disparity in CVD risk. We compared central and local arterial stiffness between White Europeans and South Asians and investigated which factors are associated with arterial stiffness.

METHODS

Data were collected from cohorts of White Europeans (the Netherlands) and South Asians (India). We matched cohorts on individual level using age, sex, and body mass index (BMI). Arterial stiffness was measured with ARTSENS® Plus. Central stiffness was expressed as carotid-femoral pulse wave velocity (cf-PWV, m/s), and local carotid stiffness was quantified using the carotid stiffness index (Beta) and pressure-strain elastic modulus (Epsilon, kPa). We compared arterial stiffness between cohorts and used multivariable linear regression to identify factors related to stiffness.

RESULTS

We included n = 121 participants per cohort (age 53±10 years, 55% male, BMI 24 kg/m2). Cf-PWV was lower in White Europeans compared to South Asians (6.8±1.9 vs. 8.2±1.8 m/s, p<0.001), but no differences were found for local stiffness parameters Beta (5.4±2.4 vs. 5.8±2.3, p = 0.17) and Epsilon (72±35 vs. 70±31 kPa, p = 0.56). Age (standardized β, 95% confidence interval: 0.28, 0.17-0.39), systolic blood pressure (0.32, 0.21-0.43), and South Asian ethnicity (0.46, 0.35-0.57) were associated with cf-PWV; associations were similar between cohorts (p>0.05 for interaction). Systolic blood pressure was associated with carotid stiffness in both cohorts, whereas age was associated to carotid stiffness only in South Asians and BMI only in White Europeans.

CONCLUSION

Ethnicity is associated with central but not local arterial stiffness. Conversely, ethnicity seems to modify associations between CVD risk factors and local but not central arterial stiffness. This suggests that ethnicity interacts with arterial stiffness measures and the association of these measures with CVD risk factors.

Rapid Improvements in Physical Activity and Sedentary Behavior in Patients With Acute Myocardial Infarction Immediately Following Hospital Discharge

Background Little is known about changes in physical activity (PA) and sedentary behavior (SB) patterns in the acute phase of a myocardial infarction (MI). We objectively assessed PA and SB during hospitalization and the first week after discharge. Methods and Results Consecutively admitted patients hospitalized with an MI were approached to participate in this prospective cohort study. SB, light-intensity PA, and moderate-vigorous intensity PA were objectively assessed for 24 h/d during hospitalization and up to 7 days after discharge in 165 patients. Changes in PA and SB from the hospital to home phase were evaluated using mixed-model analyses, and outcomes were stratified for predefined subgroups based on patient characteristics. Patients (78% men) were aged 65±10 years and diagnosed with ST-segment-elevation MI (50%) or non-ST-segment-elevation MI (50%). Sedentary time was high during hospitalization (12.6 [95% CI, 11.8-13.7] h/d) but substantially decreased following transition to the home environment (-1.8 [95% CI, -2.4 to -1.3] h/d). Furthermore, the number of prolonged sedentary bouts (≥60 minutes) decreased between hospital and home (-1.6 [95% CI, -2.0 to -1.2] bouts/day). Light-intensity PA (1.1 [95% CI, 0.8-1.6] h/d) and moderate-vigorous intensity PA (0.2 [95% CI, 0.1-0.3] h/d) were low during hospitalization but significantly increased following transition to the home environment (light-intensity PA: 1.8 [95% CI, 1.4-2.3] h/d; moderate-vigorous intensity PA: 0.4 [95% CI, 0.3-0.5] h/d; both P<0.001). Improvements in PA and SB were similar across groups, except for patients who underwent coronary artery bypass grafting and who did not improve their PA patterns after discharge. Conclusions Patients with MI demonstrate high levels of SB and low PA volumes during hospitalization, which immediately improved following discharge at the patient's home environment. Registration URL: trialsearch.who.int/; Unique identifier: NTR7646.

Physical activity and sedentary behavior show distinct associations with tissue-specific insulin sensitivity in adults with overweight

AIM

The aim of this study is to investigate associations between the physical activity (PA) spectrum (sedentary behavior to exercise) and tissue-specific insulin resistance (IR).

METHODS

We included 219 participants for analysis (median [IQR]: 61 [55; 67] years, BMI 29.6 [26.9; 32.0] kg/m² ; 60% female) with predominant muscle or liver IR, as determined using a 7-point oral glucose tolerance test (OGTT). PA and sedentary behavior were measured objectively (ActivPAL) across 7 days. Context-specific PA was assessed with the Baecke questionnaire. Multiple linear regression models (adjustments include age, sex, BMI, site, season, retirement, and dietary intake) were used to determine associations between the PA spectrum and hepatic insulin resistance index (HIRI), muscle insulin sensitivity index (MISI) and whole-body IR (HOMA-IR, Matsuda index).

RESULTS

In fully adjusted models, objectively measured total PA (standardized regression coefficient β = 0.17, p = 0.020), light-intensity PA (β = 0.15, p = 0.045) and moderate-to-vigorous intensity PA (β = 0.13, p = 0.048) were independently associated with Matsuda index, but not HOMA-IR (p > 0.05). A higher questionnaire-derived sport index and leisure index were associated with significantly lower whole-body IR (Matsuda, HOMA-IR) in men but not in women. Results varied across tissues: more time spent sedentary (β = -0.24, p = 0.045) and a higher leisure index (β = 0.14, p = 0.034) were respectively negatively and positively associated with MISI, but not HIRI. A higher sport index was associated with lower HIRI (β = -0.30, p = 0.007, in men only).

CONCLUSION

While we confirm a beneficial association between PA and whole-body IR, our findings indicate that associations between the PA spectrum and IR seem distinct depending on the primary site of insulin resistance (muscle or liver).

Exercise Volume Versus Intensity and the Progression of Coronary Atherosclerosis in Middle-Aged and Older Athletes: Findings From the MARC-2 Study

BACKGROUND

Physical activity and exercise training are associated with a lower risk for coronary events. However, cross-sectional studies in middle-aged and older male athletes revealed increased coronary artery calcification (CAC) and atherosclerotic plaques, which were related to the amount and intensity of lifelong exercise. We examined the longitudinal relationship between exercise training characteristics and coronary atherosclerosis.

METHODS

Middle-aged and older men from the MARC-1 (Measuring Athlete's Risk of Cardiovascular Events 1) study were invited for follow-up in MARC-2 (Measuring Athlete's Risk of Cardiovascular Events 2) study. The prevalence and severity of CAC and plaques were determined by coronary computed tomography angiography. The volume (metabolic equivalent of task [MET] hours/week) and intensity (moderate [3 to 6 MET hours/week]; vigorous [6 to 9 MET hours/week]; and very vigorous [≥9 MET hours/week]) of exercise training were quantified during follow-up. Linear and logistic regression analyses were performed to determine the association between exercise volume/intensity and markers of coronary atherosclerosis.

RESULTS

We included 289 (age, 54 [50 to 60] years [median (Q1 to Q3)]) of the original 318 MARC-1 participants with a follow-up of 6.3±0.5 years (mean±SD). Participants exercised for 41 (25 to 57) MET hours/week during follow-up, of which 0% (0 to 19%) was at moderate intensity, 44% (0 to 84%) was at vigorous intensity, and 34% (0 to 80%) was at very vigorous intensity. Prevalence of CAC and the median CAC score increased from 52% to 71% and 1 (0 to 32) to 31 (0 to 132), respectively. Exercise volume during follow-up was not associated with changes in CAC or plaque. Vigorous intensity exercise (per 10% increase) was associated with a lesser increase in CAC score (β, -0.05 [-0.09 to -0.01]; P=0.02), whereas very vigorous intensity exercise was associated with a greater increase in CAC score (β, 0.05 [0.01 to 0.09] per 10%; P=0.01). Very vigorous exercise was also associated with increased odds of dichotomized plaque progression (adjusted odds ratio [aOR], 1.09 [1.01 to 1.18] per 10% vs 2.04 [0.93 to 4.15] for highest vs lowest very vigorous intensity tertiles, respectively), and specifically with increased calcified plaques (aOR, 1.07 [1.00 to 1.15] per 10% vs 2.09 [1.09 to 4.00] for highest vs lowest tertile, respectively).

CONCLUSIONS

Exercise intensity but not volume was associated with progression of coronary atherosclerosis during 6-year follow-up. It is intriguing that very vigorous intensity exercise was associated with greater CAC and calcified plaque progression, whereas vigorous intensity exercise was associated with less CAC progression.

Resistance Exercise Program in Cognitively Normal Older Adults: CERT-Based Exercise Protocol of the AGUEDA Randomized Controlled Trial

OBJECTIVES

To provide a comprehensive CERT (Consensus on Exercise Reporting Template)-based description of the resistance exercise program implemented in the AGUEDA (Active Gains in brain Using Exercise During Aging) study, a randomized controlled trial investigating the effects of a 24-week supervised resistance exercise program on executive function and related brain structure and function in cognitively normal older adults.

DESIGN AND PARTICIPANTS

90 cognitively normal older adults aged 65 to 80 were randomized (1:1) to a: 1) resistance exercise group; or a 2) wait-list control group. Participants in the exercise group (n = 46) performed 180 min/week of resistance exercise (3 supervised sessions per week, 60 min/session) for 24 weeks.

INTERVENTION

The exercise program consisted of a combination of upper and lower limb exercises using elastic bands and the participant's own body weight as the main resistance. The load and intensity were based on the resistance of the elastic bands (7 resistances), number of repetitions (individualized), motor complexity of exercises (3 levels), sets and rest (3 sets/60 sec rest), execution time (40-60 sec) and velocity (as fast as possible).

SETTINGS

The maximum prescribed-target intensity was 70-80% of the participants' maximum rate of perceived exertion (7-8 RPE). Heart rate, sleep quality and feeling scale were recorded during all exercise sessions. Those in the wait-list control group (n = 44) were asked to maintain their usual lifestyle. The feasibility of AGUEDA project was evaluated by retention, adherence, adverse events and cost estimation on the exercise program.

RESULTS AND CONCLUSIONS

This study details the exercise program of the AGUEDA trial, including well-described multi-language manuals and videos, which can be used by public health professionals, or general public who wish to implement a feasible and low-cost resistance exercise program. The AGUEDA exercise program seems to be feasible by the high retention (95.6%) and attendance rate (85.7%), very low serious adverse event (1%) and low economic cost (144.23 € /participant/24 weeks). We predict that a 24-week resistance exercise program will have positive effects on brain health in cognitively normal older adults.

Long-term cardiovascular health status and physical functioning of nonhospitalized patients with COVID-19 compared with non-COVID-19 controls

Coronavirus disease 2019 (COVID-19) is reported to have long-term effects on cardiovascular health and physical functioning, even in the nonhospitalized population. The physiological mechanisms underlying these long-term consequences are however less well described. We compared cardiovascular risk factors, arterial stiffness, and physical functioning in nonhospitalized patients with COVID-19, at a median of 6 mo postinfection, versus age- and sex-matched controls. Cardiovascular risk was assessed using blood pressure and biomarker concentrations (amino-terminal pro-B-type-natriuretic-peptide, high-sensitive cardiac troponin I, C-reactive protein), and arterial stiffness was assessed using carotid-femoral pulse wave velocity. Physical functioning was evaluated using accelerometry, handgrip strength, gait speed and questionnaires on fatigue, perceived general health status, and health-related quality of life (hrQoL). We included 101 former patients with COVID-19 (aged 59 [interquartile range, 55-65] yr, 58% male) and 101 controls. At 175 [126-235] days postinfection, 32% of the COVID-19 group reported residual symptoms, notably fatigue, and 7% required post-COVID-19 care. We found no differences in blood pressure, biomarker concentrations, or arterial stiffness between both groups. Former patients with COVID-19 showed a higher handgrip strength (43 [33-52] vs. 38 [30-48] kg, P = 0.004) and less sleeping time (8.8 [7.7-9.4] vs. 9.8 [8.9-10.3] h/day, P < 0.001) and reported fatigue more often than controls. Accelerometry-based habitual physical activity levels, gait speed, perception of general health status, and hrQoL were not different between groups. In conclusion, one in three nonhospitalized patients with COVID-19 reports residual symptoms at a median of 6 mo postinfection, but we were unable to relate these symptoms to increases in cardiovascular risk factors, arterial stiffness, or physical dysfunction.NEW & NOTEWORTHY We examined cardiovascular and physical functioning outcomes in nonhospitalized patients with COVID-19, at a median of 6 mo postinfection. When compared with matched controls, minor differences in physical functioning were found, but objective measures of cardiovascular risk and arterial stiffness did not differ between groups. However, one in three former patients with COVID-19 reported residual symptoms, notably fatigue. Follow-up studies should investigate the origins of residual symptoms and their long-term consequences in former, nonhospitalized patients with COVID-19.

Sitting patterns in cardiovascular disease patients compared with healthy controls and impact of cardiac rehabilitation

PURPOSE

To identify how and when to intervene in cardiovascular disease (CVD) patients' sedentary behavior, we moved beyond studying total volume of sitting and examined sitting patterns. By analyzing the timing of stand-to-sit and sit-to-stand transitions, we compared sitting patterns (a) between CVD patients and healthy controls, and (b) before and after cardiac rehabilitation (CR).

METHODS

One hundered twenty nine CVD patients and 117 age-matched healthy controls continuously wore a tri-axial thigh-worn accelerometer for 8 days (>120 000 posture transitions). CVD patients additionally wore the accelerometer directly and 2 months after CR.

RESULTS

With later time of the day, both CVD patients and healthy controls sat down sooner (i.e., shorter standing episode before sitting down; HR = 1.01, 95% CI [1.011, 1.015]) and remained seated longer (HR = 0.97, CI [0.966, 0.970]). After more previous physical activity, both groups sat down later (HR = 0.97, CI [0.959, 0.977]), and patients remained seated longer (HR = 0.96; CI [0.950, 0.974]). Immediately and 2-months following CR, patients sat down later (HR_post-CR  = 0.96, CI [0.945, 0.974]; HR_follow-up  = 0.96, CI [0.948, 0.977]) and stood up sooner (HR_post-CR  = 1.04, CI [1.020, 1.051]; HR_follow-up  = 1.03, CI [1.018, 1.050]). These effects were less pronounced with older age, higher BMI, lower sedentary behavior levels, and/or higher physical activity levels at baseline.

CONCLUSION

Cardiac rehabilitation programs could be optimized by targeting CVD patients' sit-to-stand transitions, by focusing on high-risk moments for prolonged sitting (i.e., in evenings and after higher-than-usual physical activity) and attending to the needs of specific patient subgroups.

Prognostic value of left ventricular global longitudinal strain in patients with severe aortic stenosis for transcatheter aortic valve implantation-related morbidity and mortality: a meta-analysis

Aims

Current methods, including left ventricular ejection fraction (LVEF), demonstrate limited prognostic value for post-Transcatheter Aortic Valve Implantation (TAVI) outcomes. Studies elaborating on LV global longitudinal strain (GLS) showed promising results, but are often underpowered.

Purpose

This meta-analysis aims to evaluate the prognostic value of preprocedural global longitudinal strain (GLS) for post-TAVI mortality and morbidity.

Methods

A systematic search was conducted in PubMed, Embase and Web of Science from 2001 to 2021. All studies that comprised patients with severe aortic stenosis who underwent TAVI and investigated the association between preprocedural speckle-tracking-derived GLS and clinical outcomes, were included. An inversely-weighted random effects meta-analysis was adopted to investigate the association between preprocedural GLS vs primary (i.e. all-cause mortality) and secondary (i.e. major cardiovascular events [MACE]) post-TAVI outcomes.

Results

Of the 1,057 identified records, 12 were eligible, all of which had a low-to-moderate risk of bias (Newcastle-Ottawa scale). On average, the 2,068 unique patients demonstrated preserved ejection fraction but impaired longitudinal function (mean LVEF 52.2±4.4%, GLS −13.5±1.6%). Patients with a lower GLS had a higher all-cause mortality (pooled hazard ratio (HR) 1.99 [95% confidence interval (CI): 1.59, 2.50]) and MACE (1.26 [95% CI: 1.08, 1.46]) risk compared to patients with higher GLS. In addition, each 1% decrease of GLS was associated with an increased postprocedural mortality (HR 1.06 [95% CI: 1.03, 1.08]) and MACE risk (pooled HR 1.08 [95% CI: 1.01, 1.15]).

Conclusion

Preprocedural GLS was significantly associated with post-TAVI mortality and morbidity. This suggests a potential clinically important role of pre-TAVI evaluation of GLS for risk stratification of patients with severe aortic stenosis.

Funding Acknowledgement

Type of funding sources: Public hospital(s).

Impact of a COVID-19 infection on exercise levels of recreational athletes one- and three-months post-infection

We examined the effect of a COVID-19 infection on changes in exercise levels in recreational athletes in the first three months after infection, and identified personal factors associated with a larger change in exercise level and recovery time. Recreational athletes (n=4360) completed an online questionnaire on health and exercise levels. 601 Athletes have had a diagnostically confirmed COVID-19 infection, while 3479 athletes did not (non-COVID-19 group). Exercise levels (in MET-min/week) were examined prior to (2019) and during the COVID-19 pandemic (2020) for the non-COVID-19 group, and in 2019, 1-month pre-COVID-19 infection, 1-month post-COVID-19 infection and 3 months post-COVID-19 infection in the COVID-19 group. Median exercise level at baseline in the COVID-19 group was 3528 (IQR=1488-5760) MET-min/week. One-month post-COVID-19 infection, exercise level dropped 58% (2038 MET-min/week), which partly stabilized to 36% (1256 MET-min/week) below baseline values 3 months post-COVID-19 infection. Moreover, in both the COVID-19 (pre-COVID-19 infection) and non-COVID-19 group exercise levels during the pandemic decreased with ~260 MET-min/week. These results illustrate that even a relatively physically active population of recreational athletes is significantly affected by a COVID-19 infection, particularly those athletes who are overweight. COVID-19 disease burden, age, sex, comorbidities and smoking were not associated with reduced exercise levels.

Long-term cardiovascular health and physical functioning of non-hospitalised ex-COVID-19 patients: a case-control study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation (Nederlandse Hartstichting)

Background/Introduction

SARS-CoV-2 and the associated coronavirus disease 2019 (COVID-19) has substantial acute effects on cardiovascular health and physical functioning, but the long-term effects are less clear, especially in individuals that recover from COVID-19 at home, representing ~95% of all cases.

Purpose

We compared cardiovascular health and physical functioning of non-hospitalised ex-COVID-19 patients versus age- and sex-matched healthy peers.

Methods

We recruited non-hospitalised adults with PCR-proven COVID-19 and age- and sex-matched controls for this case-control study. Duration of COVID-19 illness and presence of residual complaints were inquired. Cardiovascular health status and physical functioning were assessed through a series of measurements: blood pressure, blood biomarkers (NT-proBNP, high-sensitive cardiac troponin I, C-reactive protein), carotid-femoral pulse wave velocity (ARTSENS), handgrip strength, 4-metre gait speed, habitual physical activity (days per week with at least 30 minutes of moderate physical activity) and quality of life based on the 12-item short form.

Results

We included 101 ex-COVID-19 patients (median age 59.0 [54.5-65.5], 59 (58.4%) male) at a median of 5.0 [4.0-7.0] months post-infection and 101 age- and sex-matched controls (median age 58.0 [54.0-64.5], 58 (57.4%) male). Median duration of COVID-19 illness was 8.0 days [6.0-14.0] and 32.3% of the cases reported residual complaints at the time of inclusion. We found no differences between ex-COVID-19 patients and controls in blood pressure (134-81 vs. 133-81 mmHg, p=0.40 and p=0.30 for systolic and diastolic pressures respectively), concentrations of NT-proBNP (8.50 vs. 7.00 pmol/L, p=0.22), high-sensitive cardiac troponin I (4.11 vs. 3.38 ng/L, p=0.06), C-reactive protein (4.00 vs. 4.00 mg/L, p=0.93) and carotid-femoral pulse wave velocity (6.63 vs. 7.01 m/s, p=0.30). Ex-COVID-19 patients showed higher handgrip strength compared to controls (43 kg vs. 38 kg, p=0.004), but 4-metre gait speed (2.62 vs. 2.56 s, p=0.33), habitual physical activity levels (6.0 vs. 6.0 days, p=0.16) and reported quality of life (86.4% vs. 88.6%, p=0.10) were not different between groups.

Conclusion(s)

Cardiovascular health and physical functioning parameters were not different between non-hospitalised ex-COVID-19 patients and age- and sex-matched controls at five months post-infection. This suggests that individuals who recovered from COVID-19 at home do not have an increased cardiovascular risk or impaired physical functioning in the long-term.

COVID-19 survivors are physically inactive with high levels of sedentary time, regardless of patient characteristics, disease severity or cardiac dysfunction

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation

Background

More than 250 million cases of the coronavirus disease-2019 (COVID-19) infection were confirmed across the globe since 2020, leading to a substantial number of COVID-19 related hospital admissions. Many COVID-19 survivors experience long-term health consequences, but data on physical activity patterns and the impact on recovery post-infection are scarce.

Purpose

This study aimed to objectively assess physical (in)activity patterns among COVID-19 survivors and to explore the association with patient characteristics, disease severity and cardiac dysfunction. We hypothesized that COVID-19 survivors will demonstrate low volumes of physical activity and a high sedentary time, especially those with a more severe disease course (e.g. longer hospital duration; admission to intensive care), cardiac dysfunction, and persistent symptoms at 3-6 months post-discharge.

Methods

In this cross-sectional cohort study, we objectively assessed physical activity, sedentary behaviour and sleep duration for 24 hrs/day during 8 subsequent days in COVID-19 survivors at 3-6 months post-hospitalisation. Activity patterns were compared across pre-defined subgroups based on patient- and disease characteristics, cardiac biomarker release during hospitalisation, abnormal transthoracic echocardiogram regarding left- and right ventricular function and volumes at 3-6 months of follow-up, and persistence of symptoms post-discharge.

Results

Physical activity patterns were assessed in 37 patients (60±10 years old; 78% male) at 125 [116; 132] days after discharge. Patients spent 4.2 [3.2; 5.3] hrs/day in light-intensity physical activity and 1.0 [0.8; 1.4] hrs/day in moderate-to-vigorous intensity physical activity. Median sleep duration was 8.6 [8.2; 9.1] hrs/day. Time spent sitting was 9.8 [8.7; 11.2] hrs/day, which was accumulated in 6.0 [4.7; 6.9] prolonged sitting bouts (≥30 min) and 41.4 [31.5; 48.1] short sitting bouts (<30 min, Central Figure). No differences in activity patterns were found across subgroups, but sleep duration was slightly higher in women versus men (9.2 vs 8.5 hrs/day, p=0.03) and patients with versus without persistent symptoms (9.1 vs 8.3 hrs/day, p=0.02).

Conclusions

COVID-19 survivors are physically inactive for most of their time at 3-6 months post-hospitalisation. Physical (in)activity patterns are not impacted by patient- nor disease characteristics, underlining the need for a uniform approach for re-activation of COVID-19 survivors.

Central Figure.

A: objectively measured light-intensity physical activity (LIPA), moderate-to-vigorous intensity physical activity (MVPA), sleep duration and sedentary time in COVID-19 patients at 3-6 months post-hospitalisation (median and interquartile range).

B: sitting bout frequency (mean + standard deviation).

Acute and long-term mortality rates among participants of mass-participation sport events versus the general population

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The work of T.M.H.E is supported by the Netherlands Heart Foundation.

Background

Exercise training improves cardiovascular health and lowers the risk for morbidity and mortality. However, an acute bout of exercise transiently increases the risk for sudden death. It is unknown how participation in a mass-participation exercise event impacts mortality risk compared to non-participation.

Purpose

To assess the acute and long-term mortality risk among participants of mass-participation exercise events and to place these risks into perspective.

Methods

Data was collected among participants of Dutch running, cycling and long-distance walking events between 1995 and 2017. We retrieved age, sex, exercise type from the database of event organizers. The survival status and date of death were extracted from the Dutch Population Register (DPR). A time-stratified case-crossover design with an 8-day risk and reference period was used to examine if deceased athletes more frequently participated in mass-participation exercise events at 0 to 8 days before their death compared to the reference period (i.e., 14 to 21 weeks before death). Mixed-effects logistic regression was used to calculate the odds ratio (OR) with 95% confidence intervals (95% CI). We also retrieved controls (i.e., individuals not partaking in mass-participation exercise events) from the DPR (n=211,592) and compared long-term mortality risks between athletes and controls using stratified Kaplan-Meier curves and Cox regression models.

Results

547,014 athletes (age 41 years [Q25 31; Q75 50], 56% male, 72% runners, 11% cyclists) and 211,592 controls (age 41 years [Q25 31; Q75 50], 67% male) were included in this study. Participation in mass-participation exercise events was higher at 0 to 8 days before death (i.e., risk period, n=23 deceased athletes) compared to 14 to 21 days before death (i.e., reference period, n=12 deceased athletes), but the mortality risk was not significantly elevated after participation in an exercise event (OR 1.92; 95%CI 0.95-3.85). During a median follow-up of 3.3 years [Q25 1.1; Q75 4.8], 4,625 (0.8%) athletes and 2,494 (1.2%) controls died. Amateur athletes had a 30% lower risk of death (hazard ratio 0.70; 95% CI 0.67-0.74, Figure 1) compared to controls, after adjustment for age and sex.

Conclusion

Participants of a mass-participation exercise event had a non-significant increased odds of death within 8-days after the event. In contrast, mortality risk was significantly lower for amateur athletes compared to controls from the general population during long-term follow-up, emphasizing that the health benefits of exercise and participation in a mass-participation exercise event outweigh the risks.

Figure 1. Stratified Kaplan-Meier curves with hazard ratio (HR) adjusted for age and sex for amateur athletes compared to controls.

High Levels of Sedentary Time in Patients with COVID-19 after Hospitalisation

Many patients with COVID-19 experience severe and even fatal disease. Survivors may have long-term health consequences, but data on physical activity and sedentary behaviour are scarce. Therefore, we objectively assessed physical activity (PA) patterns among post-hospitalised patients with COVID-19 and explored associations with patient characteristics, disease severity and cardiac dysfunction. We objectively assessed PA, sedentary behaviour and sleep duration for 24 h/day during 8 days at 3-6 months after COVID-19 hospitalisation. PA and sedentary time were compared across pre-defined subgroups based on patient and disease characteristics, cardiac biomarker release during hospitalisation, abnormal transthoracic echocardiogram at 3-6 months post-hospitalisation and persistence of symptoms post-discharge. PA and sedentary behaviour were assessed in 37 patients (60 ± 10 years old; 78% male). Patients spent 4.2 [3.2; 5.3] h/day light-intensity PA and 1.0 [0.8; 1.4] h/day moderate-to-vigorous intensity PA. Time spent sitting was 9.8 [8.7; 11.2] h/day, which was accumulated in 6 [5; 7] prolonged sitting bouts (≥30 min) and 41 [32; 48] short sitting bouts (<30 min). No differences in PA and sedentary behaviour were found across subgroups, but sleep duration was higher in patients with versus without persistent symptoms (9.1 vs. 8.3 h/day, p = 0.02). Taken together, high levels of sedentary time are common at 3–6 months after COVID-19 hospitalisation, whilst PA and sedentary behaviour are not impacted by patient or disease characteristics.

Impact of Dutch COVID-19 restrictive policy measures on physical activity behavior and identification of correlates of physical activity changes: a cohort study

Background

Identification of characteristics of individuals that are related to decreases in physical activity (PA) levels during lockdown is needed to develop targeted-interventions. This study aims to evaluate changes in domain-specific (i.e. leisure time, transportation, occupational, and household) and total PA due to the Dutch COVID-19 lockdown, which started on March 15 2020. Furthermore, we aim to identify demographic, health-related, and psychological correlates of these changes.

Methods

Individuals who participated in the Nijmegen Exercise Study during 2017-2019 were invited to this study, which was conducted between April 16 and May 12 2020. Participant characteristics (i.e. age, sex, body mass index (BMI), marital status, education, household composition, and occupation status), living environment (i.e. housing type and degree of urbanization), psychological characteristics (i.e. resilience, outcome expectations, vitality, and mental health), and medical history were collected via an online questionnaire. Short Questionnaire to Assess Health-enhancing physical activity was used to assess PA behavior before and during lockdown. Wilcoxon signed-rank test was used to compare PA levels, in metabolic equivalent of task (MET)-minutes per week (min/wk), before and during lockdown. Multivariable linear regression analyses were performed to examine correlates of PA changes.

Results

4033 participants (57% male; 59 ± 13 years) were included. PA decreased significantly during lockdown with mean ± SD changes of 393 ± 2735 MET-min/wk for total, 133 ± 785 MET-min/wk for transportation, 137 ± 1469 MET-min/wk for occupation, and 136 ± 1942 MET-min/wk for leisure time PA. Household PA did not change significantly. Unemployment, COVID-19-related occupational changes, higher BMI, and living in an apartment or semi-detached/terraced house were significantly related to larger decreases in total and domain-specific PA. Higher vitality was related to smaller decreases in total and domain-specific PA. Higher age was significantly associated with a larger decrease in leisure time PA. Lower education was associated with smaller decreases in transportation and occupational PA compared to higher education.

Conclusion

PA levels significantly reduced during lockdown compared to before lockdown. Declines were observed during transportation and occupation, but were not compensated by an increase in leisure time PA. We identified subgroups that were more susceptible to reductions in domain-specific or total PA levels and should therefore be encouraged to increase their PA levels during lockdown.

Association between sedentary time and cognitive function: A focus on different domains of sedentary behavior

Studies which examined the association between sedentary behavior (SB) and cognitive function have presented equivocal findings. Mentally active/inactive sedentary domains may relate differently to cognitive function. We examined associations between SB and cognitive function, specifically focusing on different domains. Participants were recruited from the Nijmegen Exercise Study 2018 in the Netherlands. SB (h/day) was measured with the Sedentary Behavior Questionnaire. Cognitive function was assessed with a validated computer self-test (COST-A), and a z-score calculated for global cognitive function. Multivariate linear regression assessed associations between tertiles of sedentary time and cognitive function. Cognition tests were available from 2821 participants, complete data from 2237 participants (43% female), with a median age of 61 [IQR 52-67] and a mean sedentary time of 8.3 ± 3.2 h/day. In fully adjusted models, cognitive function was significantly better in participants with the highest total sedentary time (0.07 [95% CI 0.02-0.12], P = 0.01), work-related sedentary time (0.13 [95% CI 0.07-0.19], P < 0.001), and non-occupational computer time (0.07 [95% CI 0.02-0.12], P = 0.01), compared to the least sedentary. Leisure sedentary time and time spent sedentary in the domains TV, reading or creative time showed no association with cognitive function in final models (all P > 0.05). We found a strong, independent positive association between total SB and cognitive function in a heterogenous population. This relation was not consistent across different domains, with especially work- and computer-related SB being positively associated with cognitive function. This highlights the importance of assessing the various sedentary domains in understanding the relation between sedentary time and cognitive function.

Changes in Physical Activity and Sedentary Behaviour in Cardiovascular Disease Patients during the COVID-19 Lockdown

The COVID-19 lockdown has been associated with physical inactivity. We prospectively evaluated changes in moderate-to-vigorous physical activity (MVPA) and sedentary time (ST) among 1565 cardiovascular disease (CVD) patients using validated questionnaires at 5 weeks after lockdown initiation (i.e., baseline, April 2020) and at every 4 subsequent weeks, until July 2020. Multivariate mixed model analyses were performed to identify whether age, sex, CVD-subtype, lockdown adherence and mental health factors impacted changes in physical (in)activity. Patients were 67 (interquartile range: 60–73) years and primarily diagnosed with coronary artery disease. Time spent in MVPA was 143 min/day (95% confidence interval (CI) 137; 148) at baseline. Female sex, heart-failure, fear of COVID-19 infection and limited possibilities for physical activity were independently associated with lower levels of MVPA across time. After adjusting for confounders, overall MVPA did not change. ST was 567 (95% CI 555; 578) min/day at baseline. Lack of social contact, limited possibilities for physical activity and younger age were independently associated with higher levels of ST. After adjusting for confounders, ST progressively increased following 8 (Δ+19.7 (95% CI 0.4; 39.0)) and 12 weeks (Δ+25.2 (95% CI 5.4; 47.1) min/day) of lockdown. Despite a phased relaxation of the lockdown, CVD patients progressively increased ST and reported no change in MVPA. This highlights the need to target physical inactivity during and beyond the COVID-19 pandemic.

Fatigue in chronic myeloid leukemia patients on tyrosine kinase inhibitor therapy: predictors and the relationship with physical activity

Fatigue is a common side effect of tyrosine kinase inhibitor (TKI) therapy in patients with chronic myeloid leukemia (CML). However, the prevalence of TKI-induced fatigue remains uncertain and little is known about predictors of fatigue and its relationship with physical activity. In this study, 220 CML patients receiving TKI therapy and 110 genderand age-matched controls completed an online questionnaire to assess fatigue severity and fatigue predictors (Part 1). In addition, physical activity levels were objectively assessed for 7 consecutive days in 138 severely fatigued and non-fatigued CML patients using an activity monitor (Part 2). We demonstrated that the prevalence of severe fatigue was 55.5% in CML patients and 10.9% in controls (P<0.001). We identified five predictors of fatigue in our CML population: age (odds ratio [OR] 0.96, 95% confidence interval [95% CI]: 0.93-0.99), female gender (OR 1.76, 95% CI: 0.92-3.34), Charlson Comorbidity Index (OR 1.91, 95% CI: 1.16-3.13), the use of comedication known to cause fatigue (OR 3.43, 95% CI: 1.58-7.44), and physical inactivity (OR of moderately active, vigorously active and very vigorously active compared to inactive 0.43 (95% CI: 0.12-1.52), 0.22 (95% CI: 0.06-0.74), and 0.08 (95% CI: 0.02-0.26), respectively). Objective monitoring of activity patterns confirmed that fatigued CML patients performed less physical activity of both light (P=0.017) and moderate to vigorous intensity (P=0.009). In fact, compared to the non-fatigued patients, fatigued CML patients performed 1 hour less of physical activity per day and took 2,000 fewer steps per day. Our findings facilitate the identification of patients at risk of severe fatigue and highlight the importance of setting reduction of fatigue as a treatment goal in CML care. This study was registered at The Netherlands Trial Registry, NTR7308 (Part 1) and NTR7309 (Part 2).

Impact of cardiovascular health status on the association between changes in physical activity and major cardiovascular events and mortality among 88,320 adults: outcomes of the Lifelines Cohort Study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Lifelines Biobank initiative received funding from the Dutch Ministry of Health, Welfare and Sport, the Dutch Ministry of Economic Affairs, the University Medical Center Groningen [UMCG], University Groningen and the Northern Provinces of the Netherlands. The work of T.M.H.E is supported by the Netherlands Heart Foundation [Senior E-Dekker grant #2017T051].

Background. Regular physical activity (PA) improves health. Many observational studies investigated the association between PA and health at a single time-point, but PA might change over time.

Purpose. To examine the association between change in PA and major adverse cardiovascular events (MACE) and all-cause mortality, and to investigate the impact of cardiovascular health status at baseline on these outcomes.

Methods. This study used data from the Lifelines Cohort Study (N = 88,320). Self-reported PA volumes were presented as Metabolic Equivalent of Task (MET) min/week. Change in PA was calculated by subtracting MET-min/week at the first assessment from the second assessment (median interval: 4 yrs), and 5 groups were created; large reduction (&lt; -1500), moderate reduction (-1500 to -250), no change (-250 to 250), moderate improvement (-250 to 250) and large improvement (&gt;1500). The outcome was a combination of MACE and all-cause mortality.

Results. During a median follow-up of 7 years, 667 events occurred among healthy individuals (43 ± 12 yrs, 1% of 69,818) and 599 in individuals with CVRF (55 ± 11 yrs, 3% of 18,502). Adjusted for confounders and baseline PA, healthy individuals with a large reduction in PA had a greater risk of incident MACE and mortality (Table). In CVRF, moderate to large improvements in PA were associated with reductions in adverse outcomes. Risk estimates became stronger in individuals with lower baseline PA (&lt;2000 MET-min/week), Table).

Conclusions. Maintaining PA in healthy individuals and increasing PA in individuals with CVRF over time is important to prevent MACE and mortality. The impact of changes in PA was stronger for individuals with lower baseline PA.

Table. Change of PA, MACE and mortality. Changes in PA Healthy CVRF Large reduction 1.40 [1.02;1.93] 1.27 [0.95;1.70] Moderate reduction 1.22 [0.89;1.68] 0.97 [0.72;1.30] No changes Ref Ref Moderate improvement 1.04 [0.74;1.44] 0.65 [0.47;0.91] Large improvement 0.96 [0.71;1.31] 0.69 [0.51; 0.94] Individuals with lower baseline PA Large reduction 2.24 [0.96;5.21] 2.85 [1.44;5.63] Moderate reduction 1.77 [1.10;2.84] 1.33 [0.89;1.98] No changes Ref Ref Moderate improvement 1.16 [0.73;1.83] 0.49 [0.31;0.76] Large improvement 0.77 [0.48;1.23] 0.58 [0.39;0.86]

Physical activity and sedentary behaviour in cardiovascular disease patients during the COVID-19 lockdown in the Netherlands; a longitudinal cohort study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation - senior E-Dekker grant

Physical activity and sedentary behaviour in cardiovascular disease patients during the COVID-19 lockdown in the Netherlands; a longitudinal cohort study

Background

Previous studies showed that the COVID-19 lockdown caused a more inactive lifestyle, but it is unknown whether these acute effects persist over time. We prospectively evaluated changes in physical activity and sedentary behaviour among chronic cardiovascular disease (CVD) patients during the first-wave COVID-19 lockdown and aimed to identify factors associated with physical inactivity.

Methods

1,565 CVD patients were included and baseline physical activity and sedentary behaviour were assessed using validated questionnaires at 5 weeks after the initiation of the Dutch lockdown (March 2020). Follow-up measures were collected every subsequent 4 weeks until July 2020. Multivariate mixed model analyses were performed to identify whether age, gender, CVD subtype, lockdown adherence and mental health factors impacted changes in physical (in)activity.

Results

Patients were 67 (interquartile range [60, 73]) years, mostly male (73%) and primarily diagnosed with myocardial infarction (48%) or angina pectoris (18%). Daily time spent in moderate-to-vigorous physical activity was 143 minutes (95% confidence interval (CI) 137; 148) at baseline, with almost no changes during follow-up on a group level (Δ+8.0 (95%CI -1.1; 17.0); Δ+11.2 (95%CI 1.9; 20.5) and Δ+8.0 (95%CI -1.5; 17.5) min/day after 4, 8 and 12 weeks, respectively).Female gender (Δ-40.7 (95%CI -48.5; -33.0) min/day); heart failure (Δ-23.0 (95%CI -36.5; -9.5) min/day); fear of a COVID-19 infection (Δ-6.6 (95%CI -9.4; -3.8) min/day) and limited possibilities for physical activity (Δ-7.4 (95%CI -10.1; -4.7) min/day) were independently associated with a decrease in physical activity.

Sedentary time was 567 (95%CI 555; 578) min/day at baseline which did not change after 4 weeks (Δ+12.1 (95%CI -6.0; 30.2) min/day) and after 8 weeks (Δ+15.2 (95%CI -3.3; 33.8) min/day), but significantly increased after 12 weeks of follow-up (Δ+19.0 (95%CI 0.1; 37.8) min/day). Lack of social contact (Δ+8.4 (95%CI 2.3; 14.5); limited possibilities for physical activity (Δ+14.7 (95%CI 8.8; 20.5) and younger age (Δ+2.1 (95%CI 1.3; 2.8) min/day were independently associated with an increase in sedentary time.

Conclusions

A time-dependent increase in daily sedentary time was observed among chronic CVD patients during the COVID-19 lockdown, whereas physical activity levels did not substantially change. Our findings highlight the need to develop and implement novel solutions to increase physical activity and reduce sedentary time during (and beyond) the COVID-19 pandemic, especially in CVD patients who are female, younger, diagnosed with heart failure, have a lack of social contact, fear of COVID-19 infection and experience limited physical activity possibilities during the lockdown.

Impact of COVID-19 lockdown on physical activity and sedentary behaviour in Dutch cardiovascular disease patients

BACKGROUND

Coronavirus disease 2019 (COVID-19) lockdown restrictions may impact lifestyle and therefore also physical (in)activity patterns in patients with cardiovascular disease (CVD). This study aimed to evaluate the effect of lockdown on physical activity and sedentary behaviour.

METHODS

A total of 1565 Dutch CVD patients participated in this prospective cohort study, in which we compared physical activity and sedentary behaviour before and during the COVID-19 lockdown period. Baseline measures were assessed in 2018 and data on follow-up measures were collected between 17 and 24 April 2020 (5 weeks after the introduction of COVID-19 lockdown restrictions). Validated questionnaires were used to assess physical activity and sedentary behaviour.

RESULTS

Moderate-to-vigorous physical activities increased from 1.6 (0.9, 2.8) to 2.0 (1.0, 3.5) h/day [median (interquartile range)] (p < 0.001) during the COVID-19 lockdown, mainly due to an increase in time spent walking and doing odd jobs. In contrast, time spent exercising significantly declined [1.0 (0.0, 2.3) to 0.0 (0.0, 0.6) h/week], whereas sedentary time increased from 7.8 (6.1, 10.4) to 8.9 (6.8, 11.4) h/day (p < 0.001). The absolute increase in physical activity was 13 (-36, 81) min/day, whereas sedentary behaviour increased by 55 (-72, 186) min/day.

CONCLUSION

Despite a small increase in physical activities, the larger increase in sedentary time induced a net reduction in habitual physical activity levels in Dutch CVD patients during the first-wave COVID-19 lockdown. Since a more inactive lifestyle is strongly associated with disease progression and mortality, we encourage CVD patients and their caregivers to explore novel solutions to increase physical activity levels and reduce sedentary time during (and beyond) the COVID-19 pandemic.

Associations of total and aerobic steps with the prevalence and incidence of frailty in older adults with hypertension

PURPOSE

To examine the associations of total steps/day and faster aerobic steps/day (≥60 steps/min) with the development of frailty in older adults with hypertension (HTN) using a two-phased cross-sectional and prospective approach.

METHODS

The sample consisted of 427 older adults with HTN from the Physical Activity and Aging Study (PAAS), aged ≥65 years, with valid step data from an accelerometer-based pedometer. Participants were classified into tertiles of total steps/day (low, mid, high) and three categories of aerobic steps/day (none, low, high). Frailty was defined using a modified Fried score with 5 subdomains including shrinking, weakness, slowness, low physical activity (PA), and exhaustion.

RESULTS

We observed a negative dose-response relationship across categories of total steps/day and aerobic steps/day for the prevalence of frailty and the subdomains of slowness, low PA, and exhaustion (all p for trends <0.05). Greater aerobic steps/day, but not total steps/day, was associated with lower incidence of developing frailty in the 241 participants with a follow-up examination who had no frailty at baseline.

CONCLUSION

Higher aerobic steps/day were more strongly associated with the lower prevalence and incidence of frailty compared to total steps/day, suggesting that faster aerobic walking may potentially provide greater benefits regarding frailty in older adults with HTN.

Sedentary behaviour in cardiovascular disease patients: Risk group identification and the impact of cardiac rehabilitation

BACKGROUND

Sedentary behaviour (SB) is potentially an important target to improve cardiovascular health. This study 1) compared SB between cardiovascular disease (CVD) patients and age-matched controls, 2) identified characteristics associated with high SB levels, and 3) determined the impact of contemporary cardiac rehabilitation (CR) on SB.

METHODS

For objective 1, we recruited 131 CVD patients and 117 controls. All participants were asked about their general characteristics and medical history. SB was assessed by an objective accelerometer (activPAL3 micro). For objective 2, 2584 CVD patients were asked to fill in a questionnaire about their general characteristics, lifestyle, medical history and their SB. For objective 3, 131 CVD patients were followed over time and measured, pre-, directly post- and 2 months post-CR.

RESULTS

Objective 1. CVD patients spent 10.4 h/day (Q25 9.5; Q75 11.2) sedentary which was higher compared to healthy controls (9.4 h/day [Q25 8.4; Q75 10.29]). Objective 2. CVD patients being male, single or divorced, employed, physically inactive, reporting high alcohol consumption, living in an urban environment, having comorbidities and cardiac anxiety demonstrated a greater odds for large amounts of SB. Objective 3. The CR program significantly reduced sedentary time (-0.4 h/day [95%CI -0.7; -0.1]), which remained lower at 2-months post-CR (-0.3 h/day [95%CI -0.6; -0.03]).

CONCLUSIONS

CVD patients had greater amounts of objectively measured sedentary time compared to healthy controls. Sedentarism was associated with personal- and lifestyle characteristics, and comorbidities. Participation in a contemporary CR program slightly reduced sedentary time, but tailored interventions are needed to target SB in CVD patients.

Assessing physical activity and function in patients with chronic kidney disease: a narrative review

Physical activity potentially improves health outcomes in patients with chronic kidney disease (CKD) and recipients of kidney transplants. Although studies have demonstrated the beneficial effects of physical activity and exercise for primary and secondary prevention of non-communicable diseases, evidence for kidney patients is limited. To enlarge this evidence, valid assessment of physical activity and exercise is essential. Furthermore, CKD is associated with a decline in physical function, which may result in severe disabilities and dependencies. Assessment of physical function may help clinicians to monitor disease progression and frailty in patients receiving dialysis. The attention on physical function and physical activity has grown and new devices have been developed and (commercially) launched on the market. Therefore the aims of this review were to summarize different measures of physical function and physical activity, provide an update on measurement instruments and discuss options for easy-to-use measurement instruments for day-to-day use by CKD patients. This review demonstrates that large variation exists in the different strategies to assess physical function and activity in clinical practice and research settings. To choose the best available method, accuracy, content, preferable outcome, necessary expertise, resources and time are important issues to consider.

Association of Cardiac Rehabilitation With All-Cause Mortality Among Patients With Cardiovascular Disease in the Netherlands

IMPORTANCE

Cardiac rehabilitation (CR) is an effective strategy to improve clinical outcomes, but it remains underused in some subgroups of patients with cardiovascular disease (CVD).

OBJECTIVE

To investigate the implications of sex, age, socioeconomic status, CVD diagnosis, cardiothoracic surgery, and comorbidity for the association between CR participation and all-cause mortality.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study with patient enrollment between July 1, 2012, and December 31, 2017, and a follow-up to March 19, 2020. The dates of analysis were March to May 2020. This study was performed among Dutch patients with CVD with a multidisciplinary outpatient CR program indication and who were insured at Coöperatie Volksgezondheidszorg, one of the largest health insurance companies in the Netherlands. Among 4.1 million beneficiaries, patients with CVD with an acute coronary event (myocardial infarction or unstable angina pectoris), stable angina pectoris, chronic heart failure, or cardiothoracic surgery (coronary artery bypass grafting, valve replacement, or percutaneous coronary intervention) were identified by inpatient diagnosis codes and included in the study.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards models were used to evaluate the association between CR participation and all-cause mortality. Stabilized inverse propensity score weighting was used to account for patient and disease characteristics associated with CR participation.

RESULTS

Among 83 687 eligible patients with CVD (mean [SD] age, 67 [12] years; 60.4% [n = 50 512] men), only 31.3% (n = 26 171) participated in CR, with large variation across different subgroups (range, 5.1%-73.0%). During a mean (SD) of 4.7 (1.8) years of follow-up, 1966 CR participants (7.5%) and 13 443 CR nonparticipants (23.4%) died. After multivariable adjustment, CR participation was associated with a 32% lower risk of all-cause mortality (adjusted hazard ratio, 0.68; 95% CI, 0.65-0.71) compared with nonparticipation. Sex, age, socioeconomic status, and comorbidity did not alter risk reduction after CR participation, but a statistically significant interaction association was found across categories of CVD diagnosis and cardiothoracic surgery. Larger reductions in risk estimates for all-cause mortality were found after CR participation for STEMI (adjusted HR, 0.59; 95% CI, 0.52-0.68 vs 0.72; 95% CI, 0.65-0.79; P < .001), NSTEMI (adjusted HR, 0.64; 95% CI, 0.58-0.70 vs 0.72; 95% CI, 0.65-0.79; P < .001), and stable AP (adjusted HR, 0.69; 95% CI, 0.63-0.76 vs 0.72; 95% CI, 0.65-0.79; P < .001) compared with patients with chronic heart failure, whereas unstable AP had a smaller risk reduction (adjusted HR, 0.75; 95% CI, 0.67-0.85 vs 0.72; 95% CI, 0.65-0.79; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, CR participation was associated with a 32% risk reduction in all-cause mortality, and this benefit was independent of sex, age, socioeconomic status, and comorbidity. These findings reinforce the importance of CR participation in secondary prevention and highlight the possibility that CR should be prescribed more widely to vulnerable patients with CVD, such as older adults with chronic diseases or multimorbidity.

Validity and reliability of subjective methods to assess sedentary behaviour in adults: a systematic review and meta-analysis

BACKGROUND

Subjective measures of sedentary behaviour (SB) (i.e. questionnaires and diaries/logs) are widely implemented, and can be useful for capturing type and context of SBs. However, little is known about comparative validity and reliability. The aim of this systematic review and meta-analysis was to: 1) identify subjective methods to assess overall, domain- and behaviour-specific SB, and 2) examine the validity and reliability of these methods.

METHODS

The databases MEDLINE, EMBASE and SPORTDiscus were searched up to March 2020. Inclusion criteria were: 1) assessment of SB, 2) evaluation of subjective measurement tools, 3) being performed in healthy adults, 4) manuscript written in English, and 5) paper was peer-reviewed. Data of validity and/or reliability measurements was extracted from included studies and a meta-analysis using random effects was performed to assess the pooled correlation coefficients of the validity.

RESULTS

The systematic search resulted in 2423 hits. After excluding duplicates and screening on title and abstract, 82 studies were included with 75 self-reported measurement tools. There was wide variability in the measurement properties and quality of the studies. The criterion validity varied between poor-to-excellent (correlation coefficient [R] range - 0.01- 0.90) with logs/diaries (R = 0.63 [95%CI 0.48-0.78]) showing higher criterion validity compared to questionnaires (R = 0.35 [95%CI 0.32-0.39]). Furthermore, correlation coefficients of single- and multiple-item questionnaires were comparable (1-item R = 0.34; 2-to-9-items R = 0.35; ≥10-items R = 0.37). The reliability of SB measures was moderate-to-good, with the quality of these studies being mostly fair-to-good.

CONCLUSION

Logs and diaries are recommended to validly and reliably assess self-reported SB. However, due to time and resources constraints, 1-item questionnaires may be preferred to subjectively assess SB in large-scale observations when showing similar validity and reliability compared to longer questionnaires.

REGISTRATION NUMBER

CRD42018105994.

Correlates of Total and domain-specific Sedentary behavior: a cross-sectional study in Dutch adults

Background

Sedentary behavior (SB) is associated with increased risks of detrimental health outcomes. Few studies have explored correlates of SB in physically active individuals. Furthermore, SB correlates may depend on settings of SB, such as occupation, transportation and leisure time sitting. This study aims to identify subject-, lifestyle- and health-related correlates for total SB and different SB domains: transportation, occupation, and leisure time.

Methods

Dutch participants were recruited between June, 2015 and December, 2016. Participant characteristics (i.e. age, sex, weight, height, marital status, education level, employment), lifestyle (sleep, smoking, alcohol consumption, physical activity) and medical history were collected via an online questionnaire. SB was assessed using the Sedentary Behavior Questionnaire and estimated for 9 different activities during weekdays and weekend days. Logistic regression was used to calculate odds ratios and 95% confidence intervals for the association between correlates and SB. Total SB was dichotomized at > 8 h/day and > 10 h/day, and being sedentary during transportation, occupation and leisure time at the 75th percentile (60 min/day, 275 min/day and 410 min/day, respectively).

Results

In total, 8471 participants (median age 55, 55% men) were included of whom 86% met the physical activity guidelines. Median SB was 9.1 h/day (Q₂₅ 6.3-Q₇₅ 12.0) during weekdays and 7.4 h/day (Q₂₅ 5.5-Q₇₅ 9.5) during weekend days. SB was most prevalent during leisure time (5.3 h/day; Q₂₅ 3.9-Q₇₅ 6.8), followed by occupation (2 h/day; Q₂₅ 0.1-Q₇₅ 4.6) and transportation (0.5 h/day; Q₂₅ 0.2-Q₇₅ 1.0). Younger age, male sex, being unmarried, higher education, employment and higher BMI were significantly related to higher levels of total SB. Younger age, male sex, employment, and higher BMI increased the odds for high SB volumes during occupation and transportation. Higher education, being unmarried and smoking status were positively associated with high volumes of occupational SB only, whereas older age, being unmarried, unemployment, higher BMI and poor health were positively linked to leisure time SB.

Conclusions

SB is highly prevalent in physically active individuals, with SB during leisure time as the most important contributor. Correlates for high volumes of SB vary substantially across SB domains, emphasizing the difficulty to target this unhealthy lifestyle.

P1513Exercise-induced cardiac troponin I release and incident cardiovascular morbidity and mortality

Background

Blood concentrations of cardiac troponin I (cTnI) above the 99th percentile (upper reference limit, URL) are a key criterion for the diagnosis of acute myocardial injury and infarction. cTnI concentrations, even below the URL, also predict adverse outcomes in general and patient populations. cTnI increases after exercise, but the clinical significance of this exercise-induced cTnI increase is unknown. We examined the association between exercise-induced cTnI elevations and clinical outcomes in long-distance walkers.

Methods

cTnI was measured in 726 participants (median 61 [54–69] yrs) before and immediately after 30–55 km of walking. The primary endpoint was a composite of all-cause mortality and major adverse cardiovascular events (MACE, i.e. myocardial infarction, stroke, heart failure, revascularization or sudden cardiac arrest).

Results

Participants walked 498 [440–555] min at 68±10% of their maximum heart rate. Baseline cTnI concentrations were 2 [0–8] ng/L, with 9 participants (1%) demonstrating a baseline cTnI value above the URL (>40 ng/L). cTnI increased after walking (8 [1–18] ng/L, p<0.001) and 63 participants (9%) had a post-exercise cTnI value >URL. During 43 [23–77] months of follow-up, 62 participants (9%) experienced a primary endpoint; 29 died and 33 had MACE. 27% of participants with post-exercise cTnI >URL experienced a primary endpoint compared to only 7% with cTnI below the URL (log-rank p<0.001). The hazard ratio was 2.35 (95% CI: 1.21–4.53) after adjusting for age, sex, cardiovascular risk factors (hypertension, hypercholesterolemia or diabetes mellitus), cardiovascular diseases (myocardial infarction, stroke or heart failure) and baseline cTnI.

Kaplan-Meier of Mortality and MACE

Conclusion

Post-exercise cTnI concentrations >URL were associated with higher all-cause mortality and MACE, independent of age, sex, presence of cardiovascular risk factors or cardiovascular diseases and baseline cTnI concentrations in a large cohort of older long-distance walkers. Exercise-induced increases in cTnI may not be a benign physiological response to exercise in all, but an early marker of future mortality and cardiovascular events.

Acknowledgement/Funding

V.L.A was supported by a grant from the Radboud Institute for Health Sciences, T.M.H.E by a Horizon 2020 grant from the European Commission

Exercise-Induced Cardiac Troponin I Increase and Incident Mortality and Cardiovascular Events

BACKGROUND

Blood concentrations of cardiac troponin above the 99^th percentile are a key criterion for the diagnosis of acute myocardial injury and infarction. Troponin concentrations, even below the 99^th percentile, predict adverse outcomes in patients and the general population. Elevated troponin concentrations are commonly observed after endurance exercise, but the clinical significance of this increase is unknown. We examined the association between postexercise troponin I concentrations and clinical outcomes in long-distance walkers.

METHODS

We measured cardiac troponin I concentrations in 725 participants (61 [54-69] yrs) before and immediately after 30 to 55 km of walking. We tested for an association between postexercise troponin I concentrations above the 99^th percentile (>0.040 µg/L) and a composite end point of all-cause mortality and major adverse cardiovascular events (myocardial infarction, stroke, heart failure, revascularization, or sudden cardiac arrest). Continuous variables were reported as mean ± standard deviation when normally distributed or median [interquartile range] when not normally distributed.

RESULTS

Participants walked 8.3 [7.3-9.3] hours at 68±10% of their maximum heart rate. Baseline troponin I concentrations were >0.040 µg/L in 9 participants (1%). Troponin I concentrations increased after walking (P<.001), with 63 participants (9%) demonstrating a postexercise troponin concentration >0.040 µg/L. During 43 [23-77] months of follow-up, 62 participants (9%) experienced an end point; 29 died and 33 had major adverse cardiovascular events. Compared with 7% with postexercise troponin I ≤0.040 µg/L (log-rank P<.001), 27% of participants with postexercise troponin I concentrations >0.040 µg/L experienced an end point. The hazard ratio was 2.48 (95% CI, 1.29-4.78) after adjusting for age, sex, cardiovascular risk factors (hypertension, hypercholesterolemia or diabetes mellitus), cardiovascular diseases (myocardial infarction, stroke, or heart failure), and baseline troponin I concentrations.

CONCLUSIONS

Exercise-induced troponin I elevations above the 99^th percentile after 30 to 55 km of walking independently predicted higher mortality and cardiovascular events in a cohort of older long-distance walkers. Exercise-induced increases in troponin may not be a benign physiological response to exercise, but an early marker of future mortality and cardiovascular events.

Association Between Statin Use and Prevalence of Exercise-Related Injuries: A Cross-Sectional Survey of Amateur Runners in the Netherlands

Background

HMG-CoA reductase inhibitors (statins) are the first-choice therapy for primary prevention of cardiovascular disease. Some maintain that statins cause adverse musculoskeletal outcomes in highly active individuals, but few studies have examined the effects of statins on exercise-related injuries.

Objective

We sought to compare the prevalence of exercise-related injuries between runners who do or do not use statins.

Methods

Amateur runners (n = 4460) completed an extensive online questionnaire on their exercise patterns and health status. Participants replied to questions on the prevalence of exercise-related injuries in the previous year. Injuries were divided into general injuries, tendon- and ligament-related injuries, and muscle-related injuries. Participants were also queried about statin use: the type of statin, statin dose, and duration of treatment. Runners were divided into statin users, non-statin users with hypercholesterolemia, and controls for analysis.

Results

The crude odds ratios (ORs) for injuries, tendon- or ligament-related injuries, and muscle-related injuries in statin users compared with controls were 1.14 (95% confidence interval [CI] 0.79–1.66), 1.10 (95% CI 0.71–1.72), and 1.15 (95% CI 0.69–1.91), respectively. After adjustment for age, sex, body mass index (BMI), and metabolic equivalent of task (MET) h/week of exercise, the ORs were 1.11 (95% CI 0.76–1.62), 1.06 (95% CI 0.68–1.66), and 0.98 (95% CI 0.58–1.64), respectively. Similar effect measures were found when comparing non-statin users with hypercholesterolemia and controls.

Conclusion

We did not find an association between statin use and the prevalence of exercise-related injuries or tendon-, ligament-, and muscle-related injuries. Runners receiving statins should continue normal physical activity without concern for increased risk of injuries.

Absence of Fitness Improvement Is Associated with Outcomes in Heart Failure Patients

PURPOSE

This study aimed to examine the clinical effect of cardiorespiratory fitness (CRF) and improvements in CRF after cardiac rehabilitation (CR) in heart failure (HF) patients for their risk for all-cause mortality and unplanned hospitalization and to investigate possible factors associated with the absence of improvement in CRF after rehabilitation.

METHODS

We included 155 HF patients receiving CR between October 2009 and January 2015. Patients performed an incremental bicycle test to assess CRF through peak oxygen uptake (V˙O2-peak) before and after CR-based supervised exercise training. Patients were classified as responders or nonresponders on the basis of pre-to-post CR changes in V˙O2-peak (≥6% and <6%, respectively). Cox proportional hazards models evaluated all-cause mortality and unplanned hospitalization during 5 yr of follow-up. Patient characteristics, HF features, and comorbidities were used to predict changes in V˙O2-peak using logistic regression analysis.

RESULTS

Seventy HF patients (45%) were classified as responder. Nonresponders had a significantly higher risk for all-cause mortality or hospitalization (hazard ratio, 2.15; 95% confidence interval (CI), 1.17-3.94) compared with responders. This was even higher in nonresponders with low CRF at baseline (hazard ratio, 4.88; 95% CI, 1.71-13.93). Factors associated with nonresponse to CR were age (odds ratio (OR), 1.07/yr; 95% CI, 1.03-1.11), baseline V˙O2-peak (OR, 1.16 mL·min·kg; 95% CI, 1.06-1.26), and adherence to CR (OR, 0.98/percentage; 95% CI, 0.96-0.998).

CONCLUSIONS

Independent from baseline CRF, the inability to improve V˙O2-peak by CR doubled the risk for death or unplanned hospitalization. The combination of lower baseline CRF and nonresponse was associated with even poorer clinical outcomes. Especially older HF patients with higher baseline V˙O2-peak and lower adherence have a higher probability of becoming a nonresponder.

Association of Resistance Exercise With the Incidence of Hypercholesterolemia in Men

OBJECTIVE

To examine the associations of resistance exercise, independent of and combined with aerobic exercise, with the risk of development of hypercholesterolemia in men.

PATIENTS AND METHODS

This study used data from the Aerobics Center Longitudinal Study, which is a cohort examining the associations of clinical and lifestyle factors with the development of chronic diseases and mortality. Participants received extensive preventive medical examinations at the Cooper Clinic in Dallas, Texas, between January 1, 1987, and December 31, 2006. A total of 7317 men aged 18 to 83 years (mean age, 46 years) without hypercholesterolemia at baseline were included. Frequency (times per week) and total amount (min/wk) of resistance and aerobic exercise were determined by self-report. Hypercholesterolemia was defined as a total cholesterol level of 240 mg/dL or higher or physician diagnosis.

RESULTS

During a median (interquartile range) follow-up of 4 (2 to 7) years, hypercholesterolemia developed in 1430 of the 7317 men (20%). Individuals meeting the resistance exercise guidelines (≥2 d/wk) had a 13% lower risk of development of hypercholesterolemia (hazard ratio [HR], 0.87; 95% CI, 0.76-0.99; P=.04) after adjustment for general characteristics, lifestyle factors, and aerobic exercise. In addition, less than 1 h/wk and 2 sessions per week of resistance exercise were associated with 32% and 31% lower risks of hypercholesterolemia (HR, 0.68; 95% CI, 0.54-0.86; P=.001; and HR, 0.69; 95% CI, 0.54-0.88; P=.003), respectively, compared with no resistance exercise. Higher levels of resistance exercise did not provide benefits. Meeting both resistance and aerobic exercise guidelines (≥500 metabolic equivalent task min/wk) lowered the risk of development of hypercholesterolemia by 21% (HR, 0.79; 95% CI, 0.68-0.91; P=.002). compared with meeting none of the guidelines.

CONCLUSION

Compared with no resistance exercise, less than 1 h/wk of resistance exercise, independent of aerobic exercise, is associated with a significantly lower risk of development of hypercholesterolemia in men (P=.001). However, the lowest risk of hypercholesterolemia was found at 58 min/wk of resistance exercise. This finding suggests that resistance exercise should be encouraged to prevent hypercholesterolemia in men. However, future studies with a more rigorous analysis including major potential confounders (eg, diet, medications) are warranted.

Association of Resistance Exercise, Independent of and Combined With Aerobic Exercise, With the Incidence of Metabolic Syndrome

OBJECTIVE

To determine the association of resistance exercise, independent of and combined with aerobic exercise, with the risk of development of metabolic syndrome (MetS).

PATIENTS AND METHODS

The study cohort included adults (mean ± SD age, 46±9.5 years) who received comprehensive medical examinations at the Cooper Clinic in Dallas, Texas, between January 1, 1987, and December, 31, 2006. Exercise was assessed by self-reported frequency and minutes per week of resistance and aerobic exercise and meeting the US Physical Activity Guidelines (resistance exercise ≥2 d/wk; aerobic exercise ≥500 metabolic equivalent min/wk) at baseline. The incidence of MetS was based on the National Cholesterol Education Program Adult Treatment Panel III criteria. We used Cox regression to generate hazard ratios (HRs) and 95% CIs.

RESULTS

Among 7418 participants, 1147 (15%) had development of MetS during a median follow-up of 4 years (maximum, 19 years; minimum, 0.1 year). Meeting the resistance exercise guidelines was associated with a 17% lower risk of MetS (HR, 0.83; 95% CI, 0.73-0.96; P=.009) after adjusting for potential confounders and aerobic exercise. Further, less than 1 hour of weekly resistance exercise was associated with 29% lower risk of development of MetS (HR, 0.71; 95% CI, 0.56-0.89; P=.003) compared with no resistance exercise. However, larger amounts of resistance exercise did not provide further benefits. Individuals meeting both recommended resistance and aerobic exercise guidelines had a 25% lower risk of development of MetS (HR, 0.75; 95% CI, 0.63-0.89; P<.001) compared with meeting neither guideline.

CONCLUSION

Participating in resistance exercise, even less than 1 hour per week, was associated with a lower risk of development of MetS, independent of aerobic exercise. Health professionals should recommend that patients perform resistance exercise along with aerobic exercise to reduce MetS.

Lifelong Exercise Patterns and Cardiovascular Health

OBJECTIVE

To determine the relationship between lifelong exercise dose and the prevalence of cardiovascular morbidity.

PATIENTS AND METHODS

From June 1, 2011, through December 31, 2014, 21,266 individuals completed an online questionnaire regarding their lifelong exercise patterns and cardiovascular health status. Cardiovascular disease (CVD) was defined as a diagnosis of myocardial infarction, stroke, or heart failure, and cardiovascular risk factors (CVRFs) were defined as hypertension, hypercholesterolemia, or type 2 diabetes. Lifelong exercise patterns were measured over a median of 32 years for 405 patients with CVD, 1379 patients with CVRFs, and 10,656 controls. Participants were categorized into nonexercisers and quintiles (Q1-Q5) of exercise dose (metabolic equivalent task [MET] minutes per week).

RESULTS

The CVD/CVRF prevalence was lower for each exercise quintile compared with nonexercisers (CVD: nonexercisers, 9.6% vs Q1: 4.4%, Q2: 2.8%, Q3: 2.4%, Q4: 3.6%, Q5: 3.9%; P<.001; CVRF: nonexercisers, 24.6% vs Q1: 13.8%, Q2: 10.2%, Q3: 9.0%, Q4: 9.4%, Q5: 12.0%; P<.001). The lowest exercise dose (Q1) significantly reduced CVD and CVRF prevalence, but the largest reductions were found at 764 to 1091 MET-min/wk for CVD (adjusted odds ratio=0.31; 95% CI, 0.20-0.48) and CVRFs (adjusted odds ratio=0.36; 95% CI, 0.28-0.47). The CVD/CVRF prevalence did not further decrease in higher exercise dose groups. Exercise intensity did not influence the relationship between exercise patterns and CVD or CVRFs.

CONCLUSION

These findings demonstrate a curvilinear relationship between lifelong exercise patterns and cardiovascular morbidity. Low exercise doses can effectively reduce CVD/CVRF prevalence, but engagement in exercise for 764 to 1091 MET-min/wk is associated with the lowest CVD/CVRF prevalence. Higher exercise doses do not yield additional benefits.

[Patients on the move: validated methods to quantify physical activity]

Physical activity is an important component in the maintenance and improvement of general health; physical inactivity is, however, an increasing problem in the Netherlands. Requests for advice on physical activity are increasing within the healthcare. Assessment of an individual's physical activity pattern is required to provide tailored advice. There are a number of methods for measuring physical activity; these are divided into subjective and objective methods. Subjective measures include physical activity questionnaires and diaries. Objective measures include indirect calorimetry, measurement with doubly labelled water, heart-rate monitoring and the use of an accelerometer or pedometer. The choice of method depends predominantly on the aim of the measurement, and the availability of personnel, time and financial resources. In clinical practice a validated questionnaire is usually the preferred method, but when measuring effects this should be combined with an objective measurement instrument.

On-line NIR analysis of fat, water and protein in industrial scale ground meat batches

Fat, water and protein contents in industrial scale meat batches were determined on-line by near infrared (NIR) reflectance spectroscopy. The NIR instrument was mounted at the outlet of a large meat grinder, and the measurements were performed in an industrial environment. Beef and pork samples, with chemical compositions of 7-26% fat, 58-75% water and 15-21% protein, were processed with hole diameters of 13mm in the grinder plate. Calibrations were made both for a combined set of beef and pork samples, and for separate sets of beef and pork samples. Validations were either done by full cross validation of the calibration set, or by bias corrected prediction of a test set. Prediction errors for the two sample sets, expressed as root mean square errors of cross validation or standard error of prediction, were in the ranges 0.82-1.49% fat, 0.94-1.33% water and 0.35-0.70% protein, depending of sample set and species of animal. The presented application is an improvement to the existing manual meat standardisation procedure, and has been implemented for regular use in a Norwegian meat manufacturing plant.