Combining Web-Based Gamification and Physical Nudges With an App (MoveMore) to Promote Walking Breaks and Reduce Sedentary Behavior of Office Workers: Field Study.

BACKGROUND: Sedentary behavior (SB) and lack of physical activity (PA) have been associated with poorer health outcomes and are increasingly prevalent in individuals working in sedentary occupations such as office jobs. Gamification and nudges have attracted attention as promising strategies to promote changes in health behavior. However, most effectiveness studies thus far lacked active controls, and few studies have tested interventions combining these strategies. OBJECTIVE: This study investigates the effectiveness of combining a gamified digital app with physical nudges to increase PA and reduce SB in Dutch office workers. METHODS: Employees in the municipality of Rotterdam (N=298) from two office locations were randomized at the location level to either a 10-week intervention, combining a 5-week gamification phase encompassing a gamified digital app with social support features and a 5-week physical nudges phase, or to an active control (ie, basic digital app with self-monitoring and goal setting). The primary outcome was the daily step count, objectively measured via accelerometers. Secondary outcomes were self-reported PA and SB measured at baseline and at 5, 10, and 14 weeks. Mixed effects models were used to analyze the effects of the intervention on the outcome measures. RESULTS: A total of 78.5% (234/298) of participants completed the study and provided accelerometer data, whereas 36.9% (110/298) participants completed the self-report measures at 14 weeks. In the gamification phase, step count data were missing for 13.5% (473/3492) of observations in the control and 11.4% (445/3888) in the intervention condition; however, these percentages increased to 39.6% (1154/2910) and 59.6% (1932/3492) at follow-up, respectively. During the gamification phase, intervention participants increased their number of daily steps by 634 (95% CI 154.2-1113.8; P=.01) more than participants in the control group, after controlling for relevant factors. Improvements were not sustained during the physical nudges phase (P=.76) or follow-up (P=.88). CONCLUSIONS: A digital intervention with gamification and social support features significantly increased the step count of office workers compared with an active control. Physical nudges in the workplace were insufficient to promote the maintenance of behavioral changes achieved in the gamification phase. Future research should explore the long-term effectiveness of similar gamified digital interventions. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 49129401; https://www.isrctn.com/ISRCTN14881571.

The BeHealthyR Study: a randomized trial of a multicomponent intervention to reduce stress, smoking and improve financial health of low-income residents in Rotterdam.

BACKGROUND: Compared to higher socioeconomic status (SES) groups, those in lower SES groups are financially strained, experience higher rates of smoking-related morbidity, are in poorer health and have reduced life expectancy. This is especially true for the city of Rotterdam, where a large inequality in health is observed between low and high SES groups. The BeHealthyR study (Dutch: Grip en Gezondheid) is a randomized controlled trial (RCT) which will evaluate the impact of a theory-based multicomponent behavior intervention aiming to reduce stress, smoking, and improve financial health by means of a group-based stress management program combining cognitive and behavioral techniques, and nudges in low-SES residents living in Rotterdam. METHODS: The BeHealthyR study is a three-arm RCT. Between February 2018 and July 2019, low-SES participants who perceive stress, smoke, are financially strained and reside in Rotterdam (one of the four largest cities in The Netherlands) are recruited. Subsequently, participants are randomly assigned to either a stress management condition (SM), stress management with a buddy condition (SM-B) or a control condition (CC). Participants in the SM and SM-B conditions will attend four weekly group sessions (1.5 h/session) and a follow-up session eight weeks later. The SM condition includes psychoeducation and exercises, and cognitive and behavioral intervention techniques. Demographic data and objective measures will be collected at baseline (T0), four weeks post-baseline (T1), and twelve weeks post-baseline (T2). Primary outcome measures are to reduce stress, smoking and improve financial health. We hypothesize that low-SES participants in the intervention conditions, compared with those in the control condition, will experience less stress, smoke less and have improved financial health. DISCUSSION: This study is a group-based intervention which aims to investigate the effects of a theory-based behavioral change intervention employing several components on reducing stress, smoking, and improving financial health in low-SES residents living in Rotterdam. If effective, the findings from the present study will serve to inform future directions of research and clinical practice with regard to behavioral change interventions for low-SES groups. TRIAL REGISTRATION: ClinicalTrials.gov (ID: NCT03553979 ). Registered on January 1 2018.

Residential area characteristics and disabilities among Dutch community-dwelling older adults.

BACKGROUND: Living longer independently may be facilitated by an attractive and safe residential area, which stimulates physical activity. We studied the association between area characteristics and disabilities and whether this association is mediated by transport-related physical activity (TPA). METHODS: Longitudinal data of 271 Dutch community-dwelling adults aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study in 2011-2013 were used. Associations between objectively measured aesthetics (range 0-22), functional features (range 0-14), safety (range 0-16), and destinations (range 0-15) within road network buffers surrounding participants' residences, and self-reported disabilities in instrumental activities of daily living (range 0-8; measured twice over a 9 months period) were investigated by using longitudinal tobit regression analyses. Furthermore, it was investigated whether self-reported TPA mediated associations between area characteristics and disabilities. RESULTS: A one unit increase in aesthetics within the 400 m buffer was associated with 0.86 less disabilities (95% CI -1.47 to -0.25; p < 0.05), but other area characteristics were not related to disabilities. An increase in area aesthetics was associated with more TPA, and more minutes of TPA were associated with less disabilities. TPA however, only partly mediated the associated between area aesthetics and disabilities. CONCLUSIONS: Improving aesthetic features in the close by area around older persons' residences may help to prevent disability.

The role of high-intensity physical exercise in the prevention of disability among community-dwelling older people.

BACKGROUND: Moderate to vigorous physical activity (MVPA) is considered important to prevent disability among community-dwelling older people. To develop MVPA programs aimed at reducing or preventing disability more insight is needed in the contributions of exercise duration and intensity and the interplay between the two. METHODS: Longitudinal data of 276 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study were used. MVPA exercise (yes/no), duration (hours per two weeks), intensity (Metabolic Equivalent of Task; METs), and energy expenditure (MET-hours per two weeks), and disability in instrumental activities of daily living (range 0-8) were measured twice within 9 months to account for fluctuations over time. Associations between the four exercise measures and disability were tested with longitudinal tobit regression analyses. RESULTS: MVPA exercise was associated with fewer disabilities. While exercise duration was not associated with disability, whereas an increase of one MET in exercise intensity was associated with 0.14 fewer disabilities (95 % CI: -0.26 to -0.02). For exercise energy expenditure, an increase of one MET-hour exercise per two weeks was associated with 0.03 fewer disabilities (95 % CI: -0.05 to -0.01). CONCLUSIONS: Higher-intensity exercise may help to prevent disability among community-dwelling older people. Further investigation is needed to explore the preventive effects in more detail.

Do lifestyle, health and social participation mediate educational inequalities in frailty worsening?

BACKGROUND: Lower educated older persons are at increased risk of becoming frail as compared with higher educated older persons. To reduce educational inequalities in the development of frailty, we investigated whether lifestyle, health and social participation mediate this relationship. METHODS: Longitudinal data of 14 082 European community-dwelling persons aged 55 years and older participating in the Survey on Health, Ageing, and Retirement in Europe (SHARE) in 2004 and 2006, were used. Associations of lifestyle (smoking behaviour and alcohol consumption), health (depression, memory function, chronic diseases) and social participation, with educational level and frailty worsening were investigated using regression models. In multinomial logistic regression analysis, mediators were added to models in which educational level was associated with worsening in frailty over 2 years follow-up. RESULTS: In all countries, frailty worsening was more prevalent among lower as compared with higher educated persons, although odds ratios were only statistically significant in five of the 11 countries included [ORs varying from 1.40 (95% CI: 1.06-1.84) to 1.61 (95% CI: 1.21-2.14)]. Except for smoking behaviour and memory function, the factors under study all showed associations with educational level and frailty worsening that met the conditions for mediation. After inclusion of the four relevant mediators, attenuation of odds ratios varied between 4.9 and 31.5%. CONCLUSION: While lifestyle, health and social participation were associated with frailty worsening over 2 years among European community-dwelling older persons, only small to moderate parts of educational inequalities in frailty worsening were explained by these factors.

Characteristics of residential areas and transportational walking among frail and non-frail Dutch elderly: does the size of the area matter?

BACKGROUND: A residential area supportive for walking may facilitate elderly to live longer independently. However, current evidence on area characteristics potentially important for walking among older persons is mixed. This study hypothesized that the importance of area characteristics for transportational walking depends on the size of the area characteristics measured, and older person's frailty level. METHODS: The study population consisted of 408 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighborhood (ELANE) study in 2011-2012. Characteristics (aesthetics, functional features, safety, and destinations) of areas surrounding participants' residences ranging from a buffer of 400 meters up to 1600 meters (based on walking path networks) were linked with self-reported transportational walking using linear regression analyses. In addition, interaction effects between frailty level and area characteristics were tested. RESULTS: An increase in functional features (e.g. presence of sidewalks and benches) within a 400 meter buffer, in aesthetics (e.g. absence of litter and graffiti) within 800 and 1200 meter buffers, and an increase of one destination per buffer of 400 and 800 meters were associated with more transportational walking, up to 2.89 minutes per two weeks (CI 1.07-7.32; p < 0.05). No differences were found between frail and non-frail elderly. CONCLUSIONS: Better functional and aesthetic features, and more destinations in the residential area of community-dwelling older persons were associated with more transportational walking. The importance of area characteristics for transportational walking differs by area size, but not by frailty level. Neighbourhood improvements may increase transportational walking among older persons, thereby contributing to living longer independently.

Participation levels of physical activity programs for community-dwelling older adults: a systematic review.

BACKGROUND: Although many physical activity (PA) programs have been implemented and tested for effectiveness, high participation levels are needed in order to achieve public health impact. This study aimed to determine participation levels of PA programs aimed to improve PA among community-dwelling older adults. METHODS: We searched five databases up until March 2013 (PubMed, PubMed publisher, Cochrane Library, EMBASE, and Web of Science) to identify English-written studies investigating the effect of PA programs on at least one component of PA (e.g. frequency, duration) among community-dwelling populations (i.e. not in a primary care setting and/or assisted living or nursing home) of persons aged 55 years and older. Proportions of participants starting and completing the PA programs (initial and sustained participation, respectively) were determined. RESULTS: The search strategy yielded 11,994 records of which 16 studies were included reporting on 17 PA programs. The number of participants enrolled in the PA programs ranged between 24 and 582 persons. For 12 PA programs it was not possible to calculate initial participation because the number of older adults invited to participate was unknown due to convenience sampling. Of the five remaining programs, mean initial participation level was 9.2% (±5.7%). Mean sustained participation level of all 17 programs was 79.8% (±13.2%). CONCLUSIONS: Understanding how to optimize initial participation of older adults in PA programs deserves more attention in order to improve the population impact of PA programs for community-dwelling older adults.

Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure).

BACKGROUND: up till now, the risk of falls has been expressed as falls incidence (i.e. the number of falls or fallers per 100 person-years). However, the risk of an accident or injury is the probability of having an accident or injury per unit of exposure. The FARE (Falls risk by Exposure) is a measure for falls risk which incorporates physical activity as a measure of exposure. The objective of this study was to compare falls incidence and the FARE when expressing the age-related risk of fall-related injuries. METHODS: data of 21,020 community-dwelling elderly aged ≥55 years (60.3% women) obtained from a national survey (2000-05) were used to compare incidence of fall-related injuries and the FARE. In order to compare both measures, risk ratios (of both outcome measures) were calculated for each age group. Hierarchical regression analyses (linear versus exponential model) were conducted to check the best model fit when expressing falls risk by age for the total study population and for men and women separately. RESULTS: the risk of fall-related injuries, calculated on the basis of the incidence of fall-related injuries, showed a linear relationship with age, whereas the risk calculated on the basis of fall-related injuries corrected for exposure (falls risk by exposure, FARE) showed an exponential relationship. Calculations on the basis of the incidence of fall-related injuries underestimated the risk of fall-related injuries in people aged 70 years and older, and especially in women. CONCLUSION: calculation of the risk of fall-related injuries based on the incidence of these injuries underestimates the risk of such injuries relative to that calculated on the basis of the FARE. FARE-based calculations enable the early identification of people at high risk of falls and provide a more sensitive outcome measure for studies evaluating falls prevention interventions.

Socioeconomic inequalities in frailty among older adults in six low- and middle-income countries: Results from the WHO Study on global AGEing and adult health (SAGE).

OBJECTIVES: The aim of this study was to investigate socioeconomic inequalities in frailty among older adults in six low- and middle-income countries (LMICs), and to examine to what extent chronic diseases account for these inequalities. STUDY DESIGN: Data were used from the Study on global AGEing and adult health (SAGE) wave 1 (2007-2010). Nationally representative samples of adults aged 50+ years from China, Ghana, India, Mexico, the Russian Federation and South Africa were analyzed (n = 31,174). MAIN OUTCOME MEASURES: Educational level and wealth were used as socioeconomic indicators. Frailty was assessed with modified criteria for the frailty phenotype. Self-reported disease diagnoses were used. A relative index of inequality (RII) was calculated to compare socioeconomic inequalities in frailty between countries. RESULTS: People in lower socioeconomic positions had higher prevalence rates of frailty. The largest inequalities in frailty were found in Mexico (RII 3.7, 95% CI 2.1-6.4), and the smallest inequalities in Ghana (RII 1.1, 95% CI 0.7-1.8). Mediation analyses revealed that the chronic diseases considered in this study do not explain the higher prevalence of frailty seen in lower socioeconomic groups. CONCLUSIONS: Substantial socioeconomic inequalities in frailty were observed in LMICs, but additional research is needed to find explanations for these. Given that the population of older adults in many LMICs is expanding at a greater rate than in many high-income countries, our results indicate an urgent public health need to address frailty in these countries.

Physical activity in non-frail and frail older adults.

INTRODUCTION: Physical activity (PA) is important for healthy ageing. Better insight into objectively measured PA levels in older adults is needed, since most previous studies employed self-report measures for PA assessment, which are associated with overestimation of PA. AIM: This study aimed to provide insight in objectively measured indoor and outdoor PA of older adults, and in PA differences by frailty levels. METHODS: Data were collected among non-frail (N = 74) and frail (N = 10) subjects, aged 65 to 89 years. PA, measured for seven days with accelerometers and GPS-devices, was categorized into three levels of intensity (sedentary, light, and moderate-to-vigorous PA). RESULTS: Older adults spent most time in sedentary and light PA. Subjects spent 84.7%, 15.1% and 0.2% per day in sedentary, light and moderate-to-vigorous PA respectively. On average, older adults spent 9.8 (SD 23.7) minutes per week in moderate-to-vigorous activity, and 747.0 (SD 389.6) minutes per week in light activity. None of the subjects met the WHO recommendations of 150 weekly minutes of moderate-to-vigorous PA. Age-, sex- and health status-adjusted results revealed no differences in PA between non-frail and frail older adults. Subjects spent significantly more sedentary time at home, than not at home. Non-frail subjects spent significantly more time not at home during moderate-to-vigorous activities, than at home. CONCLUSIONS: Objective assessment of PA in older adults revealed that most PA was of light intensity, and time spent in moderate-to-vigorous PA was very low. None of the older adults met the World Health Organization recommendations for PA. These levels of MVPA are much lower than generally reported based on self-reported PA. Future studies should employ objective methods, and age specific thresholds for healthy PA levels in older adults are needed. These results emphasize the need for effective strategies for healthy PA levels for the growing proportion of older adults.

Socio-demographic determinants of worsening in frailty among community-dwelling older people in 11 European countries.

BACKGROUND: The rapid increase of frail older people worldwide will have a substantial impact on healthcare systems. The frailty process may be delayed or even reversed, which makes it attractive for early interventions. However, little is known about the determinants of frailty state changes. The aim of this study is to compare socio-demographic determinants of worsening in frailty state in 11 European countries. METHODS: Data of 14,424 community-dwelling persons aged ≥55 years, enrolled in 2004 in the Survey of Health, Ageing and Retirement in Europe, were analysed. Three frailty states were identified (non-frail, pre-frail and frail) using Fried's criteria, and frailty state changes over a 2-year period were determined. Multinomial regression analyses adjusted for baseline frailty state were conducted to investigate whether sex, age, marital status and level of education determined a worsening in frailty state in the total and country-specific European population. RESULTS: Of all individuals, 22.1% worsened, 61.8% showed no change and 16.1% improved in frailty state. Women, those aged ≥65 years, and lower educated persons showed an increased risk of worsening in frailty state. In Southern European countries, there was an earlier and larger increase in risk of worsening in frailty state in life, which was more pronounced in women compared with men. CONCLUSIONS: In Europe, persons aged ≥65 years, women and lower educated persons are at increased risk of worsening in frailty state. Differences between countries indicate that interventions aimed at delaying the frailty process in Southern European countries should start earlier with more attention towards women.