Use of a toolbox of tailored evidence-based interventions to improve children's physical activity and cardiorespiratory fitness in primary schools: results of the ACTIPROS cluster-randomized feasibility trial.

BACKGROUND: School-based physical activity (PA) promotion is usually conducted by providing one specific intervention. In contrast, the ACTIvity PROmotion via Schools (ACTIPROS) toolbox provides a set of twelve evidence-based PA interventions serving different domains of the Health Promoting Schools framework that primary schools can select according to their requirements. In this study, we tested the feasibility of the toolbox approach in primary schools. METHODS: A two-arm cluster-randomized feasibility trial at primary schools (n = 5 intervention schools [IS], n = 5 control schools) located in the Federal State of Bremen, Germany, was conducted. Children's habitual PA (GENEActiv, Activinsights Ltd.) and motor skills (Deutscher Motorik Test; DMT) were measured at the beginning (t0: Sept and Oct 2021) and at the end of the school year (t1: June and July 2022). Between Oct 2021 and July 2022, the ACTIPROS toolbox was implemented at IS. Teachers documented intervention choices and implementation within a short questionnaire (SIQ) at t1. RESULTS: IS successfully implemented at least one intervention of the toolbox. In total, seven out of twelve possible interventions were selected. Two schools decided to replace an intervention with another during the trial. Results of the SIQ indicated that IS tended to choose similar interventions while implementation frequency was highly different. N = 429 students from two classes per school were recruited. The mean consent rate was 75.1% (n = 322). At t0 and t1, n = 304 (94.4%) and n = 256 (79.3%) of consented children took part in the DMT, respectively. The accelerometry sample included one class per participating school. At t0 and t1, n = 166 and n = 151 devices were handed out to students and n = 133 (80.1%) and n = 106 (70.2%) valid records could be retrieved, respectively. Linear mixed models showed an intervention effect of 15.5 min (95% CI: 4.5; 26.6) in children's daily MVPA at IS between t0 and t1 compared to controls. CONCLUSIONS: All IS were able to implement at least one intervention from the toolbox, and unsuitable interventions were successfully replaced in a timely manner, highlighting the feasibility of implementing the ACTIPROS toolbox. Good consent rates for accelerometer and motor skills data were achieved. Results indicate a substantial increase in MVPA associated with the ACTIPROS toolbox and need to be tested in a larger sample. TRIAL REGISTRATION: German Clinical Trials Register DRKS00025840.

Examining supporting and constraining factors of physicians' acceptance of telemedical online consultations: a survey study.

As healthcare demands exceed outpatient physicians' capacities, telemedicine holds far-reaching potential for both physicians and patients. It is crucial to holistically analyze physicians' acceptance of telemedical applications, such as online consultations. This study seeks to identify supporting and constraining factors that influence outpatient physicians' acceptance of telemedicine.We develop a model based on the unified theory of acceptance and use of technology (UTAUT). To empirically examine our research model, we conducted a survey among German physicians (n = 127) in 2018-2019. We used the partial least squares (PLS) modeling approach to test our model, including a mediation analysis. The results indicate that performance expectancy (ß = .397, P < .001), effort expectancy (ß = .134, P = .03), and social influence (ß = .337, P < .001) strongly impact the intention to conduct online consultations and explain 55% of its variance. Structural conditions regarding data security comprise a key antecedent, associating with performance expectancy (ß = .193, P < .001) and effort expectancy (ß = .295, P < .001). Regarding potential barriers to usage intentions, we find that IT anxiety predicts performance (ß = -.342, P < .001) and effort expectancy (ß = -.364, P < .001), while performance expectancy fully mediates (ßdirect = .022, P = .71; ßindirect = -.138, P < .001) the direct relationship between IT anxiety and the intention to use telemedical applications.This research provides explanations for physicians' behavioral intention to use online consultations, underlining UTAUT's applicability in healthcare contexts. To boost acceptance, social influences, such as personal connections and networking are vital, as colleagues can serve as multipliers to reach convergence on online consultations among peers. To overcome physicians' IT anxiety, training, demonstrations, knowledge sharing, and management incentives are recommended. Furthermore, regulations and standards to build trust in the compliance of online consultations with data protection guidelines need reinforcement from policymakers and hospital management alike.

Improving cardiorespiratory fitness protects against inflammation in children: the IDEFICS study.

BACKGROUND: Muscular and cardiorespiratory fitness (MF and CRF) have been related to inflammation. Thus, the aim of this study was to assess the relationship between fitness and high-sensitivity C-reactive protein (hs-CRP) in European children both in the cross-sectional and longitudinal analysis. METHODS: Three hundred and fifty-seven children (46.2% males) aged 2-9 years with hs-CRP measured, data from MF and CRF, diet quality, objectively measured physical activity (PA) and screen time at baseline and follow-up after 2 years were included. Body mass index z-score (zBMI), waist circumference (WC) and fat mass index (FMI) were assessed. MF and CRF were also dichotomized as follows: low-medium quartiles (Q1-Q3) and highest quartile (Q4). RESULTS: At follow-up, children with the highest CRF (Q4) showed a lower probability of having high hs-CRP. In the longitudinal analysis, children who improved their CRF over time showed a significantly lower probability (p < 0.05) of being in the highest hs-CRP category at follow-up, independently of the body composition index considered: odds ratio (OR) = 0.22 for zBMI, OR = 0.17 for WC, and OR = 0.21 for FMI. CONCLUSIONS: Improving CRF during childhood reduces the odds of an inflammatory profile, independently of body composition and lifestyle behaviours. These highlight the importance of enhancing fitness, especially CRF, to avoid an inflammatory state in children. IMPACT: Improvements in the cardiorespiratory profile during childhood could reverse an unfavourable inflammatory status. There is a longitudinal and inverse association between CRF and inflammation in children. This is the first longitudinal study assessing the relationship between fitness and inflammation during childhood that takes also into account the lifestyle behaviours. Results from the present study suggest a protective role of fitness already in childhood. Efforts to improve fitness in children should be aimed at as inflammation could trigger future cardiovascular disease.

Longitudinal association of childhood physical activity and physical fitness with physical activity in adolescence: insights from the IDEFICS/I.Family study.

BACKGROUND: This study aimed to examine associations of early childhood physical fitness and physical activity (PA) with PA during later childhood/early adolescence while accounting for gender differences. METHODS: We selected data of N = 4329 children from the IDEFICS/I. Family cohort (age 2.4-11.7 years) with data on baseline fitness and accelerometer measurements. At baseline, physical fitness tests were conducted including Flamingo balance, Backsaver sit and reach, Handgrip strength, Standing Long Jump, 40-m sprint and 20-m Shuttle run (to estimate cardio-respiratory fitness levels). PA was measured with Actigraph accelerometers over 3 days at baseline (ActiTrainer or GT1M) and 7 days at follow-up (GT3X). Evenson cutpoints were used to determine moderate-to-vigorous PA (MVPA) time, and children with ≥60mins/day of average MVPA were deemed as having met WHO guidelines at baseline and follow-up. Linear and logistic regressions were performed to examine longitudinal associations between meeting WHO guidelines, MVPA, and physical fitness tests at baseline with meeting WHO guidelines and MVPA at follow-up. Models were conducted on the entire sample, the sex-stratified sample, and stratified by sex and pubertal status at follow-up. RESULTS: Results showed that meeting WHO guidelines for MVPA at baseline was positively associated with MVPA (Standardized Beta (B) = 0.13, 95%CI:(5.6;11.1)) and meeting WHO guidelines at follow-up for the entire sample (OR = 2.1, 95%CI:(1.5; 3.14), and stratified by males (OR = 2.5, 95%CI:(1.5; 4.1)) and females (OR = 1.8, 95%CI:(1.0; 3.2)). This was also found for both male pre/early pubertal and pubertal groups but only in the female pre/early pubertal group, and not the female pubertal group (MVPA: B = .00, 95%CI:(- 6.1; 5.6), WHO: OR = 0.61, 95%CI:(0.23;1.6)). Models indicated that Standing Long jump, 40-m sprint, Shuttle run and Flamingo balance at baseline were associated with MVPA and meeting the guidelines at follow-up. CONCLUSIONS: Meeting WHO guidelines and certain fitness tests at baseline were strongly associated with MVPA and meeting WHO guidelines at follow-up, but this association varied with sex and pubertal status. Consequently, these findings underline the importance of ensuring sufficient physical activity in terms of quality and quantity for children at the earliest stages of life. TRIAL REGISTRATION: ISRCTN62310987.

General Practitioners' Attitudes Toward Artificial Intelligence-Enabled Systems: Interview Study.

BACKGROUND: General practitioners (GPs) care for a large number of patients with various diseases in very short timeframes under high uncertainty. Thus, systems enabled by artificial intelligence (AI) are promising and time-saving solutions that may increase the quality of care. OBJECTIVE: This study aims to understand GPs' attitudes toward AI-enabled systems in medical diagnosis. METHODS: We interviewed 18 GPs from Germany between March 2020 and May 2020 to identify determinants of GPs' attitudes toward AI-based systems in diagnosis. By analyzing the interview transcripts, we identified 307 open codes, which we then further structured to derive relevant attitude determinants. RESULTS: We merged the open codes into 21 concepts and finally into five categories: concerns, expectations, environmental influences, individual characteristics, and minimum requirements of AI-enabled systems. Concerns included all doubts and fears of the participants regarding AI-enabled systems. Expectations reflected GPs' thoughts and beliefs about expected benefits and limitations of AI-enabled systems in terms of GP care. Environmental influences included influences resulting from an evolving working environment, key stakeholders' perspectives and opinions, the available information technology hardware and software resources, and the media environment. Individual characteristics were determinants that describe a physician as a person, including character traits, demographic characteristics, and knowledge. In addition, the interviews also revealed the minimum requirements of AI-enabled systems, which were preconditions that must be met for GPs to contemplate using AI-enabled systems. Moreover, we identified relationships among these categories, which we conflate in our proposed model. CONCLUSIONS: This study provides a thorough understanding of the perspective of future users of AI-enabled systems in primary care and lays the foundation for successful market penetration. We contribute to the research stream of analyzing and designing AI-enabled systems and the literature on attitudes toward technology and practice by fostering the understanding of GPs and their attitudes toward such systems. Our findings provide relevant information to technology developers, policymakers, and stakeholder institutions of GP care.

High-intensity activity is more strongly associated with metabolic health in children compared to sedentary time: a cross-sectional study of the I.Family cohort.

BACKGROUND: Physical activity (PA) during childhood is important for preventing future metabolic syndrome (MetS). To examine the relationship between PA and MetS in more detail, accurate measures of PA are needed. Previous studies have only utilized a small part of the information available from accelerometer measured PA. This study investigated the association between measured PA and MetS in children with a new method for data processing and analyses that enable more detailed interpretation of PA intensity level. METHODS: The association between PA pattern and risk factors related to MetS was investigated in a cross- sectional sample of children (n = 2592, mean age 10.9 years, 49.4% male) participating in the European multicenter I. Family study. The risk factors examined include body mass index, blood pressure, high-density lipoprotein cholesterol, insulin resistance and a combined risk factor score (MetS score). PA was measured by triaxial accelerometers and raw data was processed using the 10 Hz frequency extended method (FEM). The PA output was divided into an intensity spectrum and the association with MetS risk factors was analyzed by partial least squares regression. RESULTS: PA patterns differed between the European countries investigated, with Swedish children being most active and Italian children least active. Moderate intensity physical activity was associated with lower insulin resistance (R2 = 2.8%), while vigorous intensity physical activity was associated with lower body mass index (R2 = 3.6%), MetS score (R2 = 3.1%) and higher high-density lipoprotein cholesterol (R2 = 2.3%). PA of all intensities was associated with lower systolic- and diastolic blood pressure, although the associations were weaker than for the other risk factors (R2 = 1.5% and R2 = 1.4%). However, the multivariate analysis implies that the entire PA pattern must be considered. The main difference in PA was observed between normal weight and overweight children. CONCLUSIONS: The present study suggests a greater importance of more PA corresponding to an intensity of at least brisk walking with inclusion of high-intense exercise, rather than a limited time spent sedentary, in the association to metabolic health in children. The methods of data processing and statistical analysis enabled accurate analysis and interpretation of the health benefits of high intensity PA that have not been shown previously.

Media use trajectories and risk of metabolic syndrome in European children and adolescents: the IDEFICS/I.Family cohort.

BACKGROUND: Media use may influence metabolic syndrome (MetS) in children. Yet, longitudinal studies are scarce. This study aims to evaluate the longitudinal association of childhood digital media (DM) use trajectories with MetS and its components. METHODS: Children from Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden participating in the IDEFICS/I.Family cohort were examined at baseline (W1: 2007/2008) and then followed-up at two examination waves (W2: 2009/2010 and W3: 2013/2014). DM use (hours/day) was calculated as sum of television viewing, computer/game console and internet use. MetS z-score was calculated as sum of age- and sex-specific z-scores of four components: waist circumference, blood pressure, dyslipidemia (mean of triglycerides and HDL-cholesterol-1) and homeostasis model assessment for insulin resistance (HOMA-IR). Unfavorable monitoring levels of MetS and its components were identified (cut-off: ≥ 90th percentile of each score). Children aged 2-16 years with ≥ 2 observations (W1/W2; W1/W3; W2/W3; W1/W2/W3) were eligible for the analysis. A two-step procedure was conducted: first, individual age-dependent DM trajectories were calculated using linear mixed regressions based on random intercept (hours/day) and linear slopes (hours/day/year) and used as exposure measures in association with MetS at a second step. Trajectories were further dichotomized if children increased their DM duration over time above or below the mean. RESULTS: 10,359 children and adolescents (20,075 total observations, 50.3% females, mean age = 7.9, SD = 2.7) were included. DM exposure increased as children grew older (from 2.2 h/day at 2 years to 4.2 h/day at 16 years). Estonian children showed the steepest DM increase; Spanish children the lowest. The prevalence of MetS at last follow-up was 5.5%. Increasing media use trajectories were positively associated with z-scores of MetS (slope: ß = 0.54, 95%CI = 0.20-0.88; intercept: ß = 0.07, 95%CI = 0.02-0.13), and its components after adjustment for puberty, diet and other confounders. Children with increasing DM trajectories above mean had a 30% higher risk of developing MetS (slope: OR = 1.30, 95%CI = 1.04-1.62). Boys developed steeper DM use trajectories and higher risk for MetS compared to girls. CONCLUSIONS: Digital media use appears to be a risk factor for the development of MetS in children and adolescents. These results are of utmost importance for pediatricians and the development of health policies to prevent cardio-metabolic disorders later in life. TRIAL REGISTRATION: ISRCTN, ISRCTN62310987 . Registered 23 February 2018- retrospectively registered.

Trajectories of objectively measured physical activity and childhood overweight: longitudinal analysis of the IDEFICS/I.Family cohort.

BACKGROUND: Since only few longitudinal studies with appropriate study designs investigated the relationship between objectively measured physical activity (PA) and overweight, the degree PA can prevent excess weight gain in children, remains unclear. Moreover, evidence is limited on how childhood overweight determines PA during childhood. Therefore, we analyzed longitudinal trajectories of objectively measured PA and their bi-directional association with weight trajectories of children at 2- and 6-year follow-ups. METHODS: Longitudinal data of three subsequent measurements from the IDEFICS/I.Family cohort study were used to analyze the bi-directional association between moderate-to-vigorous PA (MVPA) and weight status by means of multilevel regression models. Analyses comprised 3393 (2-year follow-up) and 1899 (6-year follow-up) children aged 2-15.9 years from eight European countries with valid accelerometer data and body mass index (BMI) measurements. For categorized analyses, children's weight status was categorized as normal weight or overweight (cutoff: 90th percentile of BMI) and children's PA as (in-) sufficiently active (cutoffs: 30, 45 and 60 min of MVPA per day). RESULTS: Children engaging in at least 60 min MVPA daily at baseline and follow-ups had a lower odds of becoming overweight (odds ratio [OR] at 2-year follow-up: 0.546, 95% CI: 0.378, 0.789 and 6-year follow-up: 0.393, 95% CI: 0.242, 0.638), compared to less active children. Similar associations were found for 45 min MVPA daily. On the other side, children who became overweight had the lowest odds to achieve 45 or 60 min MVPA daily (ORs: 0.459 to 0.634), compared to normal weight children. CONCLUSIONS: Bi-directional associations between MVPA and weight status were observed. In summary, at least 60 min MVPA are still recommended for the prevention of childhood overweight. To prevent excess weight gain, 45 min MVPA per day also showed preventive effects.

Urban Moveability and physical activity in children: longitudinal results from the IDEFICS and I.Family cohort.

BACKGROUND: Physical activity (PA) is one of the major protective behaviours to prevent non-communicable diseases. Positive effects of the built environment on PA are well investigated, although evidence of this association is mostly based on cross-sectional studies. The present study aims to investigate the longitudinal effects of built environment characteristics in terms of a moveability index on PA of children in their transition phase to adolescence using data of the IDEFICS/I.Family cohort. METHODS: We used data on 3394 accelerometer measurements of 2488 children and adolescents aged 3 to 15 years old from survey centres of three countries, Germany, Italy, and Sweden, who participated in up to three surveys over 6 years. In network-dependent home neighbourhoods, a moveability index was calculated based on residential density, land use mix, street connectivity, availability of public transport and public open spaces such as green spaces and public playgrounds in order to quantify opportunities for PA of children and adolescents. Linear trajectories of light PA (LPA) and moderate-to-vigorous PA (MVPA) were estimated using linear mixed models accounting for repeated measurements nested within individuals. Least squares means were estimated to quantify differences in trajectories over age. RESULTS: LPA and MVPA declined annually with age by approximately 20 min/day and 2 min/day respectively. In girls, the moveability index showed a consistent significantly positive effect on MVPA ([Formula: see text] = 2.14, 95% CI: (0.11; 4.16)) for all ages, while in boys the index significantly lessened the decline in LPA with age for each year. ([Formula: see text] = 2.68, 95% CI: (0.46; 4.90)). Availability of public open spaces was more relevant for MVPA in girls and LPA in boys during childhood, whereas in adolescence, residential density and intersection density became more important. CONCLUSION: Built environment characteristics are important determinants of PA and were found to have a supportive effect that ameliorates the decline in PA during the transition phase from childhood to adolescence. In childhood environmental support for leisure time PA through public open spaces was found to be the most protective factor whereas in adolescence the positive influence of street connectivity and residential density was most supportive of physical activity.

Impact of the intervention program "JolinchenKids - fit and healthy in daycare" on energy balance related-behaviors: results of a cluster controlled trial.

BACKGROUND: The purpose of this study was to evaluate the multi-component health promotion program, JolinchenKids - fit and healthy in daycare, designed to promote physical activity (PA), healthy eating, and mental wellbeing among 3- to 6-year-old preschoolers. METHODS: For this cluster controlled trial, 62 daycare facilities (DFs) from thirteen different federal states in Germany were recruited (31 intervention, 31 control DFs). Outcome measures were children's habitual PA, fruits and vegetable consumption, consumption of unsweetened beverages and snacks with parents as raters. Study nurses assessed children's body composition and motor skills. Data was collected at baseline and 12 months later. To track adherence to the implementation of intervention modules at individual DF groups, an implementation calendar was used from baseline to follow-up. Linear mixed models were used to investigate effects for survey, group and their interaction at the individual level while accounting for clustering. RESULTS: Samples of 831 (baseline) and 641 (follow-up) children aged 4.3 ± 0.8 and 5.2 ± 0.8 years were analysed. More than half of the intervention DFs chose the nutrition or PA module for the first year of implementation while an implementation level of > 50% was only achieved in less than a third. A significant intervention effect (survey × group interaction) was found for the standing long jump favouring children at intervention DFs (ß = 3.08; 95% Confidence interval [CI]: (0.09; 6.07)). No significant intervention effects were found for time spent on PA, total screen time, dietary habits, and body composition, i.e. body-mass-index and percentage of body fat. CONCLUSIONS: Participation in JolinchenKids - fit and healthy in daycare led to improvements in some indicators for motor skills. However, other health outcomes and behaviours were not affected by program participation over the course of 1 year. TRIAL REGISTRATION: German Clinical Trials Register DRKS00011065 (Date of registration 16-09-2016).

Reexamination of Accelerometer Calibration with Energy Expenditure as Criterion: VO2net Instead of MET for Age-Equivalent Physical Activity Intensity.

Accelerometer calibration for physical activity (PA) intensity is commonly performed using Metabolic Equivalent of Task (MET) as criterion. However, MET is not an age-equivalent measure of PA intensity, which limits the use of MET-calibrated accelerometers for age-related PA investigations. We investigated calibration using VO2net (VO2gross - VO2stand; mL⋅min-1⋅kg-1) as criterion compared to MET (VO2gross/VO2rest) and the effect on assessment of free-living PA in children, adolescents and adults. Oxygen consumption and hip/thigh accelerometer data were collected during rest, stand and treadmill walk and run. Equivalent speed (Speedeq) was used as indicator of the absolute speed (Speedabs) performed with the same effort in individuals of different body size/age. The results showed that VO2net was higher in younger age-groups for Speedabs, but was similar in the three age-groups for Speedeq. MET was lower in younger age-groups for both Speedabs and Speedeq. The same VO2net-values respective MET-values were applied to all age-groups to develop accelerometer PA intensity cut-points. Free-living moderate-and-vigorous PA was 216, 115, 74 and 71 min/d in children, adolescents, younger and older adults with VO2net-calibration, but 140, 83, 74 and 41 min/d with MET-calibration, respectively. In conclusion, VO2net calibration of accelerometers may provide age-equivalent measures of PA intensity/effort for more accurate age-related investigations of PA in epidemiological research.

Effects of Frequency Filtering on Intensity and Noise in Accelerometer-Based Physical Activity Measurements.

In objective physical activity (PA) measurements, applying wider frequency filters than the most commonly used ActiGraph (AG) filter may be beneficial when processing accelerometry data. However, the vulnerability of wider filters to noise has not been investigated previously. This study explored the effect of wider frequency filters on measurements of PA, sedentary behavior (SED), and capturing of noise. Apart from the standard AG band-pass filter (0.29-1.63 Hz), modified filters with low-pass component cutoffs at 4 Hz, 10 Hz, or removed were analyzed. Calibrations against energy expenditure were performed with lab data from children and adults to generate filter-specific intensity cut-points. Free-living accelerometer data from children and adults were processed using the different filters and intensity cut-points. There was a contribution of acceleration related to PA at frequencies up to 10 Hz. The contribution was more pronounced at moderate and vigorous PA levels, although additional acceleration also occurred at SED. The classification discrepancy between AG and the wider filters was small at SED (1-2%) but very large at the highest intensities (>90%). The present study suggests an optimal low-pass frequency filter with a cutoff at 10 Hz to include all acceleration relevant to PA with minimal effect of noise.

Policy determinants of physical activity across the life course: a 'DEDIPAC' umbrella systematic literature review.

Background: Despite the large number of studies and reviews available, the evidence regarding the policy determinants of physical activity (PA) is inconclusive. This umbrella systematic literature review (SLR) summarizes the current evidence on the policy determinants of PA across the life course, by pooling the results of the available SLRs and meta-analyses (MAs). Methods: A systematic online search was conducted on MEDLINE, ISI Web of Science, Scopus and SPORTDiscus databases up to April 2016. SLRs and MAs of observational studies investigating the association between policy determinants of PA and having PA as outcome were considered eligible. The extracted data were assessed based on the importance of the determinants, the strength of evidence and the methodological quality. Results: Fourteen reviews on 27 policy determinants of PA were eligible for this umbrella SLR. The majority of the reviews were of moderate quality. Among children, a clear association between time spent outdoors and PA emerged. Among adults, working hours were negatively associated with PA, though evidence was limited. At the population level, community- and street-scale urban design and land use policies were found to positively support PA levels, but levels of evidences were low. Conclusions: With this umbrella SLR the policy determinants of PA at individual-level and population-level have been summarized and assessed. None of the investigated policy determinants had a convincing level of evidence, and very few had a probable level of evidence. Further research is needed, preferably by using prospective study designs, standardized definitions of PA and objective measurement of PA.

Behavioral determinants of physical activity across the life course: a "DEterminants of DIet and Physical ACtivity" (DEDIPAC) umbrella systematic literature review.

BACKGROUND: Low levels of physical activity (PA) are a global concern and increasing PA engagement is becoming a priority in current public health policies. Despite the large number of studies and reviews available, the evidence regarding the behavioral determinants of PA is still inconclusive. Thus, the aim of this umbrella systematic literature review (SLR) was to summarize the evidence on the behavioral determinants of PA across the life course. METHODS: A systematic online search was conducted on MEDLINE, ISI Web of Science, Scopus, and SPORTDiscus databases. The search was limited to studies published in English from January, 2004 to April, 2016. SLRs and meta-analyses (MAs) of observational studies that investigated the behavioral determinants of PA were considered eligible. The extracted data were assessed based on the importance of the determinants, the strength of evidence, and the methodological quality. The full protocol is available from PROSPERO (PROSPERO 2014:CRD42015010616). RESULTS: Seventeen reviews on 35 behavioral determinants of PA were eligible for this umbrella SLR. Regardless of age, the most investigated determinants were those related with 'screen use' and 'smoking'. For youth, probable positive evidence emerged for 'previous PA' and 'independent mobility and active transport' among children and adolescents. For the adult population, 'transition to university' and 'pregnancy/having a child' showed probable negative associations. CONCLUSIONS: Although the majority of the evidence was limited and most of the determinants were not associated with PA, this umbrella SLR provided a comprehensive overview of the associations between behavioral determinants and PA. Youth should be physically active in the early years and increase active transportation to/from school, independent mobility, and 'free-range activities' without adult supervision, whilst adult PA behaviors are mostly influenced by the life events. Finally, more research is needed that incorporates prospective study designs, standardized definitions of PA, objective measurement methods of PA assessment, and the use of interactionist and mediational approaches for the evaluation of different behavioral determinants influencing PA behaviors.

Socio-cultural determinants of physical activity across the life course: a 'Determinants of Diet and Physical Activity' (DEDIPAC) umbrella systematic literature review.

OBJECTIVE: Regular physical activity (PA) reduces the risk of disease and premature death. Knowing factors associated with PA might help reducing the disease and economic burden caused by low activity. Studies suggest that socio-cultural factors may affect PA, but systematic overviews of findings across the life course are scarce. This umbrella systematic literature review (SLR) summarizes and evaluates available evidence on socio-cultural determinants of PA in children, adolescents, and adults. METHODS: This manuscript was drafted following the recommendations of the 'Preferred Reporting Items for Systematic reviews and Meta-Analyses' (PRISMA) checklist. The MEDLINE, Web of Science, Scopus, and SPORTDiscus databases were searched for SLRs and meta-analyses (MAs) on observational studies published in English that assessed PA determinants between January 2004 and April 2016. The methodological quality was assessed and relevant information on socio-cultural determinants and any associations with PA was extracted. The available evidence was evaluated based on the importance of potential determinants and the strength of the evidence. RESULTS: Twenty SLRs and three MAs encompassing 657 eligible primary studies investigated potential socio-cultural PA determinants, with predominantly moderate methodological quality. Twenty-nine potential PA determinants were identified that were primarily assessed in children and adolescents and investigated the micro-environmental home/household level. We found probable evidence that receiving encouragement from significant others and having a companion for PA were associated with higher PA in children and adolescents, and that parental marital status (living with partner) and experiencing parental modeling were not associated with PA in children. Evidence for the other potential determinants was limited, suggestive, or non-conclusive. In adults, quantitative and conclusive data were scarce. CONCLUSIONS: A substantial number of SLRs and MAs investigating potential socio-cultural determinants of PA were identified. Our data suggest that receiving social support from significant others may increase PA levels in children and adolescents, whereas parental marital status is not a determinant in children. Evidence for other potential determinants was limited. This was mainly due to inconsistencies in results on potential socio-cultural determinants of PA across reviews and studies. TRIAL REGISTRATIONS: This umbrella SLR was recorded on PROSPERO (Record ID: CRD42015010616 ).

The SOS-framework (Systems of Sedentary behaviours): an international transdisciplinary consensus framework for the study of determinants, research priorities and policy on sedentary behaviour across the life course: a DEDIPAC-study.

BACKGROUND: Ecological models are currently the most used approaches to classify and conceptualise determinants of sedentary behaviour, but these approaches are limited in their ability to capture the complexity of and interplay between determinants. The aim of the project described here was to develop a transdisciplinary dynamic framework, grounded in a system-based approach, for research on determinants of sedentary behaviour across the life span and intervention and policy planning and evaluation. METHODS: A comprehensive concept mapping approach was used to develop the Systems Of Sedentary behaviours (SOS) framework, involving four main phases: (1) preparation, (2) generation of statements, (3) structuring (sorting and ranking), and (4) analysis and interpretation. The first two phases were undertaken between December 2013 and February 2015 by the DEDIPAC KH team (DEterminants of DIet and Physical Activity Knowledge Hub). The last two phases were completed during a two-day consensus meeting in June 2015. RESULTS: During the first phase, 550 factors regarding sedentary behaviour were listed across three age groups (i.e., youths, adults and older adults), which were reduced to a final list of 190 life course factors in phase 2 used during the consensus meeting. In total, 69 international delegates, seven invited experts and one concept mapping consultant attended the consensus meeting. The final framework obtained during that meeting consisted of six clusters of determinants: Physical Health and Wellbeing (71% consensus), Social and Cultural Context (59% consensus), Built and Natural Environment (65% consensus), Psychology and Behaviour (80% consensus), Politics and Economics (78% consensus), and Institutional and Home Settings (78% consensus). Conducting studies on Institutional Settings was ranked as the first research priority. The view that this framework captures a system-based map of determinants of sedentary behaviour was expressed by 89% of the participants. CONCLUSION: Through an international transdisciplinary consensus process, the SOS framework was developed for the determinants of sedentary behaviour through the life course. Investigating the influence of Institutional and Home Settings was deemed to be the most important area of research to focus on at present and potentially the most modifiable. The SOS framework can be used as an important tool to prioritise future research and to develop policies to reduce sedentary time.

Systematic literature review of determinants of sedentary behaviour in older adults: a DEDIPAC study.

BACKGROUND: Older adults are the most sedentary segment of society and high sedentary time is associated with poor health and wellbeing outcomes in this population. Identifying determinants of sedentary behaviour is a necessary step to develop interventions to reduce sedentary time. METHODS: A systematic literature review was conducted to identify factors associated with sedentary behaviour in older adults. Pubmed, Embase, CINAHL, PsycINFO and Web of Science were searched for articles published between 2000 and May 2014. The search strategy was based on four key elements: (a) sedentary behaviour and its synonyms; (b) determinants and its synonyms (e.g. correlates, factors); (c) types of sedentary behaviour (e.g. TV viewing, sitting, gaming) and (d) types of determinants (e.g. environmental, behavioural). Articles were included in the review if specific information about sedentary behaviour in older adults was reported. Studies on samples identified by disease were excluded. Study quality was rated by means of QUALSYST. The full review protocol is available from PROSPERO (PROSPERO 2014: CRD42014009823). The analysis was guided by the socio-ecological model framework. RESULTS: Twenty-two original studies were identified out of 4472 returned by the systematic search. These included 19 cross-sectional, 2 longitudinal and 1 qualitative studies, all published after 2011. Half of the studies were European. The study quality was generally high with a median of 82 % (IQR 69-96 %) using Qualsyst tool. Personal factors were the most frequently investigated with consistent positive association for age, negative for retirement, obesity and health status. Only four studies considered environmental determinants suggesting possible association with mode of transport, type of housing, cultural opportunities and neighbourhood safety and availability of places to rest. Only two studies investigated mediating factors. Very limited information was available on contexts and sub-domains of sedentary behaviours. CONCLUSION: Few studies have investigated determinants of sedentary behaviour in older adults and these have to date mostly focussed on personal factors, and qualitative studies were mostly lacking. More longitudinal studies are needed as well as inclusion of a broader range of personal and contextual potential determinants towards a systems-based approach, and future studies should be more informed by qualitative work.

Impact of physical activity, sedentary behaviour and muscle strength on bone stiffness in 2-10-year-old children-cross-sectional results from the IDEFICS study.

BACKGROUND: Physical activity (PA), weight-bearing exercises (WBE) and muscle strength contribute to skeletal development, while sedentary behaviour (SB) adversely affects bone health. Previous studies examined the isolated effect of PA, SB or muscle strength on bone health, which was usually assessed by x-ray methods, in children. Little is known about the combined effects of these factors on bone stiffness (SI) assessed by quantitative ultrasound. We investigated the joint association of PA, SB and muscle strength on SI in children. METHODS: In 1512 preschool (2- < 6 years) and 2953 school children (6-10 years), data on calcaneal SI as well as on accelerometer-based sedentary time (SED), light (LPA), moderate (MPA) and vigorous PA (VPA) were available. Parents reported sports (WBE versus no WBE), leisure time PA and screen time of their children. Jumping distance and handgrip strength served as indicators for muscle strength. The association of PA, SB and muscle strength with SI was estimated by multivariate linear regression, stratified by age group. Models were adjusted for age, sex, country, fat-free mass, daylight duration, consumption of dairy products and PA, or respectively SB. RESULTS: Mean SI was similar in preschool (79.5 ± 15.0) and school children (81.3 ± 12.1). In both age groups, an additional 10 min/day in MPA or VPA increased the SI on average by 1 or 2%, respectively (p ≤ .05). The negative association of SED with SI decreased after controlling for MVPA. LPA was not associated with SI. Furthermore, participation in WBE led to a 3 and 2% higher SI in preschool (p = 0.003) and school children (p < .001), respectively. Although muscle strength significantly contributed to SI, it did not affect the associations of PA with SI. In contrast to objectively assessed PA, reported leisure time PA and screen time showed no remarkable association with SI. CONCLUSION: This study suggests that already an additional 10 min/day of MPA or VPA or the participation in WBE may result in a relevant increase in SI in children, taking muscle strength and SB into account. Our results support the importance of assessing accelerometer-based PA in large-scale studies. This may be important when deriving dose-response relationships between PA and bone health in children.

Objective measures of the built environment and physical activity in children: from walkability to moveability.

Features of the built environment that may influence physical activity (PA) levels are commonly captured using a so-called walkability index. Since such indices typically describe opportunities for walking in everyday life of adults, they might not be applicable to assess urban opportunities for PA in children. Particularly, the spatial availability of recreational facilities may have an impact on PA in children and should be additionally considered. We linked individual data of 400 2- to 9-year-old children recruited in the European IDEFICS study to geographic data of one German study region, based on individual network-dependent neighborhoods. Environmental features of the walkability concept and the availability of recreational facilities, i.e. playgrounds, green spaces, and parks, were measured. Relevant features were combined to a moveability index that should capture urban opportunities for PA in children. A gamma log-regression model was used to model linear and non-linear effects of individual variables on accelerometer-based moderate-to-vigorous physical activity (MVPA) stratified by pre-school children (<6 years) and school children (≥6 years). Single environmental features and the resulting indices were separately included into the model to investigate the effect of each variable on MVPA. In school children, commonly used features such as residential density [Formula: see text], intersection density [Formula: see text], and public transit density [Formula: see text] showed a positive effect on MVPA, while land use mix revealed a negative effect on MVPA [Formula: see text]. In particular, playground density [Formula: see text] and density of public open spaces, i.e., playgrounds and parks combined [Formula: see text], showed positive effects on MVPA. However, availability of green spaces showed no effect on MVPA. Different moveability indices were constructed based on the walkability index accounting for the negative impact of land use mix. Moveability indices showed also strong effects on MVPA in school children for both components, expanded by playground density [Formula: see text] or by public open space density [Formula: see text], but no effects of urban measures and moveability indices were found in pre-school children. The final moveability indices capture relevant opportunities for PA in school children. Particularly, availability of public open spaces seems to be a strong predictor of MVPA. Future studies involving children should consider quantitative assessment of public recreational facilities in larger cities or urban sprawls in order to investigate the influence of the moveability on childhood PA in a broader sample.

Assessing opportunities for physical activity in the built environment of children: interrelation between kernel density and neighborhood scale.

BACKGROUND: Built environment studies provide broad evidence that urban characteristics influence physical activity (PA). However, findings are still difficult to compare, due to inconsistent measures assessing urban point characteristics and varying definitions of spatial scale. Both were found to influence the strength of the association between the built environment and PA. METHODS: We simultaneously evaluated the effect of kernel approaches and network-distances to investigate the association between urban characteristics and physical activity depending on spatial scale and intensity measure. We assessed urban measures of point characteristics such as intersections, public transit stations, and public open spaces in ego-centered network-dependent neighborhoods based on geographical data of one German study region of the IDEFICS study. We calculated point intensities using the simple intensity and kernel approaches based on fixed bandwidths, cross-validated bandwidths including isotropic and anisotropic kernel functions and considering adaptive bandwidths that adjust for residential density. We distinguished six network-distances from 500 m up to 2 km to calculate each intensity measure. A log-gamma regression model was used to investigate the effect of each urban measure on moderate-to-vigorous physical activity (MVPA) of 400 2- to 9.9-year old children who participated in the IDEFICS study. Models were stratified by sex and age groups, i.e. pre-school children (2 to <6 years) and school children (6-9.9 years), and were adjusted for age, body mass index (BMI), education and safety concerns of parents, season and valid weartime of accelerometers. RESULTS: Association between intensity measures and MVPA strongly differed by network-distance, with stronger effects found for larger network-distances. Simple intensity revealed smaller effect estimates and smaller goodness-of-fit compared to kernel approaches. Smallest variation in effect estimates over network-distances was found for kernel intensity measures based on isotropic and anisotropic cross-validated bandwidth selection. CONCLUSION: We found a strong variation in the association between the built environment and PA of children based on the choice of intensity measure and network-distance. Kernel intensity measures provided stable results over various scales and improved the assessment compared to the simple intensity measure. Considering different spatial scales and kernel intensity methods might reduce methodological limitations in assessing opportunities for PA in the built environment.