Using social networks to scale up and sustain community-based programmes to improve physical activity and diet in low-income and middle-income countries: a scoping review.

BACKGROUND: Community-based programmes [CBPs], targeting increased physical activity and/or healthier eating, have been used in the prevention and management of non-communicable diseases. However, CBPs are only useful, insofar as they can be scaled up and sustained in some meaningful way. Social networks-defined as "social structures that exists between actors, individuals or organizations"-may serve as an important tool to identify underlying mechanisms that contribute to this process. This scoping review aimed to map and collate literature on the role of social network research in scaling-up and sustaining physical activity and/or diet CBPs in low-and middle-income countries [LMICs]. METHODS: Arksey and O'Malley's framework and its enhancement were followed. Inclusion criteria were peer-reviewed articles exploring the role of social networks in scaled-up and/or sustained physical activity and/or diet CBPs in adult populations, published in English since 2000, and based in a LMIC. Databases searched were PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, International Bibliography of the Social Sciences, and Google Scholar. Books, conference abstracts, and programmes focused on children were excluded. Two reviewers independently selected and extracted eligible studies. Included publications were thematically analysed using the Framework Approach. RESULTS: Authors identified 12 articles for inclusion, covering 13 CBPs. Most were based in Latin America, with others in the Caribbean, the Pacific Islands, Iran, and India. All articles were published since 2009. Only three used social network analysis methods (with others using qualitative methods). Five main social network themes were identified: centralisation, cliques, leaders, quality over quantity, and shared goals. Contextual factors to be considered when scaling-up programmes in LMICs were also identified. CONCLUSIONS: This review has shown that the evidence of the use of social network research in programme scale-up has not yet caught up to its theoretical possibilities. Programmes aiming to scale should consider conducting social network research with identified network themes in mind to help improve the evidence-base of what network mechanisms, in what contexts, might best support the strengthening of networks in physical activity and diet programmes. Importantly, the voice of individuals and communities in these networks should not be forgotten.

Plausible conditions and mechanisms for increasing physical activity behavior in men with prostate cancer using patient education interventions: sequential explanatory mixed studies synthesis.

PURPOSE: This mixed studies synthesis sought to evaluate structured patient education interventions (PEIs) to elucidate relevant conditions and mechanisms for increasing physical activity behavior in men with prostate cancer (PCa). METHODS: Studies that randomized men diagnosed with PCa, assessed PEIs, and reported (1) between-group changes in the outcome measures of exercise self-efficacy, PA level, or patient-centered outcomes (cancer-related fatigue, aerobic fitness, and quality of life) at baseline and post-intervention, and/or (2) men's perceptions of structured PEIs were synthesized. Results from five RCTs reporting data on 895 men and qualitative reports from four studies were respectively and sequentially analyzed with narrative and thematic syntheses. Findings from both syntheses were further integrated using the context-mechanism-outcome configuration (CMO) to elucidate potential "contextual factors" or "conditions" that may support plausible PEI mechanisms. RESULTS: Structured PEIs were associated with a beneficial increase in task self-efficacy, vigorous-intensity PA, minutes/week of resistance exercise, the proportion of men meeting ≥ 150 minutes/week of moderate-vigorous intensity aerobic exercise, and overall PA. No effects were found on patient-centered outcomes. Drawing upon the CMO configuration, the inclusion of a referral process, access to "credible influence" (e.g., involving former patients as program facilitators), and adopting hybrid service delivery are likely critical conditions that may explain the success of PEIs in men with PCa. CONCLUSION: PEIs can increase PA behavior in men with PCa. The likelihood of success is higher for multicomponent interventions that prioritized credible influence and exercise referral as critical components besides offering access to interventions within hospital settings, with home-based sessions in addition.

Efficacy and safety of temelimab in multiple sclerosis: Results of a randomized phase 2b and extension study.

BACKGROUND: The envelope protein of human endogenous retrovirus W (HERV-W-Env) is expressed by macrophages and microglia, mediating axonal damage in chronic active MS lesions. OBJECTIVE AND METHODS: This phase 2, double-blind, 48-week trial in relapsing-remitting MS with 48-week extension phase assessed the efficacy and safety of temelimab; a monoclonal antibody neutralizing HERV-W-Env. The primary endpoint was the reduction of cumulative gadolinium-enhancing T1-lesions in brain magnetic resonance imaging (MRI) scans at week 24. Additional endpoints included numbers of T2 and T1-hypointense lesions, magnetization transfer ratio, and brain atrophy. In total, 270 participants were randomized to receive monthly intravenous temelimab (6, 12, or 18 mg/kg) or placebo for 24 weeks; at week 24 placebo-treated participants were re-randomized to treatment groups. RESULTS: The primary endpoint was not met. At week 48, participants treated with 18 mg/kg temelimab had fewer new T1-hypointense lesions (p = 0.014) and showed consistent, however statistically non-significant, reductions in brain atrophy and magnetization transfer ratio decrease, as compared with the placebo/comparator group. These latter two trends were sustained over 96 weeks. No safety issues emerged. CONCLUSION: Temelimab failed to show an effect on features of acute inflammation but demonstrated preliminary radiological signs of possible anti-neurodegenerative effects. Current data support the development of temelimab for progressive MS. TRIAL REGISTRATION: CHANGE-MS: ClinicalTrials.gov: NCT02782858, EudraCT: 2015-004059-29; ANGEL-MS: ClinicalTrials.gov: NCT03239860, EudraCT: 2016-004935-18.

Using social networks to scale up and sustain community-based programmes to improve physical activity and diet in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: The World Health Organisation endorses community-based programmes as a cost-effective, feasible and a 'best buy' in the prevention and management of non-communicable diseases (NCDs). These programmes are particularly successful when the community actively participates in its design, implementation and evaluation. However, they may be only useful insofar as they can be scaled up and sustained in some meaningful way. Social network research may serve as an important tool for determining the underlying mechanisms that contribute to this process. The aim of this planned scoping review is to map and collate literature on the role of social networks in scaling-up and sustaining community-based physical activity and diet programmes in low-income and middle-income countries. METHODS AND ANALYSIS: This scoping review protocol has been planned around the Arksey and O'Malley framework and its enhancement. Inclusion criteria are peer-reviewed articles and grey literature exploring the role of social networks in the scale-up and/or sustainability of NCD prevention community-based programmes in adult populations. Studies must have been published since 2000, in English, and be based in a low-income or middle-income country. The following databases will be used for this review: PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, the International Bibliography of the Social Sciences, Google and Google Scholar. Books, conference abstracts and research focused only on children will be excluded. Two reviewers will independently select and extract eligible studies. Included publications will be thematically analysed using the Framework Approach. ETHICS AND DISSEMINATION: Ethical approval will not be sought for this review as no individual-level data or human participants will be involved. This protocol is registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/KG7TX). The findings from the review will be published in an accredited journal. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews checklist will be used to support transparency and guide translation of the review.

Physical activity and fat-free mass during growth and in later life.

BACKGROUND: Physical activity may be a way to increase and maintain fat-free mass (FFM) in later life, similar to the prevention of fractures by increasing peak bone mass. OBJECTIVES: A study is presented of the association between FFM and physical activity in relation to age. METHODS: In a cross-sectional study, FFM was analyzed in relation to physical activity in a large participant group as compiled in the International Atomic Energy Agency Doubly Labeled Water database. The database included 2000 participants, age 3-96 y, with measurements of total energy expenditure (TEE) and resting energy expenditure (REE) to allow calculation of physical activity level (PAL = TEE/REE), and calculation of FFM from isotope dilution. RESULTS: PAL was a main determinant of body composition at all ages. Models with age, fat mass (FM), and PAL explained 76% and 85% of the variation in FFM in females and males < 18 y old, and 32% and 47% of the variation in FFM in females and males ≥ 18 y old, respectively. In participants < 18 y old, mean FM-adjusted FFM was 1.7 kg (95% CI: 0.1, 3.2 kg) and 3.4 kg (95% CI: 1.0, 5.6 kg) higher in a very active participant with PAL = 2.0 than in a sedentary participant with PAL = 1.5, for females and males, respectively. At age 18 y, height and FM-adjusted FFM was 3.6 kg (95% CI: 2.8, 4.4 kg) and 4.4 kg (95% CI: 3.2, 5.7 kg) higher, and at age 80 y 0.7 kg (95% CI: -0.2, 1.7 kg) and 1.0 kg (95% CI: -0.1, 2.1 kg) higher, in a participant with PAL = 2.0 than in a participant with PAL = 1.5, for females and males, respectively. CONCLUSIONS: If these associations are causal, they suggest physical activity is a major determinant of body composition as reflected in peak FFM, and that a physically active lifestyle can only partly protect against loss of FFM in aging adults.

Consumption of Monounsaturated Fatty Acids Is Associated with Improved Cardiometabolic Outcomes in Four African-Origin Populations Spanning the Epidemiologic Transition.

Long-chain omega-3 PUFAs, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are of increasing interest because of their favorable effect on cardiometabolic risk. This study explores the association between omega 6 and 3 fatty acids intake and cardiometabolic risk in four African-origin populations spanning the epidemiological transition. Data are obtained from a cohort of 2500 adults aged 25-45 enrolled in the Modeling the Epidemiologic Transition Study (METS), from the US, Ghana, Jamaica, and the Seychelles. Dietary intake was measured using two 24 h recalls from the Nutrient Data System for Research (NDSR). The prevalence of cardiometabolic risk was analyzed by comparing the lowest and highest quartile of omega-3 (EPA+ DHA) consumption and by comparing participants who consumed a ratio of arachidonic acid (AA)/EPA + DHA ≤4:1 and >4:1. Data were analyzed using multiple variable logistic regression adjusted for age, gender, activity, calorie intake, alcohol intake, and smoking status. The lowest quartile of EPA + DHA intake is associated with cardiometabolic risk 2.16 (1.45, 3.2), inflammation 1.59 (1.17, 2.16), and obesity 2.06 (1.50, 2.82). Additionally, consuming an AA/EPA + DHA ratio of >4:1 is also associated with cardiometabolic risk 1.80 (1.24, 2.60), inflammation 1.47 (1.06, 2.03), and obesity 1.72 (1.25, 2.39). Our findings corroborate previous research supporting a beneficial role for monounsaturated fatty acids in reducing cardiometabolic risk.

Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol.

BACKGROUND: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. OBJECTIVE: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. METHODS: Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. RESULTS: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. CONCLUSIONS: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26739.

Global Public Health Guidelines on Physical Activity and Sedentary Behavior for People Living With Chronic Conditions: A Call to Action.

BACKGROUND: In 2020, the World Health Organization (WHO) released global guidelines on physical activity (PA) and sedentary behavior, for the first time providing population-based recommendations for people living with selected chronic conditions. This article briefly presents the guidelines, related processes and evidence, and, importantly, considers how they may be used to support research, practice, and policy. METHODS: A brief overview of the scope, agreed methods, selected chronic conditions (adults living with cancer, hypertension, type 2 diabetes, and human immunodeficiency virus), and appraisal of systematic review evidence on PA/sedentary behavior is provided. Methods were consistent with World Health Organization protocols for developing guidelines. RESULTS: Moderate to high certainty evidence (varying by chronic condition and outcome examined) supported that PA can reduce the risk of disease progression or premature mortality and improve physical function and quality of life in adults living with chronic conditions. Direct evidence on sedentary behavior was lacking; however, evidence extrapolated from adult populations was considered applicable, safe, and likely beneficial (low certainty due to indirectness). CONCLUSIONS: Clinical and public health professionals and policy makers should promote the World Health Organization 2020 global guidelines and develop and implement services and programs to increase PA and limit sedentary behavior in adults living with chronic conditions.

Advancing the global physical activity agenda: recommendations for future research by the 2020 WHO physical activity and sedentary behavior guidelines development group.

BACKGROUND: In July, 2019, the World Health Organization (WHO) commenced work to update the 2010 Global Recommendations on Physical Activity for Health and established a Guideline Development Group (GDG) comprising expert public health scientists and practitioners to inform the drafting of the 2020 Guidelines on Physical Activity and Sedentary Behavior. The overall task of the GDG was to review the scientific evidence and provide expert advice to the WHO on the amount of physical activity and sedentary behavior associated with optimal health in children and adolescents, adults, older adults (> 64 years), and also specifically in pregnant and postpartum women and people living with chronic conditions or disabilities. METHODS: The GDG reviewed the available evidence specific to each sub-population using systematic protocols and in doing so, identified a number of gaps in the existing literature. These proposed research gaps were discussed and verified by expert consensus among the entire GDG. RESULTS: Evidence gaps across population sub-groups included a lack of information on: 1) the precise shape of the dose-response curve between physical activity and/or sedentary behavior and several of the health outcomes studied; 2) the health benefits of light-intensity physical activity and of breaking up sedentary time with light-intensity activity; 3) differences in the health effects of different types and domains of physical activity (leisure-time; occupational; transportation; household; education) and of sedentary behavior (occupational; screen time; television viewing); and 4) the joint association between physical activity and sedentary time with health outcomes across the life course. In addition, we acknowledge the need to conduct more population-based studies in low- and middle-income countries and in people living with disabilities and/or chronic disease, and to identify how various sociodemographic factors (age, sex, race/ethnicity, socioeconomic status) modify the health effects of physical activity, in order to address global health disparities. CONCLUSIONS: Although the 2020 WHO Guidelines for Physical Activity and Sedentary Behavior were informed by the most up-to-date research on the health effects of physical activity and sedentary time, there is still substantial work to be done in advancing the global physical activity agenda.

Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries.

At the time of writing, it is unclear how the COVID-19 pandemic will play out in rapidly urbanising regions of the world. In these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the COVID-19 pandemic in these contexts. COVID-19 infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. However, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. In this current debate piece, focusing on two of the four risk factors that contribute to >80% of the NCD burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. By considering mitigation responses implemented by governments in several LMIC cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. Such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term.

Association between breakfast frequency and physical activity and sedentary time: a cross-sectional study in children from 12 countries.

BACKGROUND: Existing research has documented inconsistent findings for the associations among breakfast frequency, physical activity (PA), and sedentary time in children. The primary aim of this study was to examine the associations among breakfast frequency and objectively-measured PA and sedentary time in a sample of children from 12 countries representing a wide range of human development, economic development and inequality. The secondary aim was to examine interactions of these associations between study sites. METHODS: This multinational, cross-sectional study included 6228 children aged 9-11 years from the 12 International Study of Childhood Obesity, Lifestyle and the Environment sites. Multilevel statistical models were used to examine associations between self-reported habitual breakfast frequency defined using three categories (breakfast consumed 0 to 2 days/week [rare], 3 to 5 days/week [occasional] or 6 to 7 days/week [frequent]) or two categories (breakfast consumed less than daily or daily) and accelerometry-derived PA and sedentary time during the morning (wake time to 1200 h) and afternoon (1200 h to bed time) with study site included as an interaction term. Model covariates included age, sex, highest parental education, body mass index z-score, and accelerometer waking wear time. RESULTS: Participants averaged 60 (s.d. 25) min/day in moderate-to-vigorous PA (MVPA), 315 (s.d. 53) min/day in light PA and 513 (s.d. 69) min/day sedentary. Controlling for covariates, breakfast frequency was not significantly associated with total daily or afternoon PA and sedentary time. For the morning, frequent breakfast consumption was associated with a higher proportion of time in MVPA (0.3%), higher proportion of time in light PA (1.0%) and lower min/day and proportion of time sedentary (3.4 min/day and 1.3%) than rare breakfast consumption (all p ≤ 0.05). No significant associations were found when comparing occasional with rare or frequent breakfast consumption, or daily with less than daily breakfast consumption. Very few significant interactions with study site were found. CONCLUSIONS: In this multinational sample of children, frequent breakfast consumption was associated with higher MVPA and light PA time and lower sedentary time in the morning when compared with rare breakfast consumption, although the small magnitude of the associations may lack clinical relevance. TRIAL REGISTRATION: The International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) is registered at (Identifier NCT01722500 ).

The HealthKick Study: Modifiable Lifestyle Factors in Primary Caregivers of Primary School Learners from Two School Districts in the Western Cape Province, South Africa.

Background: The HealthKick (HK) study showed that educators (teachers) had a high prevalence of risk factors for the development of non-communicable diseases (NCDs). Little data are available on parents or other primary caregivers of learners from disadvantaged schools. Aim: The aim of our study was to determine modifiable risk factors for the development of NCDs in a sample of caregivers of schools included in the HK intervention program. Participants: Caregivers of grade 4 children from 25 schools were invited to take part in the study and 175 participated. Caregivers were Black Africans and of mixed ethnic origin. Methods: Dietary intake was measured using a validated frequency questionnaire. Physical activity was measured by completing the Global Physical Activity Questionnaire (GPAQ). Caregivers described their smoking habits and alcohol usage. Weight and height were measured for each participant and body mass index (BMI) was calculated. Results: Eighty percent women and 50% men had a BMI ≥25 (overweight or obese). The most frequently consumed categories of foods were processed foods, energy-dense foods, and high-fat foods representing unhealthy food choices. More than half of the total group (81.7%) and both males and females were meeting physical activity recommendations of 600 METs/week. Many caregivers, particularly men (53%), smoked cigarettes and reportedly consumed alcohol during the week and on weekends. Conclusion: Caregivers of children in the HK study population presented with a large number of modifiable health risk behaviors. These results highlight the importance of engaging caregivers, as part of a whole school intervention, to promote healthy eating and physical activity.

Does Physical Activity Mediate the Association Between Perceived Neighborhood Aesthetics and Overweight/Obesity Among South African Adults Living in Selected Urban and Rural Communities?

BACKGROUND: To investigate the mediation effects of physical activity (PA) on the relationship between the perceived neighborhood aesthetic environment and overweight/obesity in free-living South Africans. METHODS: A cross-sectional study of 671 adults aged ≥ 35 years was analyzed. PA was assessed using the validated International Physical Activity Questionnaire. Perceived neighborhood aesthetics was assessed using the Neighborhood Environment Walkability Scale Questionnaire. RESULTS: Of 671 participants, 76.0% were women, 34.1% aged 45-54 years, and 69.2% were overweight or obese. In adjusted logistic regression models, overweight/obesity was significantly associated with neighborhood aesthetics [odds ratio (OR) = 0.68; 95% confidence interval (CI), 0.50-0.93] and PA (OR = 0.65; 95% CI, 0.65-0.90). In expanded multivariable models, overweight/obesity was associated with age 45-55 years (OR = 1.59; 95% CI, 1.05-2.40), female gender (OR = 6.24; 95% CI, 3.95-9.86), tertiary education (OR = 4.05; 95% CI, 1.19-13.86), and urban residence (OR = 2.46; 95% CI, 1.66-3.65). CONCLUSION: Aesthetics was positively associated with PA; both aesthetics and PA were negatively associated with overweight and obesity. There was no evidence to support a significant mediating effect of PA on the relationship between aesthetics and overweight/obesity. Future studies should consider objective assessment of aesthetics and PA. In addition, future studies should consider using longitudinal design to evaluate food-related environments, which are related to overweight or obesity.

Accelerometer-measured physical activity is not associated with two-year weight change in African-origin adults from five diverse populations.

BACKGROUND: Increasing population-levels of physical activity (PA) is a controversial strategy for managing the obesity epidemic, given the conflicting evidence for weight loss from PA alone per se. We measured PA and weight change in a three-year prospective cohort study in young adults from five countries (Ghana, South Africa, Jamaica, Seychelles and USA). METHODS: A total of 1,944 men and women had baseline data, and at least 1 follow-up examination including measures of anthropometry (weight/BMI), and objective PA (accelerometer, 7-day) following the three-year study period. PA was explored as 1-minute bouts of moderate and vigorous PA (MVPA) as well as daily sedentary time. RESULTS: At baseline; Ghanaian and South African men had the lowest body weights (63.4 ± 9.5, 64.9 ± 11.8 kg, respectively) and men and women from the USA the highest (93.6 ± 25.9, 91.7 ± 23.4 kg, respectively). Prevalence of normal weight ranged from 85% in Ghanaian men to 29% in USA men and 52% in Ghanaian women to 15% in USA women. Over the two-year follow-up period, USA men and Jamaican women experienced the smallest yearly weight change rate (0.1 ± 3.3 kg/yr; -0.03 ± 3.0 kg/yr, respectively), compared to South African men and Ghanaian women greatest yearly change (0.6.0 ± 3.0 kg/yr; 1.22 ± 2.6 kg/yr, respectively). Mean yearly weight gain tended to be larger among normal weight participants at baseline than overweight/obese at baseline. Neither baseline MVPA nor sedentary time were associated with weight gain. Using multiple linear regression, only baseline weight, age and gender were significantly associated with weight gain. DISCUSSION: From our study it is not evident that higher volumes of PA alone are protective against future weight gain, and by deduction our data suggest that other environmental factors such as the food environment may have a more critical role.

Results From South Africa's 2016 Report Card on Physical Activity for Children and Youth.

BACKGROUND: We present results of the 2016 Healthy Active Kids South Africa (HAKSA) Report Card on the current status of physical activity (PA) and nutrition in South African youth. The context in which we interpret the findings is that participation in PA is a fundamental human right, along with the right to "attainment of the highest standard of health." METHODS: The HAKSA 2016 Writing Group was comprised of 33 authorities in physical education, exercise science, nutrition, public health, and journalism. The search strategy was based on peer-reviewed manuscripts, dissertations, and 'gray' literature. The core PA indicators are Overall Physical Activity Level; Organized Sport Participation; Active and Outdoor Play; Active Transportation; Sedentary Behaviors; Family and Peer Influences; School; Community and the Built Environment; and National Government Policy, Strategies, and Investment. In addition, we reported on Physical Fitness and Motor Proficiency separately. We also reported on nutrition indicators including Overweight and Under-nutrition along with certain key behaviors such as Fruit and Vegetable Intake, and policies and programs including School Nutrition Programs and Tuck Shops. Data were extracted and grades assigned after consensus was reached. Grades were assigned to each indicator ranging from an A, succeeding with a large majority of children and youth (81% to 100%); B, succeeding with well over half of children and youth (61% to 80%); C, succeeding with about half of children and youth (41% to 60%); D, succeeding with less than half but some children and youth (21% to 40%); and F, succeeding with very few children and youth (0% to 20%); INC is inconclusive. RESULTS: Overall PA levels received a C grade, as we are succeeding with more than 50% of children meeting recommendations. Organized Sports Participation also received a C, and Government Policies remain promising, receiving a B. Screen time and sedentary behavior were a major concern. Under- and over-weight were highlighted and, as overweight is on the rise, received a D grade. CONCLUSIONS: In particular, issues of food security, obesogenic environments, and access to activity-supportive environments should guide social mobilization downstream and policy upstream. There is an urgent need for practice-based evidence based on evaluation of existing, scaled up interventions.

The social patterning of risk factors for noncommunicable diseases in five countries: evidence from the modeling the epidemiologic transition study (METS).

BACKGROUND: Associations between socioeconomic status (SES) and risk factors for noncommunicable diseases (NCD-RFs) may differ in populations at different stages of the epidemiological transition. We assessed the social patterning of NCD-RFs in a study including populations with different levels of socioeconomic development. METHODS: Data on SES, smoking, physical activity, body mass index, blood pressure, cholesterol and glucose were available from the Modeling the Epidemiologic Transition Study (METS), with about 500 participants aged 25-45 in each of five sites (Ghana, South Africa, Jamaica, Seychelles, United States). RESULTS: The prevalence of NCD-RFs differed between these populations from five countries (e.g., lower prevalence of smoking, obesity and hypertension in rural Ghana) and by sex (e.g., higher prevalence of smoking and physical activity in men and of obesity in women in most populations). Smoking and physical activity were associated with low SES in most populations. The associations of SES with obesity, hypertension, cholesterol and elevated blood glucose differed by population, sex, and SES indicator. For example, the prevalence of elevated blood glucose tended to be associated with low education, but not with wealth, in Seychelles and USA. The association of SES with obesity and cholesterol was direct in some populations but inverse in others. CONCLUSIONS: In conclusion, the distribution of NCD-RFs was socially patterned in these populations at different stages of the epidemiological transition, but associations between SES and NCD-RFs differed substantially according to risk factor, population, sex, and SES indicator. These findings emphasize the need to assess and integrate the social patterning of NCD-RFs in NCD prevention and control programs in LMICs.

"Choice Set" for health behavior in choice-constrained settings to frame research and inform policy: examples of food consumption, obesity and food security.

OBJECTIVES: Using the nexus between food consumption, food security and obesity, this paper addresses the complexity of health behavior decision-making moments that reflect relational social dynamics in context-specific dialogues, often in choice-constrained conditions. METHODS: A pragmatic review of literature regarding social determinants of health in relation to food consumption, food security and obesity was used to advance this theoretical model. RESULTS AND DISCUSSION: We suggest that health choice, such as food consumption, is based on more than the capacity and volition of individuals to make "healthy" choices, but is dialogic and adaptive. In terms of food consumption, there will always be choice-constrained conditions, along a continuum representing factors over which the individual has little or no control, to those for which they have greater agency. These range from food store geographies and inventories and food availability, logistical considerations such as transportation, food distribution, the structure of equity in food systems, state and non-government food and nutrition programs, to factors where the individual exercises a greater degree of autonomy, such as sociocultural foodways, family and neighborhood shopping strategies, and personal and family food preferences. At any given food decision-making moment, many factors of the continuum are present consciously or unconsciously when the individual makes a decision. These health behavior decision-making moments are mutable, whether from an individual perspective, or within a broader social or policy context. We review the construct of "choice set", the confluence of factors that are temporally weighted by the differentiated and relationally-contextualized importance of certain factors over others in that moment. The choice transition represents an essential shift of the choice set based on the conscious and unconscious weighting of accumulated evidence, such that people can project certain outcomes. Policies and interventions should avoid dichotomies of "good and bad" food choices or health behaviors, but focus on those issues that contribute to the weightedness of factors influencing food choice behavior at a given decision-making moment and within a given choice set.

NEWS for Africa: adaptation and reliability of a built environment questionnaire for physical activity in seven African countries.

BACKGROUND: Built environment and policy interventions are effective strategies for controlling the growing worldwide deaths from physical inactivity-related non-communicable diseases. To improve built environment research and develop African specific evidence, it is important to first tailor built environment measures to African contexts and assess their psychometric properties across African countries. This study reports on the adaptation and test-retest reliability of the Neighborhood Environment Walkability Scale in seven sub-Saharan African countries (NEWS-Africa). METHODS: The original NEWS comprising 8 subscales measuring reported physical and social attributes of neighborhood environments was systematically adapted for Africa through extensive input from physical activity and public health researchers, built environment professionals, and residents in seven African countries: Cameroon, Ghana, Kenya, Mozambique, Nigeria, South Africa and Uganda. Cognitive testing of NEWS-Africa was conducted among diverse residents (N = 109, 50 youth [12 - 17 years] and 59 adults [22 - 67 years], 69 % from low socioeconomic status [SES] neighborhoods). NEWS-Africa was translated into local languages and evaluated for 2-week test-retest reliability in adult participants (N = 301; female = 50.2 %; age = 32.3 ± 12.9 years) purposively recruited from neighborhoods varying in walkability (high and low walkable) and SES (high and low income) and from villages in six of seven participating countries. RESULTS: The original 67 NEWS items was expanded to 89 scores (76 individual NEWS items and 13 computed scales). Several modifications were made to individual items, and some new items were added to capture important attributes in the African environment. A new scale on personal safety was created, and the aesthetics scale was enlarged to reflect African specific characteristics. Over 95 % of all NEWS-Africa scores (items plus computed scales) demonstrated evidence of "excellent" (ICCs > .75 %) or "good" (ICCs = 0.60 to 0.74) reliability. Seven (53.8 %) of the 13 computed NEWS scales demonstrated "excellent" agreement and the other six had "good" agreement. No items or scales demonstrated "poor" reliability (ICCs < .40). CONCLUSIONS: The systematic adaptation and initial psychometric evaluation of NEWS-Africa indicates the instrument is feasible and reliable for use with adults of diverse demographic characteristics in Africa. The measure is likely to be useful for research, surveillance of built environment conditions for planning purposes, and to evaluate physical activity and policy interventions in Africa.

Impact of a South African School-based Intervention, HealthKick, on Fitness Correlates.

OBJECTIVES: To assess the impact of a whole-of-school health promotion program targeting healthy eating and physical activity on physical fitness levels, and physical activity-related knowledge, attitudes and behavior of primary school children. METHODS: Sixteen primary schools were randomly assigned as intervention (N = 8) and control (N = 8) schools. A selection of tests from the Eurofit testing battery was used to assess changes in fitness levels over the 3 years of the intervention. Anthropometric measurements included height and weight. A physical activity knowledge, attitude and behavior (KAB) questionnaire was administered to participants. Multi-level mixed effect linear models were used to assess differences between intervention and control schools. RESULTS: No overall improvement in physical fitness was found. The sit-ups score improved significantly in the intervention group (p < .05). No overall intervention effects were found on the determinants of physical activity behavior. Knowledge improved in both the intervention (p = .005) and control (p < .001) groups. CONCLUSION: The lack of a specific intervention effect on fitness levels and physical activity-related KAB indicates that a "low intensity" intervention is not effective in South African primary school settings.

Prevalence and socio-demographic correlates of physical activity levels among South African adults in Cape Town and Mount Frere communities in 2008-2009.

BACKGROUND: Physical activity has been linked to reduced risk of various cardiometabolic disease, cancer, and premature mortality. We investigated the prevalence and socio-demographic correlates of physical activity among adults in urban and rural communities in South Africa. Methods: This was a cross-sectional survey comprising 1733 adults aged ≥35 years from the Cape Town (urban) and Mount Frere (rural) sites of the Prospective Urban Rural Epidemiology study. Physical activity was assessed using the validated International Physical Activity Questionnaire. Multinomial logistic regressions were used to relate physical activity with socio-demographic characteristics. RESULTS: Overall, 74% of participants engaged in moderate-to-vigorous physical activity. In the adjusted regression models, women were 34% less likely to engage in vigorous physical activity (OR =0.66, 95%-CI = 0.47-0.93). Physical activity decreased with age, varied with marital status, education and occupation, always in differential ways between urban and rural participants (all interactions p ≤ 0.047). For instance, in urban settings, those with secondary education were more likely to engage in moderate physical activity (OR = 2.06, 95%-CI = 1.08-3.92) than those with tertiary education. Single people were more likely to engage in high physical activity (OR = 2.10, 95%-CI = 1.03-4.28) than divorced. Overall, skilled participants were more likely to engage in vigorous physical activity (OR = 2.07, 95%-CI = 1.41-3.05) driven by significant effect in rural area (OR = 2.70, 95%-CI = 1.51-4.83). Urban participants were more likely to engage in moderate physical activity (OR = 1.67, 95%-CI = 1.31-2.13) than rural participants. CONCLUSIONS: To prevent chronic diseases among South Africans, attention should be paid to specific policies and interventions aimed at promoting PA among young adults in rural and urban setting, and across the social-economic diversity.