Social, economic, political, and geographical context that counts: meta-review of implementation determinants for policies promoting healthy diet and physical activity.

BACKGROUND: This meta-review investigated the context-related implementation determinants from seven domains (geographical, epidemiological, sociocultural, economic, ethics-related, political, and legal) that were systematically indicated as occurring during the implementation of obesity prevention policies targeting a healthy diet and a physically active lifestyle. METHODS: Data from nine databases and documentation of nine major stakeholders were searched for the purpose of this preregistered meta-review (#CRD42019133341). Context-related determinants were considered strongly supported if they were indicated in ≥60% of the reviews/stakeholder documents. The ROBIS tool and the Methodological Quality Checklist-SP were used to assess the quality-related risk of bias. RESULTS: Published reviews (k = 25) and stakeholder documents that reviewed the evidence of policy implementation (k = 17) were included. Across documents, the following six determinants from three context domains received strong support: economic resources at the macro (66.7% of analyzed documents) and meso/micro levels (71.4%); sociocultural context determinants at the meso/micro level, references to knowledge/beliefs/abilities of target groups (69.0%) and implementers (73.8%); political context determinants (interrelated policies supported in 71.4% of analyzed reviews/documents; policies within organizations, 69.0%). CONCLUSIONS: These findings indicate that sociocultural, economic, and political contexts need to be accounted for when formulating plans for the implementation of a healthy diet and physical activity/sedentary behavior policies.

High Energetic Demand of Elite Rowing - Implications for Training and Nutrition.

Purpose: Elite rowers have large body dimensions, a high metabolic capacity, and they realize high training loads. These factors suggest a high total energy requirement (TER), due to high exercise energy expenditure (EEE) and additional energetic needs. We aimed to study EEE and intensity related substrate utilization (SU) of elite rowers during rowing (EEEROW) and other (EEENON-ROW) training. Methods: We obtained indirect calorimetry data during incremental (N = 174) and ramp test (N = 42) ergometer rowing in 14 elite open-class male rowers (body mass 91.8 kg, 95% CI [87.7, 95.9]). Then we calculated EEEROW and SU within a three-intensity-zone model. To estimate EEENON-ROW, appropriate estimates of metabolic equivalents of task were applied. Based on these data, EEE, SU, and TER were approximated for prototypical high-volume, high-intensity, and tapering training weeks. Data are arithmetic mean and 95% confidence interval (95% CI). Results: EEEROW for zone 1 to 3 ranged from 15.6 kcal·min-1, 95% CI [14.8, 16.3] to 49.8 kcal·min-1, 95% CI [48.1, 51.6], with carbohydrate utilization contributing from 46.4%, 95% CI [42.0, 50.8] to 100.0%, 95% CI [100.0, 100.0]. During a high-volume, a high-intensity, or a taper week, TER was estimated to 6,775 kcal·day-1, 95% CI [6,651, 6,898], 5,772 kcal·day-1, 95% CI [5,644, 5,900], or 4,626 kcal∙day-1, 95% CI [4,481, 4,771], respectively. Conclusion: EEE in elite open-class male rowers is remarkably high already during zone 1 training and carbohydrates are dominantly utilized, indicating relatively high metabolic stress even during low intensity rowing training. In high-volume training weeks, TER is presumably at the upper end of the sustainable total energy expenditure. Periodized nutrition seems warranted for rowers to avoid low energy availability, which might negatively impact performance, training, and health.

Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review.

BACKGROUND: Policy frameworks focusing on policy implementation may vary in terms of their scope, included constructs, relationships between the constructs, and context factors. Although multiple policy implementation frameworks exist, the overarching synthesis characterizing differences between the frameworks is missing. This study investigated frameworks guiding implementation of policies aiming at healthy nutrition, physical activity promotion, and a reduction of sedentary behavior. In particular, we aimed at examining the scope of the frameworks and the content of included constructs (e.g., referring to implementation processes, determinants, or implementation evaluation), the level at which these constructs operate (e.g., the individual level, the organizational/community level), relationships between the constructs, and the inclusion of equity factors. METHODS: A systematic review (the PROSPERO registration no. CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analyzed. RESULTS: Across the frameworks, 47.4% (18 in 38) addressed three aims: description of the process, determinants, and the evaluation of implementation. The majority of frameworks (65.8%; 25 in 38) accounted for constructs from three levels: individual, organizational/community, and the system level. System-level constructs were included less often (76.3%; 29 in 38) than individual-level or organizational/community-level constructs (86.8% [33 in 38 frameworks] and 94.7% [36 in 38 frameworks] respectively). The majority of frameworks (84.2%, 32 in 38) included at least some sections that were solely of descriptive character (a list of unassociated constructs); 50.0% (19 in 38) included sections of prescriptive character (general steps of implementation); 60.5% (23 in 38) accounted for explanatory sections (assuming bi- or uni-directorial associations). The complex system approach was accounted for only in 21.1% (8 in 38) of frameworks. More than half (55.3%; 21 in 38) of frameworks did not account for any equity constructs (e.g., socioeconomic status, culture). CONCLUSIONS: The majority of policy implementation frameworks have two or three aims (combining processes, determinants and/or the evaluation of implementation), include multi-level constructs (although the system-level determinants are less frequently included than those from the individual- or organizational/community-level), combine sections of purely descriptive character with sections accounting for prescriptive and/or explanatory associations, and are likely to include a little or no equity constructs. REGISTRATION: PROSPERO, #CRD42019133251.

Meta-review of implementation determinants for policies promoting healthy diet and physically active lifestyle: application of the Consolidated Framework for Implementation Research.

BACKGROUND: Although multiple systematic reviews indicate that various determinants (barriers and facilitators) occur in the implementation processes of policies promoting healthy diet, physical activity (PA), and sedentary behavior (SB) reduction, the overarching synthesis of such reviews is missing. Applying the Consolidated Framework for Implementation Research (CFIR), this meta-review aims to (1) identify determinants that were systematically indicated as occurring during the implementation processes and (2) identify differences in the presence of determinants across reviews versus stakeholder documents on healthy diet/PA/SB policies, reviews/stakeholder documents addressing healthy diet policies versus PA/SB policies targeting any population/setting, and healthy diet/PA/SB policies focusing on school settings. METHODS: A meta-review of published systematic scoping or realist reviews (k = 25) and stakeholder documents (k = 17) was conducted. Data from nine bibliographic databases and documentation of nine major stakeholders were systematically searched. Included reviews (72%) and stakeholder documents (100%) provided qualitative synthesis of original research on implementation determinants of policies promoting healthy diet or PA or SB reduction, and 28% of reviews provided some quantitative synthesis. Determinants were considered strongly supported if they were indicated by ≥ 60.0% of included reviews/stakeholder documents. RESULTS: Across the 26 CFIR-based implementation determinants, seven were supported by 66.7-76.2% of reviews/stakeholder documents. These determinants were cost, networking with other organizations/communities, external policies, structural characteristics of the setting, implementation climate, readiness for implementation, and knowledge/beliefs of involved individuals. Most frequently, published reviews provided support for inner setting and individual determinants, whereas stakeholder documents supported outer and inner setting implementation determinants. Comparisons between policies promoting healthy diet with PA/SB policies revealed shared support for only three implementation determinants: cost, implementation climate, and knowledge/beliefs. In the case of healthy diet/PA/SB policies targeting school settings, 14 out of 26 implementation determinants were strongly supported. CONCLUSIONS: The strongly supported (i.e., systematically indicated) determinants may guide policymakers and researchers who need to prioritize potential implementation determinants when planning and monitoring the implementation of respective policies. Future research should quantitatively assess the importance or role of determinants and test investigate associations between determinants and progress of implementation processes. TRIAL REGISTRATION: PROSPERO, # CRD42019133341.

Recommendations for Face Coverings While Exercising During the COVID-19 Pandemic.

In an effort to reduce transmission and number of infections of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) virus, governments and official bodies around the world have produced guidelines on the use of face masks and face coverings. While there is a growing body of recommendations for healthcare professionals and the wider population to use facial protection in "enclosed spaces" where minimal distancing from other individuals is not possible, there is a dearth of clear guidelines for individuals undertaking exercise and sporting activity. The present viewpoint aims to propose recommendations for face coverings while exercising during the COVID-19 pandemic that consider physical distancing, the environment, the density of active cases associated with the specific sports activity, and the practical use of face coverings in order to reduce potential viral transmission. Recommendations are provided on the basis of very limited available evidence in conjunction with the extensive collective clinical experience of the authors and acknowledging the need to consider the likelihood of the presence of the SARS-CoV-2 in the general population. We recommend that face coverings should be used in any environment considered to be of a high or moderate transmission risk, where tolerated and after individual risk assessment. In addition, as national caseloads fluctuate, individual sporting bodies should consider up to date guidance on the use of face coverings during sport and exercise, alongside other preventative measures.

Assessing quality of life in a clinical study on heart rehabilitation patients: how well do value sets based on given or experienced health states reflect patients' valuations?

BACKGROUND: Quality of life as an endpoint in a clinical study may be sensitive to the value set used to derive a single score. Focusing on patients' actual valuations in a clinical study, we compare different value sets for the EQ-5D-3L and assess how well they reproduce patients' reported results. METHODS: A clinical study comparing inpatient (n = 98) and outpatient (n = 47) rehabilitation of patients after an acute coronary event is re-analyzed. Value sets include: 1. Given health states and time-trade-off valuation (GHS-TTO) rendering economic utilities; 2. Experienced health states and valuation by visual analog scale (EHS-VAS). Valuations are compared with patient-reported VAS rating. Accuracy is assessed by mean absolute error (MAE) and by Pearson's correlation ρ. External validity is tested by correlation with established MacNew global scores. Drivers of differences between value sets and VAS are analyzed using repeated measures regression. RESULTS: EHS-VAS had smaller MAEs and higher ρ in all patients and in the inpatient group, and correlated best with MacNew global score. Quality-adjusted survival was more accurately reflected by EHS-VAS. Younger, better educated patients reported lower VAS at admission than the EHS-based value set. EHS-based estimates were mostly able to reproduce patient-reported valuation. Economic utility measurement is conceptually different, produced results less strongly related to patients' reports, and resulted in about 20 % longer quality-adjusted survival. CONCLUSION: Decision makers should take into account the impact of choosing value sets on effectiveness results. For transferring the results of heart rehabilitation patients from another country or from another valuation method, the EHS-based value set offers a promising estimation option for those decision makers who prioritize patient-reported valuation. Yet, EHS-based estimates may not fully reflect patient-reported VAS in all situations.

Long term effects of comprehensive cardiac rehabilitation in an inpatient and outpatient setting.

OBJECTIVES: To compare the long-term effects of comprehensive outpatient versus inpatient rehabilitation with respect to morbidity and mortality, as well as to changes in physical performance and physical activity. DESIGN: A total of 163 consecutive patients were enrolled for comprehensive cardiac rehabilitation (CCR) following a recent coronary event, to outpatient or inpatient CCR according to treatment preference because randomisation was accepted by only 4 patients. CCR was six hours per day for 4 weeks and consisted of exercise training, education, psychological support, and nutritional and occupational advice. Examinations were before, after and 12 months after CCR. Primary outcome measures were event-free survival with or without interventions, EFS-I or EFS, respectively, 12 months after rehabilitation. RESULTS: Main patient characteristics were distributed equally in the cohorts. Results were adjusted by logistic regression for age, BMI, LV-function, exercise capacity and physical activity before the event. Adjusted EFS, EFS-I , overall survival and other morbidity outcome measures did not differ significantly. During CCR, physical activity was higher in outpatients, but this difference was not maintained in the follow up. Average physical activity was increased 12 month after CR with no difference between groups. CONCLUSION: Although influenced by patient preference, participation in either inpatient or outpatient CCR led to comparable results in terms of all-cause or cardiac overall survival, event-free survival and other secondary outcome measures like cardiac morbidity, physical performance and increased physical activity.