The Health4Life e-health intervention for modifying lifestyle risk behaviours of adolescents: secondary outcomes of a cluster randomised controlled trial.

OBJECTIVES: To investigate the effectiveness of a school-based multiple health behaviour change e-health intervention for modifying risk factors for chronic disease (secondary outcomes). STUDY DESIGN: Cluster randomised controlled trial. SETTING, PARTICIPANTS: Students (at baseline [2019]: year 7, 11-14 years old) at 71 Australian public, independent, and Catholic schools. INTERVENTION: Health4Life: an e-health school-based multiple health behaviour change intervention for reducing increases in the six major behavioural risk factors for chronic disease: physical inactivity, poor diet, excessive recreational screen time, poor sleep, and use of alcohol and tobacco. It comprises six online video modules during health education class and a smartphone app. MAIN OUTCOME MEASURES: Comparison of Health4Life and usual health education with respect to their impact on changes in twelve secondary outcomes related to the six behavioural risk factors, assessed in surveys at baseline, immediately after the intervention, and 12 and 24 months after the intervention: binge drinking, discretionary food consumption risk, inadequate fruit and vegetable intake, difficulty falling asleep, and light physical activity frequency (categorical); tobacco smoking frequency, alcohol drinking frequency, alcohol-related harm, daytime sleepiness, and time spent watching television and using electronic devices (continuous). RESULTS: A total of 6640 year 7 students completed the baseline survey (Health4Life: 3610; control: 3030); 6454 (97.2%) completed at least one follow-up survey, 5698 (85.8%) two or more follow-up surveys. Health4Life was not statistically more effective than usual school health education for influencing changes in any of the twelve outcomes over 24 months; for example: fruit intake inadequate: odds ratio [OR], 1.08 (95% confidence interval [CI], 0.57-2.05); vegetable intake inadequate: OR, 0.97 (95% CI, 0.64-1.47); increased light physical activity: OR, 1.00 (95% CI, 0.72-1.38); tobacco use frequency: relative difference, 0.03 (95% CI, -0.58 to 0.64) days per 30 days; alcohol use frequency: relative difference, -0.34 (95% CI, -1.16 to 0.49) days per 30 days; device use time: relative difference, -0.07 (95% CI, -0.29 to 0.16) hours per day. CONCLUSIONS: Health4Life was not more effective than usual school year 7 health education for modifying adolescent risk factors for chronic disease. Future e-health multiple health behaviour change intervention research should examine the timing and length of the intervention, as well as increasing the number of engagement strategies (eg, goal setting) during the intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12619000431123 (prospective).

Co-designing a Physical Activity Service for Refugees and Asylum Seekers Using an Experience-Based Co-design Framework.

People from refugee and asylum seeker backgrounds resettling in Australia often experience intersecting risks for poor mental and physical health. Physical activity can promote better health outcomes, however there are limited programs tailored for this population. Therefore, understanding how to support refugees and asylum seekers to engage in physical activity is crucial. This paper aims to describe how the experience-based co-design (EBCD) process was used to identify priorities for a new physical activity service for refugees and asylum seekers. Using an EBCD framework we conducted qualitative interviews and co-design workshops with service users (refugees and asylum seekers living in the community) and service providers at a community Centre in Sydney, Australia. Sixteen participants, including eight service users and eight service providers engaged in the EBCD process over 12-months. The interviews revealed common themes or 'touchpoints' including barriers and enablers to physical activity participation such as access, safety and competing stressors. Subsequent co-design focus groups resulted in the establishment of five fundamental priorities and actionable strategies; ensuring cultural and psychological safety, promoting accessibility, facilitating support to access basic needs, enhancing physical activity literacy and fostering social connection. Using EBCD methodology, this study used the insights and lived experiences of both service users and providers to co-design a physical activity service for refugees and asylum seekers which is safe, supportive, social and accessible. The results of the implementation and evaluation of the program are ongoing.

Nonpharmacological approaches for pain and symptoms of depression in people with osteoarthritis: systematic review and meta-analyses.

People with osteoarthritis often experience pain and depression. These meta-analyses examined and compared nonpharmacological randomized controlled trials (RCTs) for pain and symptoms of depression in people living with osteoarthritis. RCTs published up until April 2022 were sourced by searching electronic databases EMBASE, PUBMED & MEDLINE, Web of Science, CINAHL and PEDro. Random-effects meta-analyses were performed to calculate pooled effect sizes (ES) and 95% confidence intervals (CI) for pain and depression. Subgroup analyses examined intervention subtypes. For pain, 29 interventions (n = 4382; 65 ± 6.9 years; 70% female), revealed a significant effect on reducing pain (ES = 0.43, 95% CI [0.25, 0.61], p < 0.001). Effect sizes were significant (p < 0.001) for movement meditation (ES = 0.52; 95% CI [0.35, 0.69]), multimodal approaches (ES = 0.37; 95% CI [0.22, 0.51]), and psychological therapy (ES = 0.21; 95% CI [0.11, 0.31]), and significant (p = 0.046) for resistance exercise (ES = 0.43, 95% CI [- 0.07, 0.94]. Aerobic exercise alone did not improve pain. For depression, 28 interventions (n = 3377; 63 ± 7.0 years; 69% female), revealed a significant effect on reducing depressive symptoms (ES = 0.29, 95% CI [0.08, 0.49], p < 0.001). Effect sizes were significant for movement meditation (ES = 0.30; 95% CI [0.06, 0.55], p = 0.008) and multimodal interventions (ES = 0.12; 95% CI [0.07, 0.18], p < 0.001). Resistance/aerobic exercise or therapy alone did not improve depressive symptoms. Mind-body approaches were more effective than aerobic/resistance exercise or therapy alone for reducing pain and depression in people with osteoarthritis.Systematic review registration: PROSPERO CRD42022338051.

Health4Life eHealth intervention to modify multiple lifestyle risk behaviours among adolescent students in Australia: a cluster-randomised controlled trial.

BACKGROUND: Lifestyle risk behaviours are prevalent among adolescents and commonly co-occur, but current intervention approaches tend to focus on single risk behaviours. This study aimed to evaluate the efficacy of the eHealth intervention Health4Life in modifying six key lifestyle risk behaviours (ie, alcohol use, tobacco smoking, recreational screen time, physical inactivity, poor diet, and poor sleep, known as the Big 6) among adolescents. METHODS: We conducted a cluster-randomised controlled trial in secondary schools that had a minimum of 30 year 7 students, in three Australian states. A biostatistician randomly allocated schools (1:1) to Health4Life (a six-module, web-based programme and accompanying smartphone app) or an active control group (usual health education) with the Blockrand function in R, stratified by site and school gender composition. All students aged 11-13 years who were fluent in English and attended participating schools were eligible. Teachers, students, and researchers were not masked to allocation. Primary outcomes were alcohol use, tobacco use, recreational screen time, moderate to vigorous physical activity (MVPA), sugar-sweetened beverage intake, and sleep duration at 24 months, measured by self-report surveys, and analysed in all students who were eligible at baseline. Latent growth models estimated between-group change over time. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000431123). FINDINGS: Between April 1, 2019, and Sept 27, 2019, we recruited 85 schools (9280 students), of which 71 schools with 6640 eligible students (36 schools [3610 students] assigned to the intervention and 35 [3030 students] to the control) completed the baseline survey. 14 schools were excluded from the final analysis or withdrew, mostly due to a lack of time. We found no between-group differences for alcohol use (odds ratio 1·24, 95% CI 0·58-2·64), smoking (1·68, 0·76-3·72), screen time (0·79, 0·59-1·06), MVPA (0·82, 0·62-1·09), sugar-sweetened beverage intake (1·02, 0·82-1·26), or sleep (0·91, 0·72-1·14) at 24 months. No adverse events were reported during this trial. INTERPRETATION: Health4Life was not effective in modifying risk behaviours. Our results provide new knowledge about eHealth multiple health behaviour change interventions. However, further research is needed to improve efficacy. FUNDING: Paul Ramsay Foundation, the Australian National Health and Medical Research Council, the Australian Government Department of Health and Aged Care, and the US National Institutes of Health.

Effect of Brief Counseling by Allied Health Professionals on Step Count of People With Peripheral Artery Disease: A Randomized Clinical Trial.

Importance: It is unclear how to effectively promote walking in people with peripheral artery disease (PAD). Objective: To test whether brief counseling delivered by allied health professionals increases step count in participants with PAD. Design, Setting, and Participants: In this randomized clinical trial, participants with symptomatic PAD were recruited from sites in Australia and randomly allocated 1:1 to the counseling intervention or an attention control. Data were collected from January 2015 to July 2021, and data were analyzed from March to November 2022. Interventions: Two 1-hour face-to-face and two 15-minute telephone counseling sessions designed to increase walking. Main Outcomes and Measures: The primary outcome was the between-group difference in change in daily step count estimated by accelerometer recordings over 7 days at baseline and 4 months, using imputation for missing values. Other outcomes at 4, 12, and 24 months included step count, 6-minute walk distance, and disease-specific and generic measures of health-related quality of life. Risk of major adverse limb events was assessed over 24 months. Results: Of 200 included participants, 144 (72.0%) were male, and the mean (SD) age was 69.2 (9.3) years. The planned sample of 200 participants was allocated to the counseling intervention group (n = 102) or attention control group (n = 98). Overall, 198 (99.0%), 175 (87.5%), 160 (80.0%) and 143 (71.5%) had step count assessed at entry and 4, 12, and 24 months, respectively. There was no significant between-group difference in the primary outcome of change in daily step count over 4 months (mean steps, 415; 95% CI, -62 to 893; P = .07). Participants in the counseling group had significantly greater improvement in the secondary outcome of disease-specific Intermittent Claudication Questionnaire score at 4 months (3.2 points; 95% CI, 0.1-6.4; P = .04) and 12 months (4.3 points; 95% CI, 0.5-8.1; P = .03) but not at 24 months (1.2 points; 95% CI, -3.1 to 5.6; P = .57). Findings were similar for mean PAD Quality of Life Questionnaire component assessing symptoms and limitations in physical functioning (4 months: 1.5 points; 95% CI, 0.3-2.8; P = .02; 12 months: 1.8 points; 95% CI, 0.3-3.3; P = .02; 24 months: 1.3 points; 95% CI. -0.5 to 3.1; P = .16). There was no significant effect of the intervention on change in mean 6-minute walking distance (4 months: 9.3 m; 95% CI, -3.7 to 22.3; P = .16; 12 months: 13.8 m; 95% CI, -4.2 to 31.7; P = .13; 24 months: 1.2 m; 95% CI, -20.0 to 22.5; P = .91). The counseling intervention did not affect the rate of major adverse limb events over 24 months (12 [6.0%] in the intervention group vs 11 [5.5%] in the control group; P > .99). Conclusions and Relevance: This randomized clinical trial found no significant effect of brief counseling on step count in people with PAD. Alternate interventions are needed to enable walking. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12614000592640.

Measurement Properties of Smartphone Approaches to Assess Physical Activity in Healthy Young People: Systematic Review.

BACKGROUND: Physical inactivity is a preventable risk factor for several chronic diseases and one of the driving forces behind the growing global burden of disease. Recent evidence has shown that interventions using mobile smartphone apps can promote a significant increase in physical activity (PA) levels. However, the accuracy and reliability of using apps is unknown. OBJECTIVE: The aim of our review was to determine the accuracy and reliability of using mobile apps to measure PA levels in young people. We conducted a systematic review guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). METHODS: Studies published from 2007 to 2020 were sourced from 8 databases-Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOhost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost), and IEEE Xplore Digital Library database. Studies were conducted in young people aged 10-24 years and without chronic illnesses, who evaluated a mobile app's ability to measure PA. Primary outcomes included validity, reliability, and responsiveness of the measurement approach. Duplicate screening was conducted for eligibility, data extraction, and assessing the risk of bias. Results were reported as a systematic review. The main physical activity measures evaluated for each study were the following: total PA time (min/day or min/week), total moderate to vigorous PA per week, daily step count, intensity measure (heart rate), and frequency measure (days per week). RESULTS: Of the 149 identified studies, 5 met the inclusion criteria (322 participants, 176 female; mean age 14, SD 3 years). A total of 3 studies measured criterion validity and compared PA measured via apps against PA measured via an Actigraph accelerometer. The 2 studies that reported on construct validity identified a significant difference between self-reported PA and the objective measure. Only 1 of the 5 apps examined was available to the public, and although this app was highly accepted by young people, the app recorded PA to be significantly different to participants' self-reported PA. CONCLUSIONS: Overall, few studies assess the reliability, validity, and responsiveness of mobile apps to measure PA in healthy young people, with studies typically only reporting on one measurement property. Of the 3 studies that measured validity, all concluded that mobile phones were acceptable and valid tools. More research is needed into the validity and reliability of smartphone apps to measure PA levels in this population as well as in populations with other characteristics, including other age groups and those with chronic diseases. TRIAL REGISTRATION: PROSPERO CRD42019122242; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=122242.

Parent-based interventions to improve multiple lifestyle risk behaviors among adolescents: A systematic review and meta-analysis.

Lifestyle risk behaviors often co-occur and are prevalent among adolescents. Parent-based interventions addressing risk behaviors concurrently have the potential to improve youth and parent outcomes. This systematic review evaluated the efficacy of parent-based interventions targeting multiple lifestyle risk behaviors among adolescents and parents. MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), Scopus, CINAHL, the Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 2010-May 2021. Eligible studies were randomised controlled trials (RCTs) of parent-based interventions addressing 2+ risk behaviors: alcohol use, smoking, poor diet, physical inactivity, sedentary behaviors, and poor sleep. Studies directly targeting parents, and that assessed adolescent outcomes (11-18 years) were eligible. Where possible, random-effects meta-analysis was conducted. From 11,975 identified records, 46 publications of 36 RCTs (n = 28,322 youth, n = 7385 parents) were eligible. Parent-based interventions were associated with improved adolescent moderate-to-vigorous physical activity (MVPA) [Odds Ratio (OR) = 1.82, 95% CI = 1.18, 2.81; p = 0.007], and reduced screen time (SMD = -0.39, 95% CI = -0.62, -0.16, p = 0.0009) and discretionary food intake (SMD = -0.18; 95% CI = -0.30, -0.06; p = 0.002) compared to controls. However, there was some evidence that interventions increased the odds of ever using tobacco in the medium-term (OR = 1.47, 95% CI = 0.99, 2.18, p = 0.06) and of past month tobacco use in the long-term (OR = 1.46, 95% CI = 1.12, 1.90; p = 0.005). Overall, the quality of evidence was moderate. Parent-based interventions targeting multiple risk behaviors improved adolescent MVPA, and reduced screen time discretionary food intake. Further research is needed to address sleep problems and increase intervention efficacy, particularly for alcohol and tobacco use.

Baseline imbalance and heterogeneity are present in meta-analyses of randomized clinical trials examining the effects of exercise and medicines for blood pressure management.

Randomized clinical trials attempt to reduce bias and create similar groups at baseline to infer causal effects. In meta-analyses, baseline imbalance may threaten the validity of the treatment effects. This meta-epidemiological study examined baseline imbalance in comparisons of exercise and antihypertensive medicines. Baseline data for systolic blood pressure, diastolic blood pressure, and age were extracted from a network meta-analysis of 391 randomized trials comparing exercise types and antihypertensive medicines. Fixed-effect meta-analyses were used to determine the presence of baseline imbalance and/or inconsistency. Meta-regression analyses were conducted on sample size, the risk of bias for allocation concealment, and whether data for all randomized participants were presented at baseline. In one exercise comparison, the resistance group was 0.3 years younger than the control group (95% confidence interval 0.6 to 0.1). Substantial inconsistency was observed in other exercise comparisons. Less data were available for medicines, but there were no occurrences of baseline imbalance and only a few instances of inconsistency. Several moderator analyses identified significant associations. We identified baseline imbalance as well as substantial inconsistency in exercise comparisons. Researchers should consider conducting meta-analyses of key prognostic variables at baseline to ensure balance across trials.

Measurement Properties of Smartphone Approaches to Assess Diet, Alcohol Use, and Tobacco Use: Systematic Review.

BACKGROUND: Poor diet, alcohol use, and tobacco smoking have been identified as strong determinants of chronic diseases, such as cardiovascular disease, diabetes, and cancer. Smartphones have the potential to provide a real-time, pervasive, unobtrusive, and cost-effective way to measure these health behaviors and deliver instant feedback to users. Despite this, the validity of using smartphones to measure these behaviors is largely unknown. OBJECTIVE: The aim of our review is to identify existing smartphone-based approaches to measure these health behaviors and critically appraise the quality of their measurement properties. METHODS: We conducted a systematic search of the Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsycINFO (EBSCOhost), CINAHL (EBSCOHost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost), and IEEE Xplore Digital Library databases in March 2020. Articles that were written in English; reported measuring diet, alcohol use, or tobacco use via a smartphone; and reported on at least one measurement property (eg, validity, reliability, and responsiveness) were eligible. The methodological quality of the included studies was assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments Risk of Bias checklist. Outcomes were summarized in a narrative synthesis. This systematic review was registered with PROSPERO, identifier CRD42019122242. RESULTS: Of 12,261 records, 72 studies describing the measurement properties of smartphone-based approaches to measure diet (48/72, 67%), alcohol use (16/72, 22%), and tobacco use (8/72, 11%) were identified and included in this review. Across the health behaviors, 18 different measurement techniques were used in smartphones. The measurement properties most commonly examined were construct validity, measurement error, and criterion validity. The results varied by behavior and measurement approach, and the methodological quality of the studies varied widely. Most studies investigating the measurement of diet and alcohol received very good or adequate methodological quality ratings, that is, 73% (35/48) and 69% (11/16), respectively, whereas only 13% (1/8) investigating the measurement of tobacco use received a very good or adequate rating. CONCLUSIONS: This review is the first to provide evidence regarding the different types of smartphone-based approaches currently used to measure key behavioral risk factors for chronic diseases (diet, alcohol use, and tobacco use) and the quality of their measurement properties. A total of 19 measurement techniques were identified, most of which assessed dietary behaviors (48/72, 67%). Some evidence exists to support the reliability and validity of using smartphones to assess these behaviors; however, the results varied by behavior and measurement approach. The methodological quality of the included studies also varied. Overall, more high-quality studies validating smartphone-based approaches against criterion measures are needed. Further research investigating the use of smartphones to assess alcohol and tobacco use and objective measurement approaches is also needed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-https://doi.org/10.1186/s13643-020-01375-w.

Effect of a Fundamental Motor Skills Intervention on Fundamental Motor Skill and Physical Activity in a Preschool Setting: A Cluster Randomized Controlled Trial.

PURPOSE: To determine the effect of a 12-week fundamental motor skill (FMS) program on FMS and physical activity (PA) on preschool-aged children. METHOD: A cluster randomized controlled trial. The intervention (PhysicaL ActivitY and Fundamental Motor Skills in Pre-schoolers [PLAYFun] Program) was a 12-week games-based program, delivered directly to the children in childcare centers by exercise physiologists. Children in the control arm received the usual preschool curriculum. Outcomes included FMS competence (Test of Gross Motor Development-2) and PA (accelerometer) assessed at baseline, 12 weeks, and 24 weeks (12-wk postintervention). RESULTS: Fifty children (mean age = 4.0 [0.6] y; 54% male) were recruited from 4 childcare centers. Two centers were randomized to PLAYFun and 2 centers were randomized to the waitlist control group. Children attended on average 2.0 (1.0) 40-minute sessions per week. The PLAYFun participants demonstrated significant increases in object control (P < .001) and total FMS (P = .010) competence at week 12, compared with controls in a group × time interaction. Girls, but not boys, in PLAYFun significantly increased moderate to vigorous PA after the intervention (P = .004). These increases were not maintained 12-week postcompletion of PLAYFun. CONCLUSIONS: The PLAYFun Program is effective at improving FMS competence in boys and girls and increasing PA in girls. However, improvements are not maintained when opportunities to practice are not sustained.

Resistance Training and High-intensity Interval Training Improve Cardiometabolic Health in High Risk Older Adults: A Systematic Review and Meta-anaylsis.

Progressive resistance training (PRT) and high-intensity interval training (HIIT) improve cardiometabolic health in older adults. Whether combination PRT+HIIT (COMB) provides similar or additional benefit is less clear. This systematic review with meta-analysis of controlled trials examined effects of PRT, HIIT and COMB compared to non-exercise control in older adults with high cardiometabolic risk. Databases were searched until January 2021, with study quality assessed using the PEDro scale. Risk factor data was extracted and analysed using RevMan V.5.3. We analysed 422 participants from nine studies (7 PRT, n=149, 1 HIIT, n=10, 1 COMB, n=60; control n=203; mean age 68.1±1.4 years). Compared to control, exercise improved body mass index (mean difference (MD) -0.33 [-0.47, -0.20], p≤0.0001), body fat% (standardised mean difference (SMD) -0.71 [-1.34, -0.08], p=0.03), aerobic capacity (SMD 0.41 [0.05, 0.78], p=0.03), low-density lipoprotein (SMD -0.27 [-0.52, -0.01], p=0.04), and blood glucose (SMD -0.31 [-0.58, -0.05], p=0.02). Therefore, PRT, HIIT and COMB can improve cardiometabolic health in older adults with cardiometabolic risk. Further research is warranted, particularly in HIIT and COMB, to identify the optimal exercise prescription, if any, for improving older adults cardiometabolic health. (PROSPERO: CRD42019128527).

The effectiveness and safety of isometric resistance training for adults with high blood pressure: a systematic review and meta-analysis.

High blood pressure (BP) is a global health challenge. Isometric resistance training (IRT) has demonstrated antihypertensive effects, but safety data are not available, thereby limiting its recommendation for clinical use. We conducted a systematic review of randomized controlled trials comparing IRT to controls in adults with elevated BP (systolic ≥130 mmHg/diastolic ≥85 mmHg). This review provides an update to office BP estimations and is the first to investigate 24-h ambulatory BP, central BP, and safety. Data were analyzed using a random-effects meta-analysis. We assessed the risk of bias with the Cochrane risk of bias tool and the quality of evidence with GRADE. Twenty-four trials were included (n = 1143; age = 56 ± 9 years, 56% female). IRT resulted in clinically meaningful reductions in office systolic (-6.97 mmHg, 95% CI -8.77 to -5.18, p < 0.0001) and office diastolic BP (-3.86 mmHg, 95% CI -5.31 to -2.41, p < 0.0001). Novel findings included reductions in central systolic (-7.48 mmHg, 95% CI -14.89 to -0.07, p = 0.035), central diastolic (-3.75 mmHg, 95% CI -6.38 to -1.12, p = 0.005), and 24-h diastolic (-2.39 mmHg, 95% CI -4.28 to -0.40, p = 0.02) but not 24-h systolic BP (-2.77 mmHg, 95% CI -6.80 to 1.25, p = 0.18). These results are very low/low certainty with high heterogeneity. There was no significant increase in the risk of IRT, risk ratio (1.12, 95% CI 0.47 to 2.68, p = 0.8), or the risk difference (1.02, 95% CI 1.00 to 1.03, p = 0.13). This means that there is one adverse event per 38,444 bouts of IRT. IRT appears safe and may cause clinically relevant reductions in BP (office, central BP, and 24-h diastolic). High-quality trials are required to improve confidence in these findings. PROSPERO (CRD42020201888); OSF ( https://doi.org/10.17605/OSF.IO/H58BZ ).

Effects of resistance training on endothelial function: A systematic review and meta-analysis.

BACKGROUND AND AIMS: The effects of resistance training on flow-mediated dilation (FMD), which has been the gold standard non-invasive assessment of endothelial function and is associated with the risk of cardiovascular events, are not well known. We conducted a systematic review to analyze the effects of resistance training on FMD. METHODS: We searched Pubmed, Embase, CINAHL, SPORTDiscuss, Scopus, Web of Science and PEDro databases for studies that met the following criteria: (a) randomized controlled trials of resistance exercise with a comparative non-exercise group or contralateral untrained limb in adults and/or elderly; (b) studies that measured post-occlusion brachial artery FMD by ultrasonography, before and after intervention. Mean differences (MDs) with 95 % confidence interval (95 % CI) were calculated using an inverse variance method with a random effects model. RESULTS: Twenty-three studies were included in the meta-analysis (n = 785 participants; 53 % females). Resistance training on FMD responses showed a favorable result for the resistance training group (n = 366) compared to the control group (n = 358) (MD 2.39, 95%CI 1.65, 3.14; p<0.00001). Subgroup analysis indicated favorable results for the dynamic resistance training (n = 545; MD 2.12, 95 % CI 1.26, 2.98; p<0.00001) and isometric handgrip training (n = 179; MD 3.32, 95 % CI 1.68, 4.96; p<0.0001) compared to the control group. The effect of resistance training on FMD responses was also favorable regardless of the condition of the participants (Healthy [n = 261]: MD 2.11, 95 % CI 1.04, 3.18; p<0.0001; Cardiovascular disease [n = 310]: MD 2.89, 95 % CI 0.88, 4.90; p = 0.005; metabolic disease [n = 153]: MD 2.40, 95 % CI 1.59, 3.21; p<0.00001). CONCLUSIONS: Resistance training improves FMD in healthy individuals and patients with cardiovascular and metabolic diseases.

Age-varying associations between lifestyle risk factors and major depressive disorder: a nationally representative cross-sectional study of adolescents.

PURPOSE: Lifestyle risk factors, such as alcohol use, smoking, high body mass index, poor sleep, and sedentary behavior, represent major public health issues for adolescents. These factors have been associated with increased rates of major depressive disorder (MDD). The purpose of this paper is to investigate critical peaks in the prevalence of MDD at certain ages and to examine how these peaks might be amplified or attenuated by the presence of lifestyle risk factors. METHODS: A nationally representative sample of adolescents aged 11-17 years old (n = 2967) and time-varying effect models were used to investigate the associations between lifestyle risk factors and the prevalence of MDD by sex. RESULTS: The estimated prevalence of MDD significantly increased among adolescents from 4% (95% CI 3-6%) at 13 years of age to 19% (95% CI 15-24%) at 16 years of age. From the age of 13, males were significantly less likely to have a diagnosis of MDD than females with the maximum sex difference occurring at the age of 15 (OR 0.24, 95% CI 0.13-0.47). All lifestyle risk factors were at some point significantly associated with MDD, but these associations did not differ by sex, except for body mass index. DISCUSSION: These findings suggest that interventions designed to prevent the development of depression should be implemented in early adolescence, ideally before or at the age of 13 and particularly among young females given that the prevalence of MDD begins to rise and diverge from young males. Interventions should also simultaneously address lifestyle risk factors and symptoms of major depression.

Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners.

Peripheral artery disease (PAD) is caused by atherosclerotic narrowing of the arteries supplying the lower limbs often resulting in intermittent claudication, evident as pain or cramping while walking. Supervised exercise training elicits clinically meaningful benefits in walking ability and quality of life. Walking is the modality of exercise with the strongest evidence and is recommended in several national and international guidelines. Alternate forms of exercise such as upper- or lower-body cycling may be used, if required by certain patients, although there is less evidence for these types of programmes. The evidence for progressive resistance training is growing and patients can also engage in strength-based training alongside a walking programme. For those unable to attend a supervised class (strongest evidence), home-based or 'self-facilitated' exercise programmes are known to improve walking distance when compared to simple advice. All exercise programmes, independent of the mode of delivery, should be progressive and individually prescribed where possible, considering disease severity, comorbidities and initial exercise capacity. All patients should aim to accumulate at least 30 min of aerobic activity, at least three times a week, for at least 3 months, ideally in the form of walking exercise to near-maximal claudication pain.

Clustering of Six Key Risk Behaviors for Chronic Disease among Adolescent Females.

Chronic diseases are the leading cause of disability and mortality globally. In Australia, females are at heightened risk. This research explored the prevalence, patterns, and correlates of six key risk behaviors (physical inactivity, poor diet, recreational screen time, inadequate sleep, alcohol use, and smoking) among adolescent females and whether knowledge of health guidelines was associated with adherence. Adolescent females completed an anonymous online questionnaire (N = 687; Mage = 13.82). Logistic regression assessed the association between knowledge and adherence. A Latent Class Analysis (LCA) and three-step procedure identified risk behavior clusters and their correlates. Despite positive health self-ratings (77% good/very good), most participants reported insufficient moderate-to-vigorous physical activity (MVPA; 89%), vegetable intake (89%), and excessive screen time (63%). Knowledge of guidelines was associated with adherence for MVPA, vegetable intake, sleep, and alcohol abstinence. Three classes emerged: "moderate risk" (76%), "relatively active, healthy eaters" (19%), and "excessive screen users" (5%). These risk-behavior clusters were associated with perceived value of academic achievement and physical wellbeing. Adolescent females commonly perceive they are in good health, despite engaging in unhealthy behaviors. Public health interventions should utilize effective behavior change strategies, adopt a multiple health behavior change approach (MHBC), and be tailored to specific risk profiles and values among females.

A Web-Based Intervention to Prevent Multiple Chronic Disease Risk Factors Among Adolescents: Co-Design and User Testing of the Health4Life School-Based Program.

BACKGROUND: Chronic diseases are the leading cause of death worldwide. Addressing key lifestyle risk factors during adolescence is critical for improving physical and mental health outcomes and reducing chronic disease risk. Schools are ideal intervention settings, and electronic health (eHealth) interventions afford several advantages, including increased student engagement, scalability, and sustainability. Although lifestyle risk behaviors tend to co-occur, few school-based eHealth interventions have targeted multiple behaviors concurrently. OBJECTIVE: This study aims to summarize the co-design and user testing of the Health4Life school-based program, a web-based cartoon intervention developed to concurrently prevent 6 key lifestyle risk factors for chronic disease among secondary school students: alcohol use, smoking, poor diet, physical inactivity, sedentary recreational screen time, and poor sleep (the Big 6). METHODS: The development of the Health4Life program was conducted over 18 months in collaboration with students, teachers, and researchers with expertise relevant to the Big 6. The iterative process involved (1) scoping of evidence and systematic literature review; (2) consultation with adolescents (N=815) via a cross-sectional web-based survey to identify knowledge gaps, attitudes, barriers, and facilitators in relation to the Big 6; (3) content and web development; and (4) user testing of the web-based program with students (n=41) and teachers (n=8) to evaluate its acceptability, relevance, and appeal to the target audience. RESULTS: The co-design process resulted in a six-module, evidence-informed program that uses interactive cartoon storylines and web-based delivery to engage students. Student and teacher feedback collected during user testing was positive in terms of acceptability and relevance. Commonly identified areas for improvement concerned the length of modules, age appropriateness of language and alcohol storyline, the need for character backstories and links to syllabus information, and feasibility of implementation. Modifications were made to address these issues. CONCLUSIONS: The Health4Life school-based program is the first universal, web-based program to concurrently address 6 important chronic disease risk factors among secondary school students. By adopting a multiple health behavior change approach, it has the potential to efficiently modify the Big 6 risk factors within one program and to equip young people with the skills and knowledge needed to achieve and maintain good physical and mental health throughout adolescence and into adulthood.

Study protocol of the Health4Life initiative: a cluster randomised controlled trial of an eHealth school-based program targeting multiple lifestyle risk behaviours among young Australians.

INTRODUCTION: Lifestyle risk behaviours, including alcohol use, smoking, poor diet, physical inactivity, poor sleep (duration and/or quality) and sedentary recreational screen time ('the Big 6'), are strong determinants of chronic disease. These behaviours often emerge during adolescence and co-occur. School-based interventions have the potential to address risk factors prior to the onset of disease, yet few eHealth school-based interventions target multiple behaviours concurrently. This paper describes the protocol of the Health4Life Initiative, an eHealth school-based intervention that concurrently addresses the Big 6 risk behaviours among secondary school students. METHODS AND ANALYSIS: A multisite cluster randomised controlled trial will be conducted among year 7 students (11-13 years old) from 72 Australian schools. Stratified block randomisation will be used to assign schools to either the Health4Life intervention or an active control (health education as usual). Health4Life consists of (1) six web-based cartoon modules and accompanying activities delivered during health education (once per week for 6 weeks), and a smartphone application (universal prevention), and (2) additional app content, for students engaging in two or more risk behaviours when they are in years 8 and 9 (selective prevention). Students will complete online self-report questionnaires at baseline, post intervention, and 12, 24 and 36 months after baseline. Primary outcomes are consumption of sugar-sweetened beverages, moderate-to-vigorous physical activity, sleep duration, sedentary recreational screen time and uptake of alcohol and tobacco use. ETHICS AND DISSEMINATION: This study has been approved by the University of Sydney (2018/882), NSW Department of Education (SERAP no. 2019006), University of Queensland (2019000037), Curtin University (HRE2019-0083) and relevant Catholic school committees. Results will be presented to schools and findings disseminated via peer-reviewed journals and scientific conferences. This will be the first evaluation of an eHealth intervention, spanning both universal and selective prevention, to simultaneously target six key lifestyle risk factors among adolescents. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12619000431123), 18 March 2019.

Measurement properties of smartphone approaches to assess key lifestyle behaviours: protocol of a systematic review.

BACKGROUND: Six core behavioural risk factors (poor diet, physical activity, sedentary behaviour, alcohol misuse, smoking and unhealthy sleep patterns) have been identified as strong determinants of chronic disease, such as cardiovascular disease, diabetes and cancers. Smartphones have the potential to provide a real-time, pervasive, unobtrusive and cost-effective way to measure health behaviours and deliver instant feedback to users. Despite this, validity of using smartphones to measure these six key behaviours is largely unknown. The proposed systematic review aims to address this gap by identifying existing smartphone-based approaches to measure these health behaviours and critically appraising, comparing and summarizing the quality of their measurement properties. METHODS: A systematic search of the Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOHost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost) and IEEE Xplore Digital Library databases will be conducted from January 2007 to March 2020. Eligible studies will be those written in English that measure at least one of the six health behaviours of interest via a smartphone and report on at least one measurement property. The primary outcomes will be validity, reliability and/or responsiveness of these measurement approaches. A secondary outcome will be the feasibility (e.g. user burden, usability and cost) of identified approaches. No restrictions will be placed on the participant population or study design. Two reviewers will independently screen studies for eligibility, extract data and assess the risk of bias. The study methodological quality (or bias) will be appraised using an appropriate tool. Our results will be described in a narrative synthesis. If feasible, random effects meta-analysis will be conducted where appropriate. DISCUSSION: The results from this review will provide important information about the types of smartphone-based approaches currently available to measure the core behavioural risk factors for chronic disease and the quality of their measurement properties. It will allow recommendations on the most suitable and effective measures of these lifestyle behaviours using smartphones. Valid and reliable measurement of these behaviours and risk factor opens the door to targeted and real-time delivery of health behaviour interventions, providing unprecedented opportunities to offset the trajectory toward chronic disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42019122242.