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Background Access to reliable information is critical to women’s experience and wellbeing during pregnancy and childbirth. In our information-rich society, women are exposed to a wide range of information sources. The primary objective of this study was to explore women’s use of information sources during pregnancy and to examine the perceived usefulness and trustworthiness of these sources. Method A quantitative cross-sectional study of Dutch women's experiences with various information sources during pregnancy, including professional (e.g. healthcare system), and informal sources, divided into conventional (e.g. family or peers) and digital sources (e.g. websites or apps). Exploratory backward stepwise multiple regression was performed to identify associations between the perceived quality of information sources and personal characteristics. Results A total of 1922 pregnant women were included in this study. The most commonly used information sources were midwives (91.5%), family or friends (79.3%), websites (77.9%), and apps (61%). More than 80% of women found professional information sources trustworthy and useful, while digital sources were perceived as less trustworthy and useful. Personal factors explain only a small part of the variation in the perceived quality of information sources. Conclusion Even though digital sources are perceived as less trustworthy and useful than professional and conventional sources, they are among the most commonly used sources of information for pregnant women. To meet the information needs of the contemporary generation of pregnant women it is essential that professionals help in the development of digital information sources.

Background Multidimensional frailty, including physical, psychological, and social components, is associated to disability, lower quality of life, increased healthcare utilization, and mortality. In order to prevent or delay frailty, more knowledge of its determinants is necessary; one of these determinants is lifestyle. The aim of this study is to determine the association between lifestyle factors smoking, alcohol use, nutrition, physical activity, and multidimensional frailty. Methods This cross-sectional study was conducted in two samples comprising in total 45,336 Dutch community-dwelling individuals aged 65 years or older. These samples completed a questionnaire including questions about smoking, alcohol use, physical activity, sociodemographic factors (both samples), and nutrition (one sample). Multidimensional frailty was assessed with the Tilburg Frailty Indicator (TFI). Results Higher alcohol consumption, physical activity, healthy nutrition, and less smoking were associated with less total, physical, psychological and social frailty after controlling for effects of other lifestyle factors and sociodemographic characteristics of the participants (age, gender, marital status, education, income). Effects of physical activity on total and physical frailty were up to considerable, whereas the effects of other lifestyle factors on frailty were small. Conclusions The four lifestyle factors were not only associated with physical frailty but also with psychological and social frailty. The different associations of frailty domains with lifestyle factors emphasize the importance of assessing frailty broadly and thus to pay attention to the multidimensional nature of this concept. The findings offer healthcare professionals starting points for interventions with the purpose to prevent or delay the onset of frailty, so community-dwelling older people have the possibility to aging in place accompanied by a good quality of life.

Background: Recent evidence suggests that prolonged sitting and its adverse impact on glycaemic indicators appear to be proportional to the degree of insulin resistance. To investigate this finding in a free-living context, we aimed to examine associations of device-measured 24-hour time-use compositions of sitting, standing, stepping, and sleeping with fasting glucose (FPG) and 2h post-load glucose (2hPLG) levels, and to examine separately the associations with time-use compositions among those at lower and at higher risk of developing type 2 diabetes. Methods: Cross-sectional analyses examined thigh-worn inclinometer data (activPAL, 7 day, 24h/day protocol) from 648 participants (aged 36-80 years) at either lower (, The Health & Fitness Journal of Canada, Vol. 14 No. 3 (2021): Proceedings from the 8th International Society for Physical Activity and Health Congress

This work was funded by the French National Cancer Institute (grant number 2015-166). Mathilde His' work reported here was undertaken during the tenure of a postdoctoral fellowship awarded by the International Agency for Research on Cancer, financed by the Fondation ARC. The coordination of EPIC is financially supported by International Agency for Research on Cancer (IARC) and also by the Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, which has additional infrastructure support provided by the NIHR Imperial Biomedical Research Centre (BRC). The national cohorts are supported by Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Generale de l'Education Nationale, Institut National de la Sante et de la Recherche Medicale (INSERM) (France); German Cancer Aid, German Cancer Research Center (DKFZ), German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Federal Ministry of Education and Research (BMBF) (Germany); Associazione Italiana per la Ricerca sul Cancro-AIRC-Italy, Compagnia di SanPaolo and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports (VWS), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF) (The Netherlands); Health Research Fund (FIS) - Instituto de Salud Carlos III (ISCIII), Regional Governments of Andalucia, Asturias, Basque Country, Murcia and Navarra, and the Catalan Institute of Oncology-ICO (Spain); Swedish Cancer Society, Swedish Research Council and County Councils of Skane and Vasterbotten (Sweden); and Cancer Research UK (14136 to EPIC-Norfolk (DOI 10.22025/2019.10.105.00004); C8221/A29017 to EPIC-Oxford), Medical Research Council (1000143, MR/N003284/1, MC-UU_12015/1 and MC_UU_00006/1 to EPIC-Norfolk; MR/M012190/1 to EPIC-Oxford) (UK). The funders were not involved in designing the study; collecting, analyzing, or interpreting the data; or writing or submitting the manuscript for publication., Background: Metabolomics is a promising molecular tool for identifying novel etiological pathways leading to cancer. In an earlier prospective study among pre- and postmenopausal women not using exogenous hormones, we observed a higher risk of breast cancer associated with higher blood concentrations of one metabolite (acetylcarnitine) and a lower risk associated with higher blood concentrations of seven others (arginine, asparagine, phosphatidylcholines (PCs) aa C36:3, ae C34:2, ae C36:2, ae C36:3, and ae C38:2). Methods: To identify determinants of these breast cancer-related metabolites, we conducted a cross-sectional analysis to identify their lifestyle and anthropometric correlates in 2358 women, who were previously included as controls in case-control studies nested within the European Prospective Investigation into Cancer and Nutrition cohort and not using exogenous hormones at blood collection. Associations of each metabolite concentration with 42 variables were assessed using linear regression models in a discovery set of 1572 participants. Significant associations were evaluated in a validation set (n = 786). Results: For the metabolites previously associated with a lower risk of breast cancer, concentrations of PCs ae C34: 2, C36:2, C36:3, and C38:2 were negatively associated with adiposity and positively associated with total and saturated fat intakes. PC ae C36:2 was also negatively associated with alcohol consumption and positively associated with two scores reflecting adherence to a healthy lifestyle. Asparagine concentration was negatively associated with adiposity. Arginine and PC aa C36:3 concentrations were not associated to any of the factors examined. For the metabolite previously associated with a higher risk of breast cancer, acetylcarnitine, a positive association with age was observed. Conclusions: These associations may indicate possible mechanisms underlying associations between lifestyle and anthropometric factors, and risk of breast cancer. Further research is needed to identify potential non-lifestyle correlates of the metabolites investigated., Institut National du Cancer (INCA) France 2015-166, International Agency for Research on Cancer - Fondation ARC, World Health Organization, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, Danish Cancer Society, Ligue Contre le Cancer (France), Institut Gustave Roussy (France), Mutuelle Generale de l'Education Nationale (France), Institut National de la Sante et de la Recherche Medicale (Inserm), Deutsche Krebshilfe, German Cancer Research Center (DKFZ) (Germany), German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE) (Germany), Federal Ministry of Education & Research (BMBF), Fondazione AIRC per la ricerca sul cancro, Compagnia di San Paolo, Consiglio Nazionale delle Ricerche (CNR), Netherlands Government, World Cancer Research Fund International (WCRF), Health Research Fund (FIS) - Instituto de Salud Carlos III (ISCIII) (Spain), Junta de Andalucia, Regional Government of Asturias (Spain), Regional Government of Basque Country (Spain), Regional Government of Murcia (Spain), Regional Government of Navarra (Spain), Catalan Institute of Oncology-ICO (Spain), Swedish Cancer Society, Swedish Research Council, County Council of Skane (Sweden), County Council of Vasterbotten (Sweden), Cancer Research UK 14136 C8221/A29017, UK Research & Innovation (UKRI), Medical Research Council UK (MRC) 1000143 MR/N003284/1 MC-UU_12015/1 MC_UU_00006/1 MR/M012190/1

Background The aim of this study was to investigate bidirectional associations between (prolonged) sitting time and sleep duration in 12- to 14-year-old adolescents using a between-subjects and within-subjects analyses approach. Methods Observational data were used from 108 adolescents (53% girls; mean age 12.9 (SD 0.7) years) from six schools in Flanders, Belgium. The Axivity AX3 triaxial accelerometer, worn on the thigh, was used to assess daily total sitting time and daily time spent in sedentary bouts of ≥30 min (as a proxy for prolonged sitting time). The Fitbit Charge 3 was used to assess nightly sleep duration. Both monitors were worn on schooldays only (ranging from 4 to 5 days). Linear mixed models were conducted to analyse the associations, resulting in four models. In each model, the independent variable (sleep duration, sitting time or prolonged sitting time) was included as within- as well as between-subjects factor. Results Within-subjects analyses showed that when the adolescents sat more and when the adolescents spent more time sitting in bouts of ≥30 min than they usually did on a given day, they slept less during the following night (p = 0.01 and p = 0.05 (borderline significant), respectively). These associations were not significant in the other direction. Between-subjects analyses showed that adolescents who slept more on average, spent less time sitting (p = 0.006) and less time sitting in bouts of ≥30 min (p = 0.004) compared with adolescents who slept less on average. Conversely, adolescents who spent more time sitting on average and adolescents who spent more time sitting in bouts of ≥30 min on average, slept less (p = 0.02 and p = 0.003, respectively). Conclusions Based on the between-subjects analyses, interventions focusing on reducing or regularly breaking up sitting time could improve adolescents’ sleep duration on a population level, and vice versa. However, the within-subjects association was only found in one direction and suggests that to sleep sufficiently during the night, adolescents might limit and regularly break up their sitting time the preceding day. Trial registration Data have been used from our trial registered at ClinicalTrials.gov (NCT04327414; registered on March 11, 2020).

Background To evaluate cycling participation and identify barriers and facilitators related to cycling participation in people with a lower limb amputation (LLA) in the Netherlands. Methods A questionnaire was sent to adults with a LLA between March and August 2019 to obtain information regarding prosthesis, individual’s characteristics, amputation, cycling barriers and facilitators, and prosthetic satisfaction. The questionnaires were distributed via 8 orthopedic workshops, post and were given directly. To find cycling predictors, variables associated with cycling (p Results Participants (n = 207, 71% males) had a mean age of 62.0 ± 13.0 years. The most frequent level of amputation was transtibial (42%), and trauma was the most frequent cause of amputation (43%). After the LLA, 141 participants (68%) cycled for recreation (80%), physical fitness (74%), and transport (50%). In the past six months, cyclists cycled for recreation (79%) and transport (66%). Most cycled less than once a day. Recreational cyclists cycled alone (75%) for a median duration of 45 min or 14 km per ride. Cyclists with a transportation purpose usually cycled to go shopping (80%) or to visit friends (68%), with a median duration of 20 min or five kilometers per ride. Cyclists reported more facilitators (median (IQR) = 5 (3, 7) than non-cyclists 0 (0, 3). The majority of cyclists reported a positive attitude toward cycling (89%) and cycled because of health benefits (81%). A dynamic foot (odds ratio: 5.2, 95% CI 2.0, 13.3) and a higher number of facilitators (odds ratio: 1.3, 95% CI 1.2, 1.5) positively predicted cycling, whereas the presence of other underlying diseases (odds ratio: 0.4, 95% CI 0.2, 0.9) negatively predicted cycling (R2: 40.2%). Conclusion In the Netherlands, the majority of adults cycled after a LLA, mainly for recreational purposes. A dynamic foot, a higher number of facilitators, and no other underlying diseases increases the likelihood of cycling after a LLA. The results suggest that personal motivation and a higher mobility level could be the key to increasing cycling participation. Future research should determine the association between motivation, mobility levels, and cycling with a LLA.

Introduction It is unclear whether adiposity leads to changes in movement behaviors, and there is a lack of compositional analyses of longitudinal data which focus on these associations. Using a compositional approach, this study aimed to examine the associations between baseline adiposity and 7-year changes in physical activity (PA) and sedentary behavior (SB) among elderly women. We also explored the longitudinal associations between change in adiposity and change in movement-behavior composition. Methods This longitudinal study included 176 older women (mean baseline age 62.8 (4.1) years) from Central Europe. Movement behavior was assessed by accelerometers and adiposity was measured by bioelectrical impedance analysis at baseline and follow-up. A set of multivariate least-squares regression analyses was used to examine the associations of baseline adiposity and longitudinal changes in adiposity as explanatory variables with longitudinal changes in a 3-part movement-behavior composition consisting of SB, light PA (LPA) and moderate-to-vigorous PA (MVPA) as outcome variables. Results No significant associations were found between baseline adiposity and longitudinal changes in the movement-behavior composition (p > 0.05). We found significant associations of changes in body mass index (BMI) and fat mass percentage (FM%) with changes in the movement-behavior composition. An increase in BMI was associated with an increase of SB at the expense of LPA and MVPA (β = 0.042, p = 0.009) and with a decrease of MVPA in favor of SB and LPA (β = − 0.059, p = 0.037). An increase in FM% was significantly associated only with an increase of SB at the expense of LPA and MVPA (β = 0.019, p = 0.031). Conclusions This study did not support the assumption that baseline adiposity is associated with longitudinal changes in movement behaviors among elderly women, but we found evidence for change-to-change associations, suggesting that a 7-year increase in adiposity is associated with a concurrent increase of SB at the expense of LPA and MVPA and with a concurrent decrease of MVPA in favor of LPA and SB. Public health interventions are needed to simultaneously prevent weight gain and promote physically active lifestyle among elderly women.

Background Nurses are in a key position to stimulate older people to maximize their functional activity and independence. However, nurses still often work in a task-oriented manner and tend to take over tasks unnecessarily. It is evident to support nurses to focus on the capabilities of older people and provide care assistance only when required. Function-Focused Care (FFC) is a holistic care-philosophy aiming to support nurses to deliver care in which functioning and independence of older people is optimized. Dutch and internationally developed FFC-based interventions often lack effectiveness in changing nurses’ and client’s behavior. Process-evaluations have yielded lessons and implications resulting in the development of an advanced generic FFC-program: the ‘SELF-program’. The SELF-program aims to improve activity stimulation behavior of nurses in long-term care services, and with that optimize levels of self-reliance in activities of daily living (ADL) in geriatric clients. The innovative character of the SELF-program lies for example in the application of extended behavior change theory, its interactive nature, and tailoring its components to setting-specific elements and needs of its participants. This paper describes the outline, content and theoretical background of the SELF-program. Subsequently, this paper describes a protocol for the assessment of the program’s effect, economic and process-evaluation in a two-arm (SELF-program vs care as usual) multicenter cluster-randomized trial (CRT). Method The proposed CRT has three objectives, including getting insight into the program’s: (1) effectiveness regarding activity stimulation behavior of nurses and self-reliance in ADL of geriatric clients, and (2) cost-effectiveness from a societal perspective including assessments of quality of life and health-care use. Measurements will take place prior to program implementation (baseline), directly after (T1), and in long-term (T2). Parallel to the CRT, a process evaluation will be conducted to provide insight into the program’s: (3) feasibility regarding implementation, mechanisms of impact and contextual factors. Discussion The SELF-program was developed following the Medical Research Council framework, which addresses the systematic development, feasibility testing, evaluation and implementation of complex interventions. The program has been subjected to a feasibility study before and results of studies described in this protocol are expected to be available from end 2022 onwards. Trial-registration The study is registered in the Dutch Trial Register (NL9189), as of December 22 2020.

Background Lifestyle interventions to prevent paediatric obesity often target family and peer settings; their success is likely to depend on the influence that peers and families exert on children’s lifestyle behaviors at different developmental stages. Objective First, to determine whether children’s lifestyle behavior more closely resembles their peers’ or siblings’ behaviors. Secondly, to investigate longitudinally whether children’s behavioral change is predicted by that of their peers or their siblings as they grow older. Methods The European prospective IDEFICS/I.Family cohort (baseline survey: 2007/2008, first follow-up: 2009/2010, and second follow-up: 2013/2014) aims at investigating risk factors for overweight and related behaviors during childhood and adolescence. The present investigation includes 2694 observations of children and their siblings aged 2 to 18 years. Peers were defined as same-sex, same-age children in the same community and identified from the full cohort. The longitudinal analysis (mean follow-up time: 3.7 years) includes 525 sibling pairs. Children’s lifestyle behaviors including fast food consumption (frequency/week), screen time (hours/week) and sports club participation (hours/week) were assessed by questionnaire. Data were analyzed using multilevel linear models. Results Children’s lifestyle behavior was associated with the respective behavior of their peers and sibling for all 3 behaviors. For fast food consumption, the peer resemblance was more than 6-fold higher than the sibling resemblance and the peer resemblance surpassed the sibling resemblance by the age of 9–10 years. The similarities with peers for fast food consumption and screen time steadily increased, while the similarities with siblings steadily decreased with increasing age of the children (P interaction

Background Physical activity, sedentary time and sleep have been shown to be associated with cardio-metabolic health. However, these associations are typically studied in isolation or without accounting for the effect of all movement behaviours and the constrained nature of data that comprise a finite whole such as a 24 h day. The aim of this study was to examine the associations between the composition of daily movement behaviours (including sleep, sedentary time (ST), light intensity physical activity (LIPA) and moderate-to-vigorous activity (MVPA)) and cardio-metabolic health, in a cross-sectional analysis of adults with pre-diabetes. Further, we quantified the predicted differences following reallocation of time between behaviours. Methods Accelerometers were used to quantify daily movement behaviours in 1462 adults from eight countries with a body mass index (BMI) ≥25 kg·m− 2, impaired fasting glucose (IFG; 5.6–6.9 mmol·l− 1) and/or impaired glucose tolerance (IGT; 7.8–11.0 mmol•l− 1 2 h following oral glucose tolerance test, OGTT). Compositional isotemporal substitution was used to estimate the association of reallocating time between behaviours. Results Replacing MVPA with any other behaviour around the mean composition was associated with a poorer cardio-metabolic risk profile. Conversely, when MVPA was increased, the relationships with cardiometabolic risk markers was favourable but with smaller predicted changes than when MVPA was replaced. Further, substituting ST with LIPA predicted improvements in cardio-metabolic risk markers, most notably insulin and HOMA-IR. Conclusions This is the first study to use compositional analysis of the 24 h movement composition in adults with overweight/obesity and pre-diabetes. These findings build on previous literature that suggest replacing ST with LIPA may produce metabolic benefits that contribute to the prevention and management of type 2 diabetes. Furthermore, the asymmetry in the predicted change in risk markers following the reallocation of time to/from MVPA highlights the importance of maintaining existing levels of MVPA. Trial registration ClinicalTrials.gov (NCT01777893).

Background Recent 24-h movement guidelines for the early years established recommendations for physical activity (PA), screen time (ST), and sleep. To date, few studies have focused on compliance with meeting the guidelines and their associations with health outcomes. Thus, we aimed to investigate: 1) compliance with the 24-h movement guidelines, and 2) associations between compliance and anthropometry in Finnish preschoolers. Methods We utilized DAGIS survey data that were collected in 2015–2016 (N = 864). PA was assessed 24 h/day over 7 days using a waist-worn ActiGraph wGT3X-BT accelerometer. ST and sleep were reported by the parents during the same 7 days. Anthropometry was assessed using body mass index (BMI, kg/m2) and waist circumference (WC, cm). Children were classified as meeting the guidelines if they averaged ≥180 min/day of PA, which consisted of ≥60 min of moderate-to-vigorous intensity; ≤60 min/day of ST; and 10–13 h/day of sleep. In total, 778 children (51% boys, mean age: 4.7 ± 0.9 years) were included in the study. The compliance with meeting the 24-h movement guidelines was calculated for each behavior separately and in combinations. Adjusted linear regression analyses were applied to examine associations of compliance with BMI and WC. Results Children were physically active on average 390 (±46.2) min/day and spent 86 (±25.5) min/day in moderate-to-vigorous PA. They spent 76 (±37.4) min/day on ST and had on average 10:21 (±0:33) h:min/day of sleep. The compliance rate in meeting all three movement guidelines overall was 24%. The highest compliance rate was found for PA (85%), followed by sleep (76%) and ST (35%). Meeting guidelines separately for PA or sleep, or for both, were associated with lower WC (PA: B = -1.37, p p = 0.009; PA + Sleep: B = -1.03, p p = 0.027; PA + Sleep: B = -0.30, p = 0.007). There were no significant associations found regarding ST. Conclusions Meeting recommendations for PA and sleep may have an important role in supporting a healthy weight status in young children. However, there is still a need to improve compliance with the 24-h movement guidelines, especially for ST.

Lifestyle is one of the most powerful instruments shaping mankind; the lifestyle includes many aspects of interactions with the environment, from nourishment and education to physical activity and quality of sleep. All these factors taken in complex affect neuroplasticity and define brain performance and cognitive longevity. In particular, physical exercise, exposure to enriched environment and dieting act through complex modifications of microglial cells, which change their phenotype and modulate their functional activity thus translating lifestyle events into remodelling of brain homoeostasis and reshaping neural networks ultimately enhancing neuroprotection and cognitive longevity.

Increasing evidence suggests a multifaceted relationship exists between cancer and cardiovascular disease (CVD). Here, we introduce a 5-tier classification system to categorize cardio-oncology syndromes (COS) that represent the aspects of the relationship between cancer and CVD. COS Type I is characterized by mechanisms whereby the abrupt onset or progression of cancer can lead to cardiovascular dysfunction. COS Type II includes the mechanisms by which cancer therapies can result in acute or chronic CVD. COS Type III is characterized by the pro-oncogenic environment created by the release of cardiokines and high oxidative stress in patients with cardiovascular dysfunction. COS Type IV is comprised of CVD therapies and diagnostic procedures which have been associated with promoting or unmasking cancer. COS Type V is characterized by factors causing systemic and genetic predisposition to both CVD and cancer. The development of this framework may allow for an increased facilitation of cancer care while optimizing cardiovascular health through focused treatment targeting the COS type.

Background Studies investigating dietary resemblance between parents and their children have gained mixed results, and the resemblance seems to vary across nutrients, foods, dietary-assessment tools used, and parent-child pairs. We investigated parent-child dietary resemblance using a novel approach in applying statistical analysis, which allowed the comparison of ‘whole-diet’ between parents and their children. Additionally, we sought to establish whether sociodemographic factors or family meals were associated with dietary resemblance and whether parent-child dietary resemblance was dependent on the parent providing food consumption data on behalf of the child (father or mother, “the respondent”). Methods The DAGIS study investigated health behaviors among Finnish preschoolers using a cross-sectional design. One parent filled in a food frequency questionnaire (FFQ) measuring the child’s food consumption outside preschool hours during the last week. In addition, we instructed both parents or legal guardians, should the child have two, to fill in a similar FFQ regarding their own food use. Parents also reported their educational level, the number of children living in the same household, and the number of family meals. As a measure of dietary resemblance between a parent and a child, we computed Spearman correlations ranging mostly from no resemblance (0) to complete resemblance (+ 1) between parent-child pairs over the ‘whole-diet’ (excluding preschool hours). These resemblance measures were further investigated using linear mixed models. Results We obtained 665 father-child and 798 mother-child resemblance measures. Mother-child resemblance was on average 0.57 and stronger than father-child resemblance (0.50, p

Background Joint contractures in nursing home residents limit the capacity to perform daily activities and restrict social participation. The purpose of this study was to develop a complex intervention to improve participation in nursing home residents with joint contractures. Methods The development followed the UK Medical Research Council framework using a mixed-methods design with re-analysis of existing interview data using a graphic modelling approach, group discussions with nursing home residents, systematic review of intervention studies, structured 2-day workshop with experts in geriatric, nursing, and rehabilitation, and group discussion with professionals in nursing homes. Results Graphic modelling identified restrictions in the use of transportation, walking within buildings, memory functions, and using the hands and arms as the central target points for the intervention. Seven group discussions with 33 residents revealed various aspects related to functioning and disability according the International Classification of Functioning, Disability and Health domains body functions, body structures, activities and participation, environmental factors, and personal factors. The systematic review included 17 studies with 992 participants: 16 randomised controlled trials and one controlled trial. The findings could not demonstrate any evidence in favour of an intervention. The structured 2-day expert workshop resulted in a variety of potential intervention components and implementation strategies. The group discussion with the professionals in nursing homes verified the feasibility of the components and the overall concept. The resulting intervention, Participation Enabling CAre in Nursing (PECAN), will be implemented during a 1-day workshop for nurses, a mentoring approach, and supportive material. The intervention addresses nurses and other staff, residents, their informal caregivers, therapists, and general practitioners. Conclusions In view of the absence of any robust evidence, the decision to use mixed methods and to closely involve both health professionals and residents proved to be an appropriate means to develop a complex intervention to improve participation of and quality of life in nursing home residents. We will now evaluate the PECAN intervention for its impact and feasibility in a pilot study in preparation for an evaluation of its effectiveness in a definitive trial. Trial registration German clinical trials register, reference number DRKS00010037 (12 February 2016).

Background: Relationships between several built environment factors and physical activity and walking behavior are well established, but internationally-comparable built environment measures are lacking. The Microscale Audit of Pedestrian Streetscapes (MAPS)-Global is an observational measure of detailed streetscape features relevant to physical activity that was developed for international use. This study examined the inter-observer reliability of the instrument in five countries. Methods: MAPS-Global was developed by compiling concepts and items from eight environmental measures relevant to walking and bicycling. Inter-rater reliability data were collected in neighborhoods selected to vary on geographic information system (GIS)-derived macro-level walkability in five countries (Australia, Belgium, Brazil, Hong Kong-China, and Spain). MAPS-Global assessments (n = 325) were completed in person along a = 0.25 mile route from a residence toward a non-residential destination, and a commercial block was also rated for each residence (n = 82). Two raters in each country rated each route independently. A tiered scoring system was created that summarized items at multiple levels of aggregation, and positive and negative valence scores were created based on the expected effect on physical activity. The intraclass correlation coefficient (ICC) was computed for scales and selected items using one-way random models. Results: Overall, 86.6% of individual items and single item indicators showed excellent agreement (ICC >= 0.75), and 13.4% showed good agreement (ICC = 0.60-0.74). All subscales and overall summary scores showed excellent agreement. Six of 123 items were too rare to compute the ICC. The median ICC for items and scales was 0.92 with a range of 0.50-1.0. Aesthetics and social characteristics showed lower ICCs than other sub-scales, but reliabilities were still in the excellent range (ICC >= 0.75). Conclusion: Evaluation of inter-observer reliability of MAPS-Global across five countries indicated all items and scales had "good" or "excellent" reliability. The results demonstrate that trained observers from multiple countries were able to reliably conduct observations of both residential and commercial areas with the new MAPS-Global instrument. Next steps are to evaluate construct validity in relation to physical activity in multiple countries and gain experience with using MAPS-Global for research and practice applications.

Background Non-adherence to immunosuppressive therapy is a prevalent risk factor for poor clinical and after kidney transplantation (KT), and has contributed to the lack of improvement in long-term graft survival over the past decade. Understanding the multilevel correlates and risk factors of non-adherence is crucial to determine the optimal level for planning interventions, namely at the patient, health care provider, KT centre, and health care system level. Brazil, having the largest public transplantation program in the world and with regional differences regarding access to health services and service implementation, is in a unique position to study this multilevel approach. Therefore, the Adhere Brazil Study (ADHERE BRAZIL) was designed to assess the prevalence and variability of non-adherence to immunosuppressants and to health behaviours among adult KT recipients in Brazil, and to assess the multilevel correlates of non-adherence to immunosuppressive medication. We describe the rationale, design, and methodology of the ADHERE BRAZIL study. Methods/Design This is an observational, cross-sectional, multicentre study that includes 20 Brazilian KT centres. A stratified sampling approach is used, based on strata, with the following characteristics considered: geographical region and transplant activity (number of KTs per year). A random sample of patients (proportional to the size of the centre within each stratum) is selected from each centre. The prevalence of different health behaviours is assessed through self-report. The assessment of multilevel correlates of non-adherence is guided by the ecological model that considers factors at the level of the patient, health-care professional, and transplant centre, using established instruments or instruments developed for this study. Data will be collected over an 18-month period, with information obtained during the regular follow-up visits to the transplant outpatient clinic and directly entered into the Research Electronic Data Capture (RedCap) system. Data entry is performed by a trained professional who is part of the transplant team. The data collection began in December 2015. Discussion This multicentre study is the first to evaluate multilevel correlates of non-adherence in KT patients and will provide a reliable estimate of non-adherence in Brazilian KT patients. Trial registration ClinicalTrials.gov on 10/10/2013, NCT02066935. Electronic supplementary material The online version of this article (10.1186/s12882-018-0840-6) contains supplementary material, which is available to authorized users.

Background: Process evaluation is an essential part of designing and assessing complex interventions. The vitamin D and lifestyle intervention study (DALI) study is testing different strategies to prevent development of gestational diabetes mellitus among European obese pregnant women with a body mass index ≥29 kg/m2. The intervention includes guidance on physical activity and/or healthy eating by a lifestyle coach trained in motivational interviewing (MI). The aim of this study was to assess the process elements: reach, dose delivered, fidelity and satisfaction and to investigate whether these process elements were associated with changes in gestational weight gain (GWG).Methods: Data on reach, dose delivered, fidelity, and satisfaction among 144 participants were collected. Weekly recruitment reports, notes from meetings, coach logs and evaluation questionnaires (n = 110) were consulted. Fidelity of eight (out of twelve) lifestyle coach practitioners was assessed by analysing audio recorded counselling sessions using the MI treatment integrity scale. Furthermore, associations between process elements and GWG were assessed with linear regression analyses.Results: A total of 20% of the possible study population (reach) was included in this analysis. On average 4.0 (of the intended 5) face-to-face sessions were delivered. Mean MI fidelity almost reached 'expert opinion' threshold for the global scores, but was below 'beginning proficiency' for the behavioural counts. High variability in quality of MI between practitioners was identified. Participants were highly satisfied with the intervention, the lifestyle coach and the intervention materials. No significant associations were found between process elements and GWG.Conclusion: Overall, the intervention was well delivered and received by the study population, but did not comply with all the principles of MI. Ensuring audio recording of lifestyle sessions throughout the study would facilitate provision of individualized feedback to improve MI skills. A larger sample size is needed to confirm the lack of association between process elements and GWG.Trial registration: ISRCTN registry: ISRCTN70595832; Registered 12 December 2011.

Cancer Research UK and Ludwig Cancer Research convened an inaugural international Cancer Prevention and Nutrition Conference in London on December 3–4, 2018. Much of the discussion focused on the need for systematic, interdisciplinary approaches to better understand the relationships of nutrition, exercise, obesity and metabolic dysfunction with cancer development. Scientists at the meeting underscored the importance of studying the temporal natural history of exposures that may cumulatively impact cancer risk later in life. A robust dialogue identified obesity as a major risk for cancer, and the food environment, especially high energy and low nutrient processed foods, as strong and prevalent risk factors for obesity. Further engagement highlighted challenges in the post-diagnostic setting, where similar opportunities to understand the complex interplay of nutrition, physical activity, and weight will inform better health outcomes. Going forward, holistic research approaches, encompassing insights from multiple disciplines and perspectives, will catalyze progress urgently needed to prevent cancer and improve public health.

BackgroundThe transition to parenthood is a cornerstone event for both parents, potentially leading to relevant changes in lifestyle and behaviour. In women, the metabolic changes during and after pregnancy and the deleterious effects of excessive gestational weight gain and postpartum weight retention have been extensively described. However, there is no full understanding about which specific energy balance related behaviours (EBRB) contribute to unfavourable weight gain and weight retention. Furthermore, information on how transition to parenthood affects men is lacking. Therefore, this study aims to investigate changes in body weight, body composition and EBRB in couples transitioning to parenthood.MethodsTRANSPARENTS is a multi-centre observational follow-up study that focuses on body weight, body composition and EBRB during the transition to parenthood. Couples (women and men) will be recruited during the first trimester of their first pregnancy. Study visits will occur at four occasions (12weeks of pregnancy, 6weeks postpartum, 6months postpartum and 12months postpartum). Anthropometrics of the parents and new-borns will be assessed including body weight, height/length, body composition (using bio-electrical impedance analysis and measurement of four skinfold thicknesses (biceps, triceps, subscapular and supraspinal/suprailiac)) and waist and hip circumference. Dietary intake, physical activity, sedentary behaviour, smoking habits, sleeping pattern, fatigue, diet and exercise related partner support, mental health, breastfeeding, contraception use, and socio-demographics will be assessed using a questionnaire. In addition, accelerometry will be used to assess physical activity and sedentary behaviour objectively. Also data from women's medical record, such as pre-pregnancy weight and pregnancy outcomes, will be included. Multilevel modelling will be used to evaluate maternal and paternal changes in body weight, body composition and EBRB during and after pregnancy (primary outcomes). Multiple linear regression analyses will be performed to identify predictors of changes in body weight, body composition and EBRB. All analyses will be adjusted for possible confounders.DiscussionTRANSPARENTS is a unique project identifying vulnerable parents and (un)favourable changes in EBRB throughout this potentially critical life period. Provided insights will facilitate the development of effective intervention strategies to help couples towards a healthy transition to parenthood.Trial registrationClinicaltrials.gov Identifier: NCT03454958. Registered March 2018. This study is funded by the Research Foundation -Flanders ('Fonds voor Wetenschappelijk Onderzoek' (FWO)). The project was evaluated by the FWO Health Sciences expert panel. Project number FWO: G033418 N. R.D. is holder of a Fundamental Clinical Investigatorship 1803311 N. Contact information: Egmontstraat 5, 1000 Brussel. Telephone: + 32 2 512 91 10. Email: post@fwo.be.The funder had no role in the study design, data collection, management, analysis, and interpretation of data, writing the report and decision to submit the report for publication, and will not have ultimate authority over any of these activities.

Background Obesity is a global epidemic with profound consequences for individuals and societies. Physical exercise is important to weight reduction and weight loss maintenance. However, results on what the most effective type of exercise are unclear. The aim of this systematic review is to evaluate the effects of various exercise modalities with and without caloric restriction on body composition and metabolic health outcomes in overweight and obese adults. Methods We will perform a comprehensive literature search in PubMed, Embase (via Ovid) and CENTRAL (through the Cochrane Library). Relevant papers will be screened in two stages: first, by title and abstract and then the full text of the remaining papers. Two reviewers will screen all the studies, and any disagreements will be discussed with and resolved by a third reviewer. Data extraction and risk of bias assessment will be performed using a pre-piloted form. A network meta-analysis combining direct and indirect treatment effect estimates will be conducted if adequate data are available. The quality of the evidence will be judged using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Discussion The results of this proposed systematic review and meta-analysis will identify whether any exercise modality should be preferred for overweight and obese adults, as well as assess the quality of the evidence. This knowledge has potential importance for clinicians and patients. © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

BACKGROUND: Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined.METHODS: In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019.DISCUSSION: A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society.TRIAL REGISTRATION: The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

The cardiometabolic health of persons with a severe mental illness (SMI) is alarming with obesity rates of 45-55% and diabetes type 2 rates of 10-15%. Unhealthy lifestyle behaviours play a large role in this. Despite the multidisciplinary guideline for SMI patients recommending to monitor and address patients’ lifestyle, most mental health care professionals have limited lifestyle-related knowledge and skills, and (lifestyle) treatment protocols are lacking. Evidence-based practical lifestyle tools may support both patients and staff in improving patients’ lifestyle. This paper describes the Lifestyle Interventions for severe mentally ill Outpatients in the Netherlands (LION) trial, to investigate whether a multidimensional lifestyle intervention using a web tool can be effective in improving cardiometabolic health in SMI patients. The LION study is a 12-month pragmatic single-blind multi-site cluster randomised controlled trial. 21 Flexible Assertive Community Treatment (ACT) teams and eight sheltered living teams of five mental health organizations in the Netherlands are invited to participate. Per team, nurses are trained in motivational interviewing and use of the multidimensional web tool, covering lifestyle behaviour awareness, lifestyle knowledge, motivation and goal setting. Nurses coach patients to change their lifestyle using the web tool, motivational interviewing and stages-of-change techniques during biweekly sessions in a) assessing current lifestyle behaviour using the traffic light method (healthy behaviours colour green, unhealthy behaviours colour red), b) creating a lifestyle plan with maximum three attainable lifestyle goals and c) discussing the lifestyle plan regularly. The study population is SMI patients and statistical inference is on patient level using multilevel analyses. Primary outcome is waist circumference and other cardiometabolic risk factors after six and twelve months intervention, which are measured as part of routine outcome monitoring using standard protocols. Secondary outcomes include depressive and negative symptoms, cost-effectiveness, and barriers and facilitators in intervention implementation. Adequate health care should target both mental health and lifestyle behaviours in SMI patients. This trial contributes by studying a 12-month multidimensional lifestyle intervention as a potential evidence based (nursing) tool for targeting multiple lifestyle behaviours in SMI patients. Nederlands Trialregister NTR3765 (trialregister.nl; registered 21 December 2012).

peer-reviewed Background: Patients with hypertension in the community frequently fail to meet treatment goals. The optimal way to organize and deliver care to hypertensive patients has not been clearly identified. The powerful on-board computing capacity of mobile devices, along with the unique relationship individuals have with newer technologies, suggests that they have the potential to influence behaviour. However, little is known regarding the views and experiences of patients using such technology to self-manage their hypertension and associated lifestyle behaviours. The aim of this study was to explore patients' views and experiences of using technology based self-management tools for the treatment of hypertension in the community. Methods: This focus group study was conducted with known hypertensive patients over 45 years of age who were recruited in a community setting in Ireland. Taped and transcribed semi-structured interviews with a purposeful sample involving 50 participants in six focus groups were used. Framework analysis was utilized to analyse the data. Results: Four key inter-related themes emerged from the analysis: individualisation; trust; motivation; and communication. The globalisation of newer technologies has triggered many substantial and widespread behaviour changes within society, yet users are unique in their use and interactions with such technologies. Trust is an ever present issue in terms of its potential impact on engagement with healthcare providers and motivation around self-management. The potential ability of technology to influence motivation through carefully selected and tailored messaging and to facilitate a personalised flow of communication between patient and healthcare provider was highlighted. Conclusions: Newer technologies such as mobile devices and the internet have been embraced across the globe despite technological challenges and concerns regarding privacy and security. In the design and development of technology based self-management tools for the treatment of hypertension, flexibility and security are vital to allow and encourage patients to customise, personalise and engage with their devices. PUBLISHED peer-reviewed

Background: Health inequalities can be tackled with appropriate health and social policies, involving all community groups and governments, from local to global. The objective of this study was to carry out a scoping review on social and health policies or interventions to tackle health inequalities in European cities published in scientific journals.Methods: Scoping review. The search was done in "PubMed" and the "Sociological Abstracts" database and was limited to articles published between 1995 and 2011. The inclusion criteria were: interventions had to take place in European cities and they had to state the reduction of health inequalities among their objectives.Results: A total of 54 papers were included, of which 35.2% used an experimental design, and 74.1% were carried out in the United Kingdom. The whole city was the setting in 27.8% of them and 44.4% were based on promoting healthy behaviours. Adults and children were the most frequent target population and half of the interventions had a universal approach and the other half a selective one. Half of the interventions were evaluated and showed positive results.Conclusions: Although health behaviours are not the main determinants of health inequalities, the majority of the selected documents were based on evaluations of interventions focusing on them.

Background The objective was to develop an index based on the Dutch Guidelines for a healthy Diet of 2006 that reflects dietary quality and to apply it to the Dutch National Food Consumption Survey (DNFCS) to examine the associations with micronutrient intakes. Methods A total of 749 men and women, aged 19–30 years, contributed two 24-hour recalls and additional questionnaires in the DNFCS of 2003. The Dutch Healthy Diet index (DHD-index) includes ten components representing the ten Dutch Guidelines for a Healthy Diet. Per component the score ranges between zero and ten, resulting in a total score between zero (no adherence) and 100 (complete adherence). Results The mean ± SD of the DHD-index was 60.4 ± 11.5 for women and 57.8 ± 10.8 for men (P for difference = 0.002). Each component score increased across the sex-specific quintiles of the DHD-index. An inverse association was observed between the sex-specific quintiles of the DHD-index and total energy intake. Calcium, riboflavin, and vitamin E intake decreased with increasing DHD-index, an inverse association which disappeared after energy adjustment. Vitamin C showed a positive association across quintiles, also when adjusted for energy. For folate, iron, magnesium, potassium, thiamin, and vitamin B6 a positive association emerged after adjustment for energy. Conclusions The DHD-index is capable of ranking participants according to their adherence to the Dutch Guidelines for a Healthy Diet by reflecting variation in nine out of ten components that constitute the index when based on two 24-hour recalls. Furthermore, the index showed to be a good measure of nutrient density of diets.

Background The aim of this study was to investigate whether the perception of the neighbourhood environment alters when changing the physical activity behaviour through a pedometer intervention. Findings The intervention was implemented for 15 weeks in a small village in Germany, and was based on the individual baseline activity level. Eighty-two inhabitants participated in the study and completed an environmental questionnaire before and after the intervention. Results showed that after the intervention the participants perceived a lower distance to local facilities, a higher availability of bike lanes and infrastructures, a better maintenance of infrastructure, a better network and a safer traffic situation. Conclusion This suggests that a change in the levels of physical activity merges the levels of exposure to the environment which results in different environmental perceptions.