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Background: Increases in physical activity through active travel have the potential to have large beneficial effects on populations, through both better health outcomes and reduced motorized traffic. However accurately identifying travel mode in large datasets is problematic. Here we provide an open source tool to quantify time spent stationary and in four travel modes(walking, cycling, train, motorised vehicle) from accelerometer measured physical activity data, combined with GPS and GIS data. Methods: The Examining Neighbourhood Activities in Built Living Environments in London study evaluates the effect of the built environment on health behaviours, including physical activity. Participants wore accelerometers and GPS receivers on the hip for seven days. We time-matched accelerometer and GPS, and then extracted data from the commutes of 326 adult participants, using stated commute times and modes, which were manually checked to confirm stated travel mode. This yielded examples of five travel modes: walking, cycling, motorised vehicle, train and stationary. We used this example data to train a gradient boosted tree, a form of supervised machine learning algorithm, on each data point (131537 points), rather than on journeys. Accuracy during training was assessed using five-fold cross-validation. We also manually identified the travel behaviour of both 21 participants from ENABLE London (402749 points), and 10 participants from a separate study (STAMP-2, 210936 points), who were not included in the training data. We compared our predictions against this manual identification to further test accuracy and test generalisability. Results: Applying the algorithm, we correctly identified travel mode 97.3% of the time in cross-validation (mean sensitivity 96.3%, mean active travel sensitivity 94.6%). We showed 96.0% agreement between manual identification and prediction of 21 individuals’ travel modes (mean sensitivity 92.3%, mean active travel sensitivity 84.9%) and 96.5% agreement between the STAMP-2 study and predictions (mean sensitivity 85.5%, mean active travel sensitivity 78.9%). Conclusion: We present a generalizable tool that identifies time spent stationary and time spent walking with very high precision, time spent in trains or vehicles with good precision, and time spent cycling with moderate precisionIn studies where both accelerometer and GPS data are available this tool complements analyses of physical activity, showing whether differences in PA may be explained by differences in travel mode. All code necessary to replicate, fit and predict to other datasets is provided to facilitate use by other researchers.

Aims With increasing age, physical inactivity and sedentary behaviour levels increase, as does cardiovascular disease (CVD) incidence. We investigate how device-measured sedentary behaviour and physical activity (PA) are related to CVD onset in men aged 70+; whether the total volume of activity is more important than pattern. Methods and results Prospective population-based cohort study of men recruited from 24 UK General Practices in 1978–80. In 2010–12, 3137 survivors were invited to complete questionnaires and wear an Actigraph GT3x accelerometer for 7 days. PA intensity was categorised as sedentary, light and moderate to vigorous (MVPA). Men were followed up for Myocardial Infarction, stroke and heart failure (ICD9 410–414, 430–438 and 428) morbidity and mortality from 2010 to 12 to June 2016. Hazard Ratios (HRs) for incident Cardiovascular Disease (CVD) were estimated. 1528/3137 (49%) men had sufficient accelerometer data. 254 men with pre-existing CVD were excluded. Participants' mean age was 78.4 (range 71–92) years. After median 4.9 years follow-up, 122 first CVD events occurred in 1181 men (22.7/1000 person-years) with complete data. For each additional 30 min in sedentary behaviour, light PA,10 min in MVPA, or 1000 steps/day, HRs for CVD were 1.09(95%CI 1.00, 1.19), 0.94(0.85, 1.04), 0.88(0.81, 0.96) and 0.86(0.78 to 0.95) respectively, adjusted for measurement-related factors, socio-demographics, health behaviours and disability. HRs for accumulating 150 min/week MVPA in bouts ≥1 min and bouts ≥10 min were 0.47(0.32 to 0.69), and 0.49(0.25, 0.98). Conclusions In older men, high volume of steps or MVPA rather than MVPA bouts was associated with reduced CVD risk., Highlights • Prospective studies report that self-reported physical activity protects against cardiovascular disease (CVD). • Yet, self-reported behaviours cannot easily be used to assess the value of the 10 min activity bouts specified in guidelines. • This is the first study of risk of fatal and non-fatal CVD based on device measured physical activity and sedentary behaviour. • Among 1181 men aged over 70 years, more time in moderate to vigorous physical activity and more steps reduced 5-year CVD risk. • The pattern of accumulating moderate to vigorous physical activity in 10 min bouts was not important for CVD risk.

Background Frailty is associated with incident cardiovascular disease (CVD). However, its association with subclinical CVD, which precedes the onset of a CVD event, remains uncertain. Non-invasive vascular markers provide valuable proxy indicators of CVD risk, permitting investigation of risk burden and the development of subclinical CVD. N-terminal pro brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTNT) are markers of cardiac injury and are strong risk predictors of CVD events such as heart failure and myocardial infarction respectively. Our aim was to examine the association of subclinical cardiovascular markers with frailty in men without a diagnosis of CVD. Methods In 2010–2012, 1622 surviving men aged 71–92 years were examined and completed a questionnaire as part of a cross-sectional study from a cohort of men from 24 British towns initially recruited in 1978–1980. Using the Fried phenotype, frailty was defined by the presence of ≥3 of the following components: unintentional weight loss, low grip strength, low physical activity, slow walking pace and exhaustion. Carotid intima media thickness (CIMT) and carotid distensibility coefficient (DC) were measured using ultrasound. A Vicorder device was used to measure pulse wave velocity (PWV) and ankle brachial pressure index (ABPI). Fasting blood samples were analysed for NT-proBNP and cTNT. Multivariable logistic regression was used for analyses. Results Three hundred and three participants (19%) were frail and 876 (54%) were pre-frail. In men without CVD, frail individuals were significantly more likely to be older, physically inactive, have a smoking history and co-morbidities such as peripheral vascular disease and diabetes compared to non-frail individuals (p 1.2, PWV and CIMT) were not associated with frailty (p>0.05). Pre-frailty was also associated with raised cardiac markers (p Conclusion Frailty is strongly associated with subclinical CVD markers (NT-proBNP, cTNT and DC), even in the absence of prevalent CVD. Further research is needed to determine whether this association is causal and to understand the underlying mechanisms. Our study findings support the need for screening older individuals with frailty, with the objective of identifying those with an underlying increased risk of CVD and its adverse outcomes.

Background Heart failure (HF) is one of the leading causes of mortality, morbidity and hospitalisation in older adults. Although short stature has been associated with increased risk of coronary heart disease previous studies have consistently shown tall stature to be associated with increased risk of atrial fibrillation (AF) a known major risk factor for the development of HF. Relatively few studies have investigated the association between height and incident HF. We have therefore examined prospectively the association between adult height and incident AF and incident HF in a population based cohort of older men. Methods Prospective study of 3530 men aged 60–79 years with no diagnosed HF, myocardial infarction or stroke at baseline (1998–2000) followed up for a mean period of 15 years, in which there were 212 incident HF cases. Incident AF was based on a subgroup of men (n=1348) who attended re-examination in 2010–2012. Men were divided into 5 height groups: 183.0 cms based on the quartile distribution of height with the top 5 percent separated out. Results CVD risk factors tended to decrease with increasing height but a positive association was seen between height and prevalent AF. Tall stature was prospectively associated with increased risk of incident AF. Both short stature ( 183.0 cms) were associated with significantly increased risk of HF in age-adjusted analysis compared to those in the second height quartile [HR (95% CI) 1.58 (1.07,3.02) and 1.90 (1.04,3.50) respectively]. The increased risk seen in short men was attenuated after adjustment for lifestyle characteristics, established CHD risk factors, inflammation (CRP) and prevalent AF [adjusted HR=1.37 (0.92,2.02) ]. Since tall men had the most favourable CHD risk factors, adjustment increased the risk further (adjusted HR (95% CI) 1.97 (1.05,3.68). However further adjustment for incident AF attenuated the increased risk seen in tall men (HR=1.76 (0.93,3.31)]. Conclusion Both short stature and tall stature are associated with increased HF risk but the pathways underlying these associations are different. The increased risk of HF in short adults appear to be largely explained by adverse CVD risk factors associated with short stature; in tall men the association was partially explained by their increased risk of developing AF. Average body height has increased worldwide over the decades and if this trend continues, the prevalence of tall older adults is likely to increase which may contribute to an increasing burden of AF and HF.

Background Frailty is a state of increased vulnerability to stressors in older age, which increases risks of disability, falls and mortality. Prevalence of frailty is very high in older populations. The extent to which socioeconomic factors are associated with frailty is less well studied. We investigated the extent to which socioeconomic factors at individual and area level are associated with frailty in two studies of older populations in the UK. Methods Data are from two studies of older populations: the British Regional Heart Study (BRHS) comprised a socially representative sample of men (n=1622) from 24 British towns aged 71–92 years in 2010–12; the English Longitudinal Study of Ageing (ELSA) comprised a representative sample of older men and women (n=5344) aged ≥60 years in 2004 from England. Using the Fried phenotype, frailty was defined by the presence of ≥3 of the following components: unintentional weight loss, low grip strength, low physical activity, slow walking pace and exhaustion. Socioeconomic measures included occupational social class and area-level deprivation was based on the Index of Multiple Deprivation (IMD). Logistic regressions models were used. Results Prevalence of frailty was 19% and 9% in the BRHS and ELSA populations respectively. In the BRHS sample, the risk of frailty increased from the highest (social class I) to lowest social class V; age-adjusted odds ratio was 1.18 (95% confidence interval (CI)=1.07–1.31) for each category from social class I to V, which remained significant on adjustment for smoking, history of cardiovascular disease (CVD) or diabetes, body mass index (BMI) and alcohol consumption. The risk of frailty also increased from the least (quintile 1) to most deprived IMD quintile (quintile 5); OR per quintile=1.19 (95% CI 1.08 to 1.30). This increased risk remained significant on further adjustment for covariates. Similarly, in the ELSA population of older men and women, frailty risk was greater in lower social classes (OR=1.21 (95% CI 1.16 to 1.27) for each group from highest to lowest social classes. Frailty risk was greater also in deprived quintiles (OR=1.35, 95% CI 1.28 to 1.43, for every increase in quintile of deprivation). These associations remained significant on adjustment for covariates. Conclusion Adverse socioeconomic factors are associated with risk of frailty in older populations. These associations were independent of lifestyle factors and comorbidities, and were observed both for individual and area-level socioeconomic factors. Socioeconomic factors are potentially important in reducing the burden of frailty in older people. These findings merit further investigation prospectively.

Background Chronic obstructive lung disease (COPD) is a common chronic inflammatory disease in the elderly and is a major cause of morbidity and mortality. Much attention has focussed on identifying factors which may influence prognosis and mortality in these patients. Although vitamin D deficiency is traditionally known for its role in bone health, there is growing interest in the role of vitamin D in COPD. Observational studies have found Vitamin D deficiency to be highly prevalent in patients with COPD. We have examined the association between vitamin D deficiency (ascertained from measuring the circulating 25-dehydroxyvitamin D [25OHD] metabolite) and lung function impairment and assessed whether vitamin D deficiency is related to long term mortality in those with impaired lung function. Methods Prospective study of 3575 men aged 60–79 years with no prevalent HF followed up for 15 years, in whom there were 1937 deaths (80 COPD deaths). The Global Initiative on Obstructive Lung diseases (GOLD) spirometry criteria was used to define airway obstruction. Vitamin D deficiency was defined as serum 25OHD levels 20 ng/mL. Results Vitamin D deficiency was associated with moderate COPD (FEV/FVC 80%) or restrictive lung disease (FEV1/FVC >70% and FVC 20 ng/ml were 1.38 (1.10, 1.75), 1.62 (1.22, 2.15), 1.93 (1.32, 2.80) and 1.34 (0.78, 2.31) for those with none/mild COPD, restrictive lung function, moderate COPD and severe COPD respectively. The corresponding HRs (95% CI) for COPD deaths were 14.3 (2.45, 83.23), 5.10 (0.96, 27.06), 3.55 (1.12, 11.22) and 0.81 (0.25, 2.57) for the 4 groups respectively. Conclusion Our findings suggest that older adults with vitamin D deficiency (

Aim To understand how device-measured sedentary behaviour and physical activity are related to cardiovascular disease (CVD) events in older men, an age-group with high levels of physical inactivity and sedentary behaviour. Activity monitors permit investigation of different activity intensities, (including light activity which is hard to recall) and the pattern of accumulating activity, (such as doing moderate to vigorous physical activity (MVPA) in 10 min bouts) or breaking up periods of sedentary behaviour. Methods Prospective population-based cohort study of 7735 men recruited from 24 UK General Practices in 1978–80. In 2010–12, 3137 surviving men were invited to complete a questionnaire about medical history and health behaviours and to wear an Actigraph GT3x accelerometer over the hip for 7 days. Physical activity intensity was categorised as sedentary: 1040 counts/minute. A sedentary break was the interruption of a sedentary bout lasting >1 min by ≥1 min of activity >100 counts/minute. Men were followed up for CVD morbidity (ICD9 410–414 and 430–438) and mortality from 2010–12 to 1 st June 2016. Cox proportional hazards models estimated Hazard Ratios (HRs) for CVD according to physical activity measured in 2010–12, controlling for confounders. Results 1,566/3137 (50%) men returned an accelerometer with data and 1528 (49%) had ≥600 minutes/day wear time on ≥3 days. 254 men with pre-existing CVD were excluded, leaving 1274 men. Participants’ mean age was 78.4 (range 71–92) years. After median 4.6 years follow-up, 82 first CVD events occurred in 1181 men with complete covariate data. For each additional 30 min in sedentary behaviour, light physical activity, 10 min in MVPA, or 1000 steps/day, hazard ratios for CVD mortality were 1.08 (95% CI 0.98, 1.18), 0.96 (95% CI 0.85, 1.08), 0.89 (95% CI 0.81, 0.98) and 0.86 (95% CI 0.77 to 0.96) respectively. Adjustments for confounders little changed the estimates. The hazard ratio for accumulating 150 min MVPA/week irrespective of bout length (achieved by 66% of men) was 0.54 (95% CI, 0.34 to 0.87) and for accumulating 150 min MVPA/week in bouts lasting ≥10 min (achieved by 16% of men) was 0.49 (95% CI, 0.21 to 1.13). Sedentary breaks were not associated with CVD events. Discussion In older men, a higher number of steps per day or accumulating more MVPA (irrespective of bouts lasting ≥10 min) was associated with reduced CVD risk. Hence, in this population CVD prevention could focus on accumulating time in activities like brisk walking each day. Future studies should replicate analyses in women and younger populations.

Background There has been increasing interest in whether the built environmentinfluences health behaviours, but robust longitudinal evidence is limited. We assessed the effect of moving into East Village (the former London 2012 Olympic Games Athletes Village), a neighbourhood built on active design principles, on levels of physical activity (PA) and adiposity among adults. Methods A cohort of 1278 adults (16+) seeking to move into social, intermediate (a mixture of shared ownership, shared equity, affordable rent), and market-rent East Village accommodation were recruited in 2013–2015, and followed up after two years. Objective measures of PA using accelerometry (ActiGraph GT3X+), body mass index (BMI) and bioelectrical impedance (fat mass %) were made. We examined change in levels of PA and adiposity, using multilevel models adjusting for sex, age group, ethnicity, housing sector (fixed effects) and household (random effect), comparing those who moved to East Village (intervention group) with those who lived outside East Village (control group). Effects by housing sector and weekdays versus weekends for PA were also examined. Results 877 adults (69%) were followed-up, half had moved to East Village. Moving to East Village was associated with a small increase in daily steps (151, 95% CI −233, 534), more so in the intermediate sector (399, 95% CI −211, 1009) than in the social and market-rent sectors, but effects were not statistically significant. There were no differences in time spent in moderate-to-vigorous PA (MVPA) or any appreciable weekday versus weekend effects. There was no evidence of differences in time spent in light PA or sedentary time both overall and by housing sector with the exception of the market-rent group in whom moving to East Village was associated with a decrease in light PA (−13.0 mins, 95% CI −24.7,–1.2 mins). There were no effects of moving to East Village on BMI or fat mass% overall or by housing sector. Conclusion At two-year follow-up, moving to East Village, a neighbourhood designed for healthy active living, did not have beneficial, consistent effects on objectively measured physical activity or adiposity of public health importance.

Background For ethnic adjustment of BMI are available but not currently used in the National Child Measurement Programme (NCMP). We evaluated the effect of ethnic-specific BMI adjustments on the prevalence of obesity and severe obesity, using cut-offs to identify children potentially needing clinical intervention, in three inner London Boroughs with high obesity prevalence and ethnic diversity. Methods We analysed de-personalised NCMP data for 21 126 (10,348 girls) five year-olds (5,463, 9065 and 6598 respectively in City & Hackney, Newham and Tower Hamlets) and 19 024 (9,361 girls) 11 year-olds (4,865, 8274 and 5,885) for the school years 2015–16 and 2016–17. We estimated, for each borough, the prevalence of obesity (BMI centile ≥98th) and severe obesity (defined as ≥120% of the 95th centile) based on unadjusted and ethnic-adjusted BMI using ethnic-specific BMI adjustments for South Asian and Black ethnicity children, developed by Hudda et al. These add ∼1.1 kg/m2 to, and deduct between 0.12 and 5.52 kg/m2 from, the BMI of South Asian and Black ethnicity children respectively. We report the net change in numbers identified for possible clinical intervention over both school years and for both ages combined. Results Proportions of five and eleven year-olds of South Asian ethnicity were highest in Tower Hamlets (58.5%; 67.4% respectively) and Newham (39.1%; 30.3%), and lowest in City & Hackney (9.7%; 6.4%). Equivalent proportions of children of Black ethnicity were highest in City & Hackney (29.6%; 22.0%) and Newham (16.5%; 13.6%), and lowest in Tower Hamlets (8.3%; 9.4%). Ethnic-specific BMI adjustments increased the respective prevalences of obesity and severe obesity in Tower Hamlets from 6.7% and 1.7% to 8.1% and 2.5% at age five, and from 11.2% and 6.9% to 11.9% and 8.6% at age 11, a net increase of 133 obese and 154 severely obese children. Equivalent prevalences in City & Hackney fell after ethnic adjustment, from 6.7% and 1.8% to 5.2% and 1.4% at age five, and from 10.7% and 8.8% to 9.4% and 7.7% at age 11, a net decrease of 145 obese and 74 severely obese children. Prevalence estimates before and after ethnic adjustment in Newham were broadly similar, resulting in three fewer obese and 28 more severely obese children. Conclusion Adoption of ethnic-adjusted BMI in ethnically diverse areas alters local estimates of childhood obesity, avoids misclassification of children of South Asian and Black ethnicity, and is essential to support clinical service planning and commissioning. Ethnic-specific BMI adjustments for children of mixed ethnicity are needed.

Background We examined associations of objectively measured physical activity ( PA ) and sedentary time with cardiovascular disease biomarkers at age 60 to 64 years. This included investigation of sex differences and the extent to which associations may be mediated by adiposity. Methods and Results Participants were 795 men and 827 women aged 60 to 64 years from the Medical Research Council National Survey of Health and Development. Combined heart rate and movement sensors worn for 5 consecutive days were used to derive overall PA energy expenditure, kJ /kg per day) and time spent sedentary (PA (>3 metabolic equivalent of tasks). Linear regression models were used to relate each PA parameter to inflammatory (C‐reactive protein, interleukin‐6), endothelial (tissue‐plasminogen activator, E‐selectin) and adipokine (leptin, adiponectin) markers extracted from fasting blood samples. Greater time in light PA and moderate‐to‐vigorous intensity PA and less sedentary time were associated with more favorable biomarker levels. For C‐reactive protein, interleukin‐6, and leptin, these differences were greater among women than men. For example, % differences (95% confidence intervals) in leptin for men and women per SD increases in sedentary time: 7.9 (2.7, 13.0) and 20.6 (15.3, 25.8); light intensity PA : −3.8 (−8.9, 12.7) and −17.7 (−23.1, −12.4), moderate‐to‐vigorous intensity PA : −12.9 (−17.9, −8.0) and −18.3 (−23.4, −13.1). Fat mass mediated a greater proportion of these associations in women than men. Conclusions Greater light PA and moderate‐to‐vigorous intensity PA and less sedentary time in early old age were associated with more favorable cardiovascular biomarker profiles. Fat mass partially mediated these associations but more strongly in women than men, which explained sex differences.

ObjectivesThe neighbourhood environment is increasingly shown to be an important correlate of health. We assessed associations between housing tenure, neighbourhood perceptions, sociodemographic factors and levels of physical activity (PA) and adiposity among adults seeking housing in East Village (formerly London 2012 Olympic/Paralympic Games Athletes’ Village).SettingCross-sectional analysis of adults seeking social, intermediate and market-rent housing in East Village.Participants1278 participants took part in the study (58% female). Complete data on adiposity (body mass index (BMI) and fat mass %) were available for 1240 participants (97%); of these, a subset of 1107 participants (89%) met the inclusion criteria for analyses of accelerometer-based measurements of PA. We examined associations between housing sector sought, neighbourhood perceptions (covariates) and PA and adiposity (dependent variables) adjusted for household clustering, sex, age group, ethnic group and limiting long-standing illness.ResultsParticipants seeking social housing had the fewest daily steps (8304, 95% CI 7959 to 8648) and highest BMI (26.0 kg/m2, 95% CI 25.5kg/m2to 26.5 kg/m2) compared with those seeking intermediate (daily steps 9417, 95% CI 9106 to 9731; BMI 24.8 kg/m2, 95% CI 24.4 kg/m2to 25.2 kg/m2) or market-rent housing (daily steps 9313, 95% CI 8858 to 9768; BMI 24.6 kg/m2, 95% CI 24.0 kg/m2to 25.2 kg/m2). Those seeking social housing had lower levels of PA (by 19%–42%) at weekends versus weekdays, compared with other housing groups. Positive perceptions of neighbourhood quality were associated with higher steps and lower BMI, with differences between social and intermediate groups reduced by ~10% following adjustment, equivalent to a reduction of 111 for steps and 0.5 kg/m2for BMI.ConclusionsThe social housing group undertook less PA than other housing sectors, with weekend PA offering the greatest scope for increasing PA and tackling adiposity in this group. Perceptions of neighbourhood quality were associated with PA and adiposity and reduced differences in steps and BMI between housing sectors. Interventions to encourage PA at weekends and improve neighbourhood quality, especially among the most disadvantaged, may provide scope to reduce inequalities in health behaviour.

Body mass index (BMI) overweight/obesity thresholds in South Asian (SA) adults, at equivalent type 2 diabetes risk are lower than for white Europeans (WE). We aimed to define adjusted overweight/obesity thresholds for UK SA children based on equivalent insulin resistance (HOMA-IR) to WE children. In 1138 WE and 1292 SA children 9.0-10.9y, multi-level regression models quantified associations between BMI and HOMA-IR, by ethnic group. HOMA-IR levels for WE children were calculated at established overweight/obesity thresholds (9.5y,10.5y), based on UK90 BMI cut-offs. Quantified associations in SA children were then used to estimate adjusted SA weight status thresholds at the calculated HOMA-IR levels. At 9.5y, current WE BMI overweight and obesity thresholds were 19.2kg/m2, 21.3kg/m2 (boys) and 20.0kg/m2, 22.5kg/m2 (girls). At equivalent HOMA-IR, SA overweight and obesity thresholds were lower by 2.9kg/m2 (95%CI: 2.5–3.3kg/m2) and 3.2kg/m2 (95%CI: 2.7–3.6kg/m2) in boys and 3.0kg/m2 (95%CI: 2.6–3.4kg/m2) and 3.3kg/m2 (95%CI: 2.8–3.8kg/m2) in girls respectively. At these lower thresholds, overweight/obesity prevalences in SA children were approximately doubled (boys:61%,girls:56%). Patterns at 10.5y were similar. In conclusion, SA adjusted overweight/obesity thresholds based on equivalent IR, were markedly lower than BMI thresholds for WE children and defined more than half of SA children as overweight/obese.

Background Guidelines recommend walking to increase moderate to vigorous physical activity (MVPA) for health benefits. Objectives To assess the effectiveness, cost-effectiveness and acceptability of a pedometer-based walking intervention in inactive adults, delivered postally or through dedicated practice nurse physical activity (PA) consultations. Design Parallel three-arm trial, cluster randomised by household. Setting Seven London-based general practices. Participants A total of 11,015 people without PA contraindications, aged 45–75 years, randomly selected from practices, were invited. A total of 6399 people were non-responders, and 548 people self-reporting achieving PA guidelines were excluded. A total of 1023 people from 922 households were randomised to usual care (n = 338), postal intervention (n = 339) or nurse support (n = 346). The recruitment rate was 10% (1023/10,467). A total of 956 participants (93%) provided outcome data. Interventions Intervention groups received pedometers, 12-week walking programmes advising participants to gradually add ‘3000 steps in 30 minutes’ most days weekly and PA diaries. The nurse group was offered three dedicated PA consultations. Main outcome measures The primary and main secondary outcomes were changes from baseline to 12 months in average daily step counts and time in MVPA (in ≥ 10-minute bouts), respectively, from 7-day accelerometry. Individual resource-use data informed the within-trial economic evaluation and the Markov model for simulating long-term cost-effectiveness. Qualitative evaluations assessed nurse and participant views. A 3-year follow-up was conducted. Results Baseline average daily step count was 7479 [standard deviation (SD) 2671], average minutes per week in MVPA bouts was 94 minutes (SD 102 minutes) for those randomised. PA increased significantly at 12 months in both intervention groups compared with the control group, with no difference between interventions; additional steps per day were 642 steps [95% confidence interval (CI) 329 to 955 steps] for the postal group and 677 steps (95% CI 365 to 989 steps) for nurse support, and additional MVPA in bouts (minutes per week) was 33 minutes per week (95% CI 17 to 49 minutes per week) for the postal group and 35 minutes per week (95% CI 19 to 51 minutes per week) for nurse support. Intervention groups showed no increase in adverse events. Incremental cost per step was 19p and £3.61 per minute in a ≥ 10-minute MVPA bout for nurse support, whereas the postal group took more steps and cost less than the control group. The postal group had a 50% chance of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold within 1 year and had both lower costs [–£11M (95% CI –£12M to –£10M) per 100,000 population] and more QALYs [759 QALYs gained (95% CI 400 to 1247 QALYs)] than the nurse support and control groups in the long term. Participants and nurses found the interventions acceptable and enjoyable. Three-year follow-up data showed persistent intervention effects (nurse support plus postal vs. control) on steps per day [648 steps (95% CI 272 to 1024 steps)] and MVPA bouts [26 minutes per week (95% CI 8 to 44 minutes per week)]. Limitations The 10% recruitment level, with lower levels in Asian and socioeconomically deprived participants, limits the generalisability of the findings. Assessors were unmasked to the group. Conclusions A primary care pedometer-based walking intervention in 45- to 75-year-olds increased 12-month step counts by around one-tenth, and time in MVPA bouts by around one-third, with similar effects for the nurse support and postal groups, and persistent 3-year effects. The postal intervention provides cost-effective, long-term quality-of-life benefits. A primary care pedometer intervention delivered by post could help address the public health physical inactivity challenge. Future work Exploring different recruitment strategies to increase uptake. Integrating the Pedometer And Consultation Evaluation-UP (PACE-UP) trial with evolving PA monitoring technologies. Trial registration Current Controlled Trials ISRCTN98538934. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 37. See the NIHR Journals Library website for further project information.

Background: There is only scarce number of studies available describing the lifestyle of adolescents living in Arab countries. Hence, we described physical activity (PA) and sedentary behaviors patterns among Kuwaiti adolescents and the associations with parental education. Methods: Cross-sectional data from 435 adolescents (201 boys and 234 girls) were collected from the Study of Health and Activity among Adolescents in Kuwait conducted between 2012 and 2013. Outcome variables included PA (ActiGraph GT1M accelerometers) and sedentary behaviors. Exposure variable was parental education. Descriptive and multiple logistic regression analyses were used to examine the association between parental education and outcome variables. Results: Total sedentary time (minutes per day) was higher in girls [568.2 (111.6)] than in boys [500.0 (102.0)], whereas boys accumulated more minutes in light, moderate, and vigorous PA (all Ps = 60 minutes per day of moderate to vigorous PA (by accelerometry), while only 21% met the screen time guidelines. Low/medium maternal education was associated with a higher odds of exceeding screen time guidelines (odds ratio = 2.09; 95% confidence interval, 1.09-4.02). Conclusions: Most Kuwaiti adolescents in this sample were physically inactive and exceeded screen time guidelines. Objective PA was not socially patterned, yet an inverse association between maternal education and screen time behaviors was found. Refereed/Peer-reviewed

Few trials have compared estimates of change in physical activity (PA) levels using self-reported and objective PA measures when evaluating trial outcomes. The PACE-UP trial offered the opportunity to assess this, using the self-administered International Physical Activity Questionnaire (IPAQ) and waist-worn accelerometry. The PACE-UP trial (N = 1023) compared usual care (n = 338) with two pedometer-based walking interventions, by post (n = 339) or with nurse support (n = 346). Participants wore an accelerometer at baseline and 12 months and completed IPAQ for the same 7-day periods. Main outcomes were weekly minutes, all in ≥10 min bouts as per UK PA guidelines of: i) accelerometer moderate-to-vigorous PA (Acc-MVPA) ii) IPAQ moderate+vigorous PA (IPAQ-MVPA) and iii) IPAQ walking (IPAQ-Walk). For each outcome, 12 month values were regressed on baseline to estimate change. Analyses were restricted to 655 (64%) participants who provided data on all outcomes at baseline and 12 months. Both intervention groups significantly increased their accelerometry MVPA minutes/week compared with control: postal group 42 (95% CI 22, 61), nurse group 43 (95% CI 24, 63). IPAQ-Walk minutes/week also increased: postal 57 (95% CI 2, 112), nurse 43 (95% CI -11, 97) but IPAQ-MVPA minutes/week showed non-significant decreases: postal -11 (95% CI -65, 42), nurse -34 (95% CI -87, 19). Our results demonstrate the necessity of using a questionnaire focussing on the activities being altered, as with IPAQ-Walk questions. Even then, the change in PA was estimated with far less precision than with accelerometry. Accelerometry is preferred to self-report measurement, minimising bias and improving precision when assessing effects of a walking intervention. Trial registration: ISRCTN, ISRCTN98538934 . Registered 2 March 2012.

Introduction: Maintenance of physical activity during later life is associated with reduced risk of cardiovascular disease; however, how long-term trajectories of physical activity into old age are associated with established and novel cardiovascular disease risk factors remains unclear. This study examined the association between 20-year physical activity trajectories and a wide range of cardiovascular disease biomarkers in early old age. Hypothesis: We assessed the hypothesis that persistent long-term physical activity from midlife to old age is associated with the lowest levels of cardiovascular disease risk factors in old age. Methods: 7735 men (mean baseline age 50.2 ± 5.8 years) recruited in 1978-80 were followed up after 12, 16 and 20 years, reporting habitual physical activity levels at each wave. At the 20-year follow up, surviving men also attended a physical examination and provided a fasting blood sample. Initially, group-based trajectory modelling was used to identify the trajectories of physical activity. Then regression analyses were used to examine the association between trajectory group membership and a number of cardiometabolic, cardiac and inflammatory markers. Analyses were adjusted for a range of sociodemographic, health and lifestyle factors and use of blood pressure-lowering and antihypertensive drugs. Results: A total of 3228 men providing physical activity data at ≥3 time points with cardiovascular biomarker data were included in the analysis. Three distinct 20-year trajectories were identified: low decreasing (20.1%), light stable (52.7%) and moderate increasing (27.2%). In comparison to the low decreasing group, membership of the light stable and moderate increasing physical activity trajectory groups was associated with a more favourable cardiometabolic profile, including lower HbA1C and insulin; lower levels of inflammation, including lower levels of interleukin 6 and C-reactive protein; and lower levels of the cardiac marker high-sensitivity troponin T. The magnitude of the associations was similar for the light stable and moderate increasing groups. Conclusion: In conclusion, twenty-year trajectories of physical activity from midlife to old age were associated with established and novel cardiovascular disease risk factors. Effect sizes were similar for members following a light stable and a moderate increasing physical activity trajectory, suggesting that even relatively light but persistent physical activity into old age can be a determinant of lower cardiovascular disease risk.

BackgroundPhysical inactivity is an important cause of noncommunicable diseases. Interventions can increase short-term physical activity (PA), but health benefits require maintenance. Few interventions have evaluated PA objectively beyond 12 months. We followed up two pedometer interventions with positive 12-month effects to examine objective PA levels at 3-4 years.Methods and findingsLong-term follow-up of two completed trials: Pedometer And Consultation Evaluation-UP (PACE-UP) 3-arm (postal, nurse support, control) at 3 years and Pedometer Accelerometer Consultation Evaluation-Lift (PACE-Lift) 2-arm (nurse support, control) at 4 years post-baseline. Randomly selected patients from 10 United Kingdom primary care practices were recruited (PACE-UP: 45-75 years, PACE-Lift: 60-75 years). Intervention arms received 12-week walking programmes (pedometer, handbooks, PA diaries) postally (PACE-UP) or with nurse support (PACE-UP, PACE-Lift). Main outcomes were changes in 7-day accelerometer average daily step counts and weekly time in moderate-to-vigorous PA (MVPA) in ≥10-minute bouts in intervention versus control groups, between baseline and 3 years (PACE-UP) and 4 years (PACE-Lift). PACE-UP 3-year follow-up was 67% (681/1,023) (mean age: 59, 64% female), and PACE-Lift 4-year follow-up was 76% (225/298) (mean age: 67, 53% female). PACE-UP 3-year intervention versus control comparisons were as follows: additional steps/day postal +627 (95% CI: 198-1,056), p = 0.004, nurse +670 (95% CI: 237-1,102), p = 0.002; total weekly MVPA in bouts (minutes/week) postal +28 (95% CI: 7-49), p = 0.009, nurse +24 (95% CI: 3-45), p = 0.03. PACE-Lift 4-year intervention versus control comparisons were: +407 (95% CI: -177-992), p = 0.17 steps/day, and +32 (95% CI: 5-60), p = 0.02 minutes/week MVPA in bouts. Neither trial showed sedentary or wear-time differences. Main study limitation was incomplete follow-up; however, results were robust to missing data sensitivity analyses.ConclusionsIntervention participants followed up from both trials demonstrated higher levels of objectively measured PA at 3-4 years than controls, similar to previously reported 12-month trial effects. Pedometer interventions, delivered by post or with nurse support, can help address the public health physical inactivity challenge.Trial registrationsPACE-UP isrctn.com ISRCTN98538934; PACE-Lift isrctn.com ISRCTN42122561.

Background Evidence largely from animal studies suggests that conjugated linoleic acid ( CLA ) may have cardiovascular health benefits. However, few prospective studies have examined the association between CLA and cardiovascular disease. We have prospectively examined the association between serum CLA and incident coronary heart disease and heart failure ( HF ) in older men. Methods and Results Prospective study of 3806 men, aged 60 to 79 years, without prevalent HF followed up for an average of 13 years, during which there were 295 incident HF cases. A high‐throughput serum nuclear magnetic resonance metabolomics platform was used to measure CLA concentration in serum, expressed as a percentage of total fatty acids ( CLA %). CLA % was adversely associated with cholesterol and high‐density lipoprotein cholesterol but was inversely associated with C‐reactive protein and NT ‐pro BNP (N‐terminal pro‐B‐type natriuretic peptide; a marker of ventricular stress). No association was seen between CLA % and incident coronary heart disease. High CLA % was associated with significantly reduced risk of HF after adjustment for HF risk factors and C‐reactive protein (hazard ratio [95% confidence interval ], 0.64 [0.43–0.96]; quartile 4 versus quartile 1). Elevated CLA % was associated with reduced HF risk only in those with higher dairy fat intake, a major dietary source of CLA (test for interaction P =0.03). The reduced risk of HF was partially explained by NT ‐pro BNP . High dairy fat intake was not associated with incident coronary heart disease but was associated with reduced risk of HF , largely because of the inverse effect of CLA . Conclusions The finding that high CLA % is associated with lower risk of incident HF in older men requires confirmation in larger studies.

PURPOSE: Living in a cold home increases the risk of dying in winter, especially in older people. However, it is unclear which individual factors predict whether older people are living in cold homes. METHODS: Thousand four hundred two men aged 74-95 years from a U.K. population-based study reported difficulties in keeping warm during winter, answering four simple "yes/no" questions. Associations between individual's characteristics and each of the four self-reported measures of cold homes were estimated using logistic regression models. Next, we investigated whether measures of cold homes predict mortality over the subsequent 2.1 years. RESULTS: Manual social class, difficulties making ends meet, and not being married were each associated (P

Aims/hypothesis: \ud \ud There is evidence that, from birth, South Asians are fatter, for a given body mass, than Europeans. The role of developmental overnutrition related to maternal adiposity and circulating glucose in these ethnic differences is unclear. Our aim was to compare associations of maternal gestational adiposity and glucose with adiposity at age 4/5 years in white British and Pakistani children.\ud \ud Methods: \ud \ud Born in Bradford is a prospective study of children born between 2007 and 2010 in Bradford, UK. Mothers completed an OGTT at 27–28 weeks of gestation. We examined associations between maternal gestational BMI, fasting glucose, post-load glucose and diabetes (GDM) and offspring height, weight, BMI and subscapular skinfold (SSF) and triceps skinfold (TSF) thickness at age 4/5 years, using data from 6060 mother–offspring pairs (2717 [44.8%] white British and 3343 [55.2%] Pakistani).\ud \ud Results: \ud \ud Pakistani mothers had lower BMI and higher fasting and post-load glucose and were twice as likely to have GDM (defined using modified WHO criteria) than white British women (15.8% vs 6.9%). Pakistani children were taller and had lower BMI than white British children; they had similar SSF and lower TSF. Maternal BMI was positively associated with the adiposity of offspring in both ethnic groups, with some evidence of stronger associations in Pakistani mother–offspring pairs. For example, the difference in adjusted mean BMI per 1 kg/m2 greater maternal BMI was 0.07 kg/m2 (95% CI 0.05, 0.08) and 0.10 kg/m2 (95% CI 0.09. 0.11) in white British and Pakistani children, respectively, with equivalent results for SSF being 0.07 mm (95% CI 0.05, 0.08) and 0.09 mm (95% CI 0.08. 0.11) (p for ethnic difference < 0.03 for both). There was no strong evidence of association of fasting and post-load glucose, or GDM, with outcomes in either group.\ud \ud Conclusions/interpretation: \ud \ud At age 4/5 years, Pakistani children are taller and lighter than white British children. While maternal BMI is positively associated with offspring adiposity, gestational glycaemia is not clearly related to offspring adiposity in either ethnic group.

Background: Pediatric blood pressure (BP) levels are typically assigned to categories when they exceed sex-, age-, and height-specific 90th (elevated) and 95th percentile (high) cutoffs. Given the number of stratum, there are hundreds of cutoffs for defining elevated and high BP that make it cumbersome to use in clinical practice. In 2017 the American Academy of Pediatrics (AAP) recommended simplified cutoffs of ≥120/80 mmHg and ≥130/80 mmHg be used to diagnose elevated BP and high BP, respectively, in clinical practice for adolescents aged 13-17 years. Accordingly, we suggest cutoffs of ≥110/70 mmHg and ≥120/80 mmHg be used for elevated BP and high BP among children aged 6-12 years. The aim of this study was to evaluate the utility of the simplified cutoffs for pediatric BP in determining high carotid intima-media thickness (cIMT) in children and adolescents. Methods: Data were from 6 population-based cross-sectional studies in Brazil, China, Greece, Italy, Spain and the UK. A total of 4280 children and adolescents aged 6-17 years were included. High cIMT was defined as cIMT ≥sex-, age- and cohort-specific 90th percentile cutoffs. Logistic regression model, receiver operating characteristic (ROC) curve and net reclassification improvement (NRI) methods were used to compare the performance of the simplified definition with three established complex definitions (i.e. 2017 AAP guideline, 2004 Fourth Report, and 2016 international BP references) in determining high cIMT (≥sex-, age- and cohort-specific 90th percentile of cIMT) in children and adolescents. Results: Compared with those who had normal BP, participants with high BP defined using either of the three complex definitions or simplified definition had similar odds of high cIMT, with odds ratios and 95% confidence intervals of 1.46 (1.15-1.86), 1.47 (1.10-1.96), 1.42 (1.12-1.80), and 1.65 (1.25-2.17), respectively, after adjustment for sex, age, race/ethnicity, body mass index, high density lipoprotein-cholesterol, triglyceride, and fasting blood glucose. The similar utility of all four high BP definitions in determining high cIMT were further confirmed by area under the ROC curve and NRI methods (all p for difference >0.05). Interpretation: The simplified BP definition performed similarly with three complex definitions in determining high cIMT in children and adolescents. The simplified definition offers a similarly accurate but more convenient means to identify pediatric high BP in clinical practice. Funding: Dr Bo Xi was supported by the National Natural Science Foundation of China (81673195). Dr. Costan G. Magnussen was supported by a National Heart Foundation of Australia Future Leader Fellowship (100849). Declaration of Interest: None Ethical Approval: Each study was approved by the corresponding institutional review board, and written informed consent was obtained from all study participants and their parents or guardians.

Background The National Child Measurement Programme (NCMP) assesses patterns of overweight–obesity in English children. It uses body mass index (BMI), which overestimates body fatness in South Asian children and underestimates body fatness in black children of presumed African ethnicity. Using previously derived BMI adjustments, ensuring that adjusted BMI was similarly related to body fatness in South Asian, black, and white children, we reassessed population body fatness, overweight, and obesity patterns in these ethnic groups in the NCMP. Methods Analyses were based on 2012–13 NCMP data in 582 899 children aged 4–5 years and 485 362 children aged 10–11 years. Standard centile-based approaches defined weight status in each age-group before and after applying BMI adjustments, derived previously with the deuterium dilution method, for South Asian and black children. Findings Among white children, overweight–obesity prevalences were 23% (45 508/197 691) for boys and 21% (39 411/188 663) for girls in 4–5 year olds and 33% (52 635/160 278) and 30% (45 978/151 146), respectively, in 10–11 year olds. Before adjustment, South Asian children had lower overweight–obesity prevalences at 4–5 years (19% of boys [4485/23 191], 19% of girls [4176/22 109]; both p Interpretation Adjusted BMI data reveal a substantial excess of overweight–obesity among English South Asian children (at 4–5 years and especially at 10–11 years) and among black girls (aged 10–11 years), with important implications for prevention. These patterns are not apparent with the use of unadjusted BMI data, which systematically underestimated overweight–obesity prevalences in South Asian children and overestimated them in black children. Funding British Heart Foundation, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (South London & North Thames).

BackgroundPolicy initiatives such as WHO Age Friendly Cities recognise the importance of the urban environment for improving health of older people, who have both low physical activity (PA) levels and greater dependence on local neighbourhoods. Previous research in this age group is limited and rarely uses objective measures of either PA or the environment.MethodsWe investigated the association between objectively measured PA (Actigraph GT3x accelerometers) and multiple dimensions of the built environment, using a cross-sectional multilevel linear regression analysis. Exposures were captured by a novel foot-based audit tool that recorded fine-detail neighbourhood features relevant to PA in older adults, and routine data.Results795 men and 638 women aged 69–92 years from two national cohorts, covering 20 British towns, were included in the analysis. Median time in moderate to vigorous PA (MVPA) was 27.9 (lower quartile: 13.8, upper quartile: 50.4) minutes per day. There was little evidence of associations between any of the physical environmental domains (eg, road and path quality defined by latent class analysis; number of bus stops; area aesthetics; density of shops and services; amount of green space) and MVPA. However, analysis of area-level income deprivation suggests that the social environment may be associated with PA in this age group.ConclusionsAlthough small effect sizes cannot be discounted, this study suggests that older individuals are less affected by their local physical environment and more by social environmental factors, reflecting both the functional heterogeneity of this age group and the varying nature of their activity spaces.

Objective We estimated associations of time of day with cardiovascular disease (CVD) risk factors measured in older men. Methods CVD risk factors (markers of inflammation and haemostasis, and cardiac markers) were measured on one occasion between 08:00 and 19:00 hours in 4252 men aged 60–79 years from the British Regional Heart Study. Linear models were used to estimate associations between time of day and risk factors. When an association was found, we examined whether the relationship between risk factors and cardiovascular mortality was affected by the adjustment for time of day using survival analyses. Results N-terminal pro-brain natriuretic peptide (NT-proBNP) levels increased by 3.3% per hour (95% CI 1.9% to 4.8%), interleukin-6 (IL-6) increased by 2.6% per hour (95% CI 1.8% to 3.4%), while tissue plasminogen activator (t-PA) decreased by 3.3% per hour (95% CI 3.7% to 2.9%); these associations were unaffected by adjustment for possible confounding factors. The percentages of variation in these risk factors attributable to time of day were less than 2%. In survival analyses, the association of IL-6, NT-proBNP and t-PA with cardiovascular mortality was not affected by the adjustment for time of day. C reactive protein, fibrinogen, D-dimer, von Willebrand factor and cardiac troponin T showed no associations with time of day. Conclusions In older men, markers of inflammation (IL-6), haemostasis (t-PA) and a cardiac marker (NT-proBNP) varied by time of day. The contribution of time of day to variations in these markers was small and did not appear to be relevant for the CVD risk prediction.

The Examining Neighbourhood Activities in Built Living Environments in London (ENABLE London) study provides a unique opportunity to examine differences in mental health and well-being amongst adults seeking social, intermediate (affordable rent), and market-rent housing in a purpose built neighbourhood (East Village, the former London 2012 Olympic Athletes’ Village), specifically designed to encourage positive health behaviours. Multi-level logistic regression models examined baseline differences in levels of depression, anxiety and well-being across the housing groups. Compared with the intermediate group, those seeking social housing were more likely to be depressed, anxious and had poorer well-being after adjustment for demographic and health status variables. Further adjustments for neighbourhood perceptions suggest that compared with the intermediate group, perceived neighbourhood characteristics may be an important determinant of depression amongst those seeking social housing, and lower levels of happiness the previous day amongst those seeking market-rent housing. These findings add to the extensive literature on inequalities in health, and provide a strong basis for future longitudinal work that will examine change in depression, anxiety and well-being after moving into East Village, where those seeking social housing potentially have the most to gain., Highlights • A natural experiment examining baseline mental health and well-being in adults seeking three housing tenures in East Village. • Those seeking social housing are more likely to report depressive symptoms and low life satisfaction at baseline. • Differences in well-being outcomes across the housing groups can be partially explained by neighbourhood perceptions. • Those seeking social housing appear to have the most to gain by moving to East Village.

Background Socioeconomic inequalities in oral health are established. However, the influence of neighbourhood-level socioeconomic factors on the oral health of older people is not well-established. We investigated both objective and perceived neighbourhood characteristics and their associations with a range of oral health measures in older age. Methods The British Regional Heart Study comprises a representative sample of men drawn from 24 general practices across Britain at 40–59 years in 1978–80. In 2010–12, the participants when aged 71–92 years had a follow-up a physical examination including a dental assessment (n=1622), and completed a questionnaire (n=2137). Oral health assessment included objective measures (tooth count and periodontal (gum) disease), and self-reported fair/poor oral health and dry mouth symptoms. Neighbourhood deprivation was based on the Index of Multiple Deprivation (IMD); a composite score of neighbourhood-level factors (income, employment, education, disability, crime, housing, living environment). Perceived neighbourhood characteristics included local area services, safety, environment, and a cumulative index of these characteristics. Multilevel and multivariate logistic regression models were used to obtain odds ratios according to quintiles of IMD and perceived neighbourhood characteristics. Results The risk of periodontal disease and tooth loss increased from IMD quintile 1 (least deprived) to 5 (most deprived); age-adjusted odds ratios (OR) for quintile 5 were 3.25 (95% CI 2.05–5.17) and 3.58 (95% CI 2.38–5.39) respectively, compared to quintile 1. These associations were attenuated only slightly on adjustment for individual social class, smoking, depression, social interactions and history of cardiovascular disease or diabetes, and remained statistically significant. Age-adjusted odds of dry mouth was increased only in quintile 2 (OR=1.41, 95% CI 1.04–1.91) and quintile 5 (1.50, 95% CI 1.09–2.07) compared to quintile 1 and was not significant after adjustments for the remaining covariates. The odds of self-reported fair/poor oral health was greater only in quintile 5 (OR=1.73, 95% CI 1.28–2.35), and remained statistically significant after adjustment for covariates. For perceived neighbourhood characteristics, significant trends were observed across quintiles of local area services, safety and a cumulative index of neighbourhood characteristics, with greater levels of tooth loss, periodontal disease, fair/poor self-rated oral health and dry mouth from quintile 1 (best rated) to quintile 5 (worse rated). Conclusion Markers of poor oral health in older age were associated with both objective and perceived neighbourhood-level socioeconomic factors. Wider socioeconomic determinants are potentially important influences on the oral health of older people. Prospective studies are needed to establish these associations.

Background and aims The soluble receptor for advanced glycation end products (sRAGE) has been implicated in diabetic vascular complications. We have examined the association between sRAGE and cardiac markers [NT-proBNP and cardiac troponin T (cTnT)] and subclinical vascular markers in older men with and without diabetes. Methods We performed a cross-sectional study of 1159 men aged 71–92 years with no history of cardiovascular disease (myocardial infarction, stroke, heart failure, coronary artery bypass graft operation or angioplasty). Prevalent diabetes included men with a doctor diagnosis of diabetes, men with fasting glucose ≥7 mmol/l or HbA1c ≥ 6.5% (N = 180). Subclinical vascular measurements included carotid intima media thickness (cIMT), arterial stiffness [pulse wave velocity (PWV)], central aortic blood pressure and arterial wave reflections [central augmentation pressure (AP) and augmentation index (AIx)]. Results sRAGE was strongly and positively associated with renal dysfunction in men with and without diabetes. sRAGE was significantly and positively associated with NT-proBNP (but not cTnT) and AP and AIx in both groups of men after adjustment for CVD risk and metabolic risk markers, renal function and inflammation. However, no association was seen between sRAGE and central aortic blood pressure, cIMT or arterial stiffness as determined by PWV in either group. Conclusions Higher plasma sRAGE was associated with increased NT-proBNP and markers of arterial wave reflections in men both with and without diabetes. Increased sRAGE may contribute to or be a marker of worsening cardiac dysfunction or HF. Further studies with cardiac imaging data are required to confirm this., Highlights • In men with no diagnosed CVD, sRAGE is associated with the cardiac marker NT-proBNP. • sRAGE also related positively to markers of arterial wave reflection. • These associations were present in both men with and without diabetes. • Whether sRAGE predicts worsening cardiac dysfunction and heart failure needs testing.

Background The PACE-UP 3-armed primary care trial recruited 45–75 year olds into a 12 week pedometer-based intervention, with one postal intervention arm and one nurse support. The PACE-Lift 2-armed primary care trial recruited 60–75 year olds into a 12 week nurse-supported pedometer-based intervention. Both trials increased step-counts by around a tenth and time in moderate-to-vigorous physical activity (MVPA) in bouts by around a third at 12 months, with no difference between nurse and postal arms in PACE-UP. Long-term physical activity (PA) maintenance, particularly MVPA in bouts, is important for a wide range of health benefits, but few trials provide objective PA measures beyond 12 months. We followed up PACE-UP and PACE-Lift cohorts at 3 and 4 years respectively, to investigate whether intervention effects persisted. Methods 3 year (PACE-UP) and 4 year (PACE-Lift) accelerometer outcomes were regressed on baseline accelerometry to estimate change in average daily step-counts and average weekly time in MVPA in ≥10 min bouts in the treatment groups compared to control groups. Imputation analyses were conducted to account for missing data effects. Results PACE-UP 3 year follow-up rate was 67% (681/1023). Both intervention groups were still doing more steps/day than the control group: postal 627 (95% CI 198, 1056); nurse 670 (95% CI 237, 1102); nurse plus postal 648 (95% CI 272, 1024). The pattern was similar for total weekly MVPA in bouts: postal 28 (95% CI 7, 49); nurse 24 (95% CI 24 (3, 45); nurse plus postal 26 (95% CI 8, 44). PACE-Lift 4 year follow-up rate was 76% (225/298). In PACE-Lift the intervention versus control comparisons were 407 (95% CI −177, 992) for steps and 32 (95% CI 5, 60) for MVPA in bouts; though the steps comparison is not statistically significant, both the steps and MVPA estimates are consistent with the PACE-UP findings. Both trials showed no wear-time differences between groups and imputation analyses did not change results interpretation. Conclusion Over two thirds of both trial cohorts provided long-term data. Both trials showed persistent effects on time in MVPA in bouts at 3 or 4 years. PACE-UP showed a significant persistent effect on step-counts and no difference between nurse and postal group outcomes. In PACE-Lift the step-count effect, while not statistically significant was consistent with both the PACE-UP findings and with the persistent significant effect for MVPA in bouts in PACE-Lift. These findings suggest that primary care pedometer interventions, delivered by post or with minimal contact, can make an important long-term contribution to addressing the public health physical inactivity challenge.

BACKGROUND: Associations between sleep duration and type 2 diabetes (T2D) risk markers in childhood have been little studied. We examined associations between self-reported sleep duration and T2D risk markers in children. METHODS: Cross-sectional study of 4525 multiethnic UK children aged 9 to 10 years. Sleep time was calculated from self-reported usual time of going to bed and getting up on a school day, validated in a subset using accelerometers. Fasting blood samples provided levels of serum lipids and insulin, plasma glucose, and HbA1c. Physical measures included height, weight, bioimpedance, and blood pressure. Multilevel linear regression models of anthropometric, T2D, and cardiovascular risk markers with sleep duration were adjusted for sex, age, month, ethnicity, socioeconomic position, observer (physical measures only), and random effect of school. RESULTS: On average, children slept 10.5 hours per night (95% range 8.0–12.0 hours). There were strong inverse graded relationships between sleep duration, adiposity, and diabetes risk markers. In adjusted models, a 1-hour-longer sleep duration was associated with 0.19 lower BMI (95% confidence interval [CI] 0.09 to 0.28), 0.03 kg/m5 lower fat mass index (95% CI 0.00 to 0.05 kg/m5), 2.9% lower homeostasis model assessment insulin resistance (95% CI 1.2% to 4.4%), and 0.24% lower fasting glucose (95% CI 0.03% to 0.44%); there was no association with HbA1c or cardiovascular risk. Associations with insulin and glucose remained after an additional adjustment for adiposity markers. CONCLUSIONS: The finding of an inverse association between sleep duration and T2D risk markers in childhood is novel. Intervention studies are needed to establish the causality of these associations, which could provide a simple strategy for early T2D prevention.

Background An estimated 9000 people died during the winter 2014–2015 in England and Wales from living in a cold home. Older people are susceptible to cold, but it is unclear how to identify those who particularly find it hard to keep warm in winter. The aim of this study was to identify individual factors associated with self-reported measures of cold homes among older people. Methods Data were from the British Regional Heart Study (BRHS) of older men, who were aged 74–95 when completing a questionnaire in 2014. This included four self-reported measures of cold housing during the previous winter (outcomes): (i) having difficulties in meeting the heating/fuel costs; (ii) staying in bed longer in order to stay warm; (iii) turning the heating off even when cold because of worries about the costs; (iv) keeping the living room comfortably warm. Individual data, including demographic characteristics, health and lifestyle factors were also collected. Cross-sectional associations between individual factors and measures of cold housing were analysed using logistic regression models. Results Descriptive statistics showed that (i) 327 out of 1608 (20.6%) men had difficulties in meeting the heating/fuel costs; (ii) 210 (13.3%) stayed in bed longer in order to stay warm; (iii) 157 (10.2%) turned heating off because of worries about the costs, and (iv) 54 (3.4%) could not keep comfortably warm in the living room. In full adjusted logistic models, some individual factors were independently associated with the four outcomes (p Conclusion Findings suggested that in older people financial difficulties and social class are key factors associated with cold housing in winter.

Background Current evidence linking socioeconomic factors to incident Type 2 Diabetes Mellitus (T2DM) in older populations is conflicting. We investigated the prospective association of individual socioeconomic position and neighbourhood-level socioeconomic deprivation with incident T2DM in older British men, and examined possible underlying factors. Methods A socially-representative cohort of 3487 men, aged 60–79 years in 1998–2000, from 24 British towns was followed-up for 14 years for incident cases of T2DM. Individual socioeconomic position was based on social class derived from the longest-held occupation in middle-age, and was categorised into non-manual and manual groups. Neighbourhood-level socioeconomic deprivation was based on national Index of Multiple Deprivation (IMD) quintiles; a composite score of neighbourhood-level factors (income, employment, education, disability, crime, housing and living environment), with a higher score indicating greater deprivation. Follow-up on type 2 diabetes was obtained from reviews of general practitioner records and self-reported from questionnaires. Cox proportional hazards models were used to obtain hazard ratios (HR) and 95% CI for incident diabetes according to social class and IMD quintiles. Prevalent cases of diabetes at baseline were excluded from the analyses. Results During the follow-up of 14 years, there were 289 incident cases of T2DM (7.1 per 1000 person-years). Diabetes risk increased from higher to lower social class groups and from IMD quintile 1 (least deprived) to quintile 5 (most deprived) (P for trend=0.001). Compared with non-manual social class groups, age-adjusted HR for manual groups was 1.58 (95%CI 1.24–2.01) – this was largely attenuated (1.38; 95% CI 1.08–1.76) on adjustment for body mass index (BMI); adjustment for blood pressure, smoking, alcohol, physical activity, diet, medication and family history resulted in little attenuation while further adjustment for triglyceride levels attenuated the association. Compared with IMD quintile 1, the risk of incident T2DM was highest in IMD quintile 4 (HR=1.79; 95% CI 1.24–2.54). This largely attenuated on adjustment for BMI (HR=1.46; 95% CI 1.02–2.10), and became non-significant after adjustment for lifestyle factors (smoking, alcohol, physical activity and diet). Conclusion Manual social class and neighbourhood-level socioeconomic deprivation was associated with an increased risk of T2DM in older British men. For social class this was mostly explained by BMI and triglycerides. For neighbourhood-level socioeconomic deprivation it was largely explained by BMI and lifestyle factors. Our results support the need for public health initiatives specifically targeting obesity as a means towards reducing socioeconomic inequalities in type 2 diabetes in later life.

Background Frailty, a vulnerability to adverse health outcomes, and sarcopenia, a decline in muscle mass and strength or performance are associated with ageing. Frailty and sarcopenia predict increased mortality and hospitalisation, and sarcopenia often occurs with an increase in body fat known as sarcopenic obesity which elevates these risks further. Diet quality is well established as a predictor of mortality, but few studies have investigated diet quality in relation to frailty or sarcopenia, and findings are inconclusive. We have therefore examined the associations between diet quality, frailty and sarcopenic obesity categories. Methods We used cross sectional data from community-dwelling men aged 71–91 years (British Regional Heart Study) in 2010–2012 recruited from 24 primary care practices. Men completed a food frequency questionnaire, from which the Healthy Dietary Index (HDI) and Elderly Dietary Index (EDI) were derived, and attended a physical examination. Frailty was based on the 5 components of the Fried frailty phenotype and we used a sarcopenic obesity classification which defines 4 groups; optimal, sarcopenic, obese or sarcopenic obese based on waist circumference and mid-arm muscle circumference. We used logistic regression models to investigate whether diet quality was associated with frailty and sarcopenia and/or obesity. Results 1331/3137 men (42%) had data for sarcopenia/obesity, all covariates and diet quality and 1119 men (36%) for frailty, covariates and diet quality. After adjusting for age, social class, region of residence, smoking, alcohol consumption, cardiovascular disease and energy intake, men in the top quartile of the HDI score had a lower odds of being frail (0.58 95% CI 0.34, 0.96) compared with men in the bottom quartile, and men in the top quartile of either HDI or EDI had a lower odds of being obese compared with men in the bottom quartile (0.52 95% CI 0.33, 0.84% and 0.57 95% CI 0.38, 0.86 respectively). Neither the HDI or EDI was associated with sarcopenia or sarcopenic obesity, and the EDI was not associated with frailty. Conclusion Higher diet quality based on both the HDI and EDI is associated with obesity but we found no evidence that diet quality is associated with sarcopenia in these elderly British men. However, our findings suggest that a higher diet quality as indicated by the HDI, a measure of adherence to WHO nutrient intake guidelines, might be relevant for the prevention or reversal of frailty.

Background High body fat (BF) levels in UK children are a major problem, with particular concerns about children of South Asian and Black (presumed African) origin. However, available national data are based on body mass index (BMI), which underestimates BF in South Asian children and overestimates BF in Black children. We reassessed childhood BF patterns and time trends between 2007–08 and 2012–13 using ethnicity-specific BMI adjustments to derive adjusted BMI levels (aBMI) that were related to BF in an equivalent way across South Asian, Black and White children. Methods Analyses were based on National Child Measurement Programme (NCMP) data from 2007–08 to 2012–13 in 3,195,323 aged 4–5 years and 2,962,673 children aged 10–11 years. aBMI values were derived for South Asian and Black children in a separate study, using body composition measured by the deuterium dilution method. These aBMI values related to BF similarly in South Asians, Blacks and Whites. To examine time trends in mean aBMI and in overweight-obesity prevalence by ethnicity, multiple linear regression and logistic regression analyses were used respectively. Results In the first year (2007–08), mean aBMIs in 10–11 year-olds (boys, girls) compared with Whites (18.64, 18.98 kg/m 2 ) were higher in South Asians (20.08, 19.94 kg/m 2 ; both p 2 ; both p 2 ) were significantly higher in South Asians (0.16, 0.32 kg/m 2 ; both p 2 ; p=0.01, p=0.41*). Among South Asians, both means and mean changes were greater among Bangladeshis and Pakistanis than Indians. Ethnic differences in mean aBMI levels were similar in younger children, but time trends were not as pronounced. Analyses examining overweight-obesity prevalence showed similar findings to those using mean aBMI. Parallel analyses in unadjusted BMI (the usual NCMP data presentation) showed similar time trends but different mean BMI patterns; Black children had highest mean unadjusted BMI values while White boys and South Asian girls had the lowest. *P-Value for difference from Whites Conclusion These analyses using aBMI data emphasise the particularly high (and rising) burden of BF among UK South Asians, compared with both White and Black children. These patterns are not adequately described by unadjusted BMI data, which tend to overestimate the BF burden in Black children and underestimate that in South Asians.

Background The relationship between physical fitness and risk markers for type 2 diabetes (T2D) in children and the contribution to ethnic differences in these risk markers have been little studied. We examined associations between physical fitness and early risk markers for T2D and cardiovascular disease in 9‐ to 10‐year‐old UK children. Methods Cross‐sectional study of 1445 9‐ to 10‐year‐old UK children of South Asian, black African‐Caribbean and white European origin. A fasting blood sample was used for measurement of insulin, glucose (from which homeostasis model assessment [HOMA]‐insulin resistance [IR] was derived), glycated hemoglobin (HbA1c), urate, C‐reactive protein (CRP), and lipids. Measurements of blood pressure (BP) and fat mass index (FMI) were made; physical activity was measured by accelerometry. Estimated VO2 max was derived from a submaximal fitness step test. Associations were estimated using multilevel linear regression. Results Higher VO2 max was associated with lower FMI, insulin, HOMA‐IR, HbA1c, glucose, urate, CRP, triglycerides, LDL‐cholesterol, BP and higher HDL‐cholesterol. Associations were reduced by adjustment for FMI, but those for insulin, HOMA‐IR, glucose, urate, CRP, triglycerides and BP remained statistically significant. Higher levels of insulin and HOMA‐IR in South Asian children were partially explained by lower levels of VO2max compared to white Europeans, accounting for 11% of the difference. Conclusions Physical fitness is associated with risk markers for T2D and CVD in children, which persist after adjustment for adiposity. Higher levels of IR in South Asians are partially explained by lower physical fitness levels compared to white Europeans. Improving physical fitness may provide scope for reducing risks of T2D.

Background Most mid-life and older adults are not achieving recommended physical activity (PA) targets and effective interventions are needed to increase and maintain PA long-term for health benefits. The Pedometer And Consultation Evaluation (PACE-UP) trial, a three-armed primary care pedometer-based walking intervention in those aged 45–75 years, demonstrated increased PA levels at 12 months. A three-year follow-up was conducted to evaluate long-term PA maintenance, including a qualitative component. Aim To examine facilitators and barriers to PA maintenance in mid-life and older adults previously involved in a PA trial. Method Semi-structured telephone interviews were conducted with 60 PACE-UP participants across all study arms. Interviews were audio-recorded, transcribed verbatim and coded independently by researchers, prior to thematic analysis. Findings Two-thirds of participants felt since the PACE-UP trial they had an awareness of PA, with the pedometer reported as ‘kick-starting’ regular activity, and then helped them to maintain regular activity. PA facilitators included: maintaining good health, self-motivation, social support and good weather. Lack of time was the most frequently cited barrier. Other barriers were often the inverse of the facilitators; for example, poor health and bad weather. Participants described the type of ‘top-up’ intervention they would find beneficial to aid PA maintenance (eg, text messages, online resources and walking groups). Conclusion A challenge for future PA interventions is to transform barriers into facilitators; for example, educating trial participants about the value of PA for many chronic health conditions to change this from inhibiting to promoting PA. Participants provided ideas for encouraging PA maintenance which could be incorporated into future interventions.

ObjectivesThis study aims to examine the tracking and predictability of physical activity in old age from overall physical activity and participation in sport, recreational activity and walking in mid-life.DesignProspective population-based cohort study.SettingBritish Regional Heart Study participants recruited from primary care centres in the UK in 1978–1980.Participants and outcome measuresMen (n=3413) self-reported their physical activity at baseline, 12, 16 and 20-year follow-ups and were categorised as inactive or active and having high or low participation in sport, walking and recreational activities. Tracking was assessed using kappa statistics and random effects models. Logistic regression estimated the odds of being active at 20-year follow-up according to physical activity participation in mid-life.ResultsAmong 3413 men (mean age at baseline 48.6±5.4 years) with complete data, tracking of overall physical activity was moderate (kappa: 0.23–0.26). Tracking was higher for sports participation (kappa: 0.35–0.38) compared with recreational activity (kappa: 0.16–0.24) and walking (kappa: 0.11–0.15). Intraclass correlation coefficients demonstrated similar levels of stability and only marginally weakened after controlling for covariates. Compared with inactive men, being active at baseline was associated with greater odds of being active at 20-year follow-up (OR 2.7, 95% CI 2.4 to 3.2) after adjusting for sociodemographic, health and lifestyle variables. Playing sport in mid-life was more strongly associated with being active at 20-year follow-up than other domains, particularly when sport participation began earlier in life.ConclusionBeing physically active in mid-life increases the odds of being active in old age. Promoting physical activity in later life might be best achieved by promoting sport participation earlier in the life course.

BACKGROUND/OBJECTIVES: Body mass index (BMI) (weight per height(2)) is the most widely used marker of childhood obesity and total body fatness (BF). However, its validity is limited, especially in children of South Asian and Black African origins. We aimed to quantify BMI adjustments needed for UK children of Black African and South Asian origins so that adjusted BMI related to BF in the same way as for White European children. METHODS: We used data from four recent UK studies that made deuterium dilution BF measurements in UK children of White European, South Asian and Black African origins. A height-standardized fat mass index (FMI) was derived to represent BF. Linear regression models were then fitted, separately for boys and girls, to quantify ethnic differences in BMI-FMI relationships and to provide ethnic-specific BMI adjustments. RESULTS: We restricted analyses to 4-12 year olds, to whom a single consistent FMI (fat mass per height(5)) could be applied. BMI consistently underestimated BF in South Asians, requiring positive BMI adjustments of +1.12 kg m(-)(2) (95% confidence interval (CI): 0.83, 1.41 kg m(-)(2); P

Background Maintenance of physical activity (PA) during later life is associated with optimal health; however, the long-term trajectories of PA into old age and their predictors have not been extensively researched using latent class methods. This study aimed to identify trajectories of self-reported PA and their predictors in men transitioning from midlife to old age. Methods 7735 men (aged 40–59 years) recruited in 1978–80 were followed up after 12, 16 and 20 years, reporting PA, health status, lifestyle behaviours and socio-demographic characteristics. Group-based trajectory modelling identified the trajectories of PA and associations with time-stable and time-varying covariates. We considered a range of sociodemographic and health and lifestyle factors as potential covariates. Results 4952 men (mean baseline age 49.1 ± 5.6 years) providing PA data at ≥3 time points were included in analyses. Three distinct 20-year trajectories were identified: low decreasing (24.6%, n = 1218), light stable (51.1%, n = 2530) and moderate increasing (24.3%, n = 1204). Being older, having a manual occupation, having never married or had children, residing in the midlands or North of England, suffering from a range of health conditions, being a smoker/ex-smoker and never consuming breakfast cereal or alcohol were independently associated with reduced odds of belonging to the moderate increasing trajectory group compared to the low decreasing group. Of the time-varying covariates considered, leaving employment was associated with a decrease in PA in the low decreasing group (β −0.306, p

Background Epidemiological evidence proposes the direct involvement of the liver enzymes in atrial fibrillation. These relationships are controversial and mechanistically unclear. As part of the British Regional Heart Study, we investigated whether change in liver enzymes over time associates with atrial fibrillation in men initially free of this heart condition. Materials and Methods We prospectively investigated change (delta) in liver enzymes and new-onset atrial fibrillation in a representative sample of 1428 men aged 60-79 years. Results Mean follow-up was 12.3 years, after which 108 new atrial fibrillation cases were identified. The liver enzymes did not differ at baseline or follow-up, except for gamma-glutamyl transferase which was higher at follow-up in men who developed atrial fibrillation compared to those who did not (P

This study aimed to determine whether higher levels of physical activity (PA) and less sedentary behavior (SB) are associated with less inflammation, indicated by inflammatory and hemostatic biomarkers, in older men.A cross-sectional study of 1139 men, from the British Regional Heart Study (mean ± SD age = 78 ± 5 yr), and longitudinal analyses of 490 men with two PA measures 1 yr apart were used in this study. Single fasting venous blood samples were analyzed for several biomarkers. PA and SB were measured using ActiGraph GT3X accelerometers. Total time and time spent in bouts of moderate to vigorous PA (MVPA), light PA, and SB were derived. Linear regression analyses were used to investigate associations.Cross-sectionally, higher total PA, daily steps, and MVPA were all associated with lower levels of interleukin 6 (IL-6), C-reactive protein (CRP), tissue plasminogen activator (tPA), von Willebrand factor (vWF), and D-dimer, whereas higher levels of SB were associated with higher levels of IL-6, CRP, and tPA. Each additional 10 min of MVPA was associated with a 3.2% lower IL-6 (95% confidence interval [CI] = -4.5% to -1.8%), 5.6% lower CRP (95% CI = -7.8 to -3.3), 2.2% lower tPA (95% CI = -3.0 to -1.4), 1.2% lower vWF (95% CI = -2.1 to -0.3), and 1.8% lower D-dimer (95% CI = -2.9 to -0.7), and for CRP, vWF, and D-dimer independently of SB. Associations between SB and IL-6 or tPA were independent of MVPA. Longer bouts of PA or SB were not more strongly associated with outcomes than shorter bouts. Longitudinal analyses were inconsistent with these findings, possibly because of power limitations.Although PA (particularly MVPA) was generally associated with inflammatory and hemostatic biomarkers, we found no evidence that longer bouts were more important than shorter bouts.

The QT interval, an electrocardiographic measure reflecting myocardial repolarization, is a heritable trait. QT prolongation is a risk factor for ventricular arrhythmias and sudden cardiac death (SCD) and could indicate the presence of the potentially lethal mendelian long-QT syndrome (LQTS). Using a genome-wide association and replication study in up to 100,000 individuals, we identified 35 common variant loci associated with QT interval that collectively explain similar to 8-10% of QT-interval variation and highlight the importance of calcium regulation in myocardial repolarization. Rare variant analysis of 6 new QT interval-associated loci in 298 unrelated probands with LQTS identified coding variants not found in controls but of uncertain causality and therefore requiring validation. Several newly identified loci encode proteins that physically interact with other recognized repolarization proteins. Our integration of common variant association, expression and orthogonal protein-protein interaction screens provides new insights into cardiac electrophysiology and identifies new candidate genes for ventricular arrhythmias, LQTS and SCD.

Since 2003/2004, the United Kingdom has implemented a salt reduction campaign; however, there are no data on salt intake in children as assessed by 24-hour urinary sodium, the gold standard method, to inform this campaign. We performed a cross-sectional study, involving South London school children across 3 age tiers: young children (5- to 6-year olds), intermediate-aged children (8- to 9-year olds), and adolescents (13- to 17-year olds). Dietary salt intake was measured by 24-hour urinary sodium excretion and compared with newly derived maximum salt intake recommendations. In addition, dietary sources of salt were assessed using a 24-hour photographic food diary. Valid urine collections were provided by 340 children (162 girls, 178 boys). The mean salt intakes were 3.75 g/d (95% confidence interval, 3.49–4.01), 4.72 g/d (4.33–5.11), and 7.55 g/d (6.88–8.22) for the 5- to 6-year olds, 8- to 9-year olds, and 13- to 17-year olds, respectively. Sixty-six percent of the 5- to 6-year olds, 73% of the 8- to 9-year olds, and 73% of 13- to 17-year olds had salt intake above their maximum daily intake recommendations. The major sources of dietary salt intake were cereal and cereal-based products (36%, which included bread 15%), meat products (19%), and milk and milk products (11%). This study demonstrates that salt intake in children in South London is high, with most of the salt coming from processed foods. Much further effort is required to reduce the salt content of manufactured foods.

OBJECTIVES: To examine associations between sarcopenia, obesity, and sarcopenic obesity and risk of cardiovascular disease (CVD) and all-cause mortality in older men.\ud \ud DESIGN: Prospective cohort study.\ud \ud SETTING: British Regional Heart Study.\ud \ud PARTICIPANTS: Men aged 60-79 years (n = 4,252).\ud \ud MEASUREMENTS: Baseline waist circumference (WC) and midarm muscle circumference (MAMC) measurements were used to classify participants into four groups: sarcopenic, obese, sarcopenic obese, or optimal WC and MAMC. The cohort was followed for a mean of 11.3 years for CVD and all-cause mortality. Cox regression analyses assessed associations between sarcopenic obesity groups and all-cause mortality, CVD mortality, CVD events, and coronary heart disease (CHD) events.\ud \ud RESULTS: There were 1,314 deaths, 518 CVD deaths, 852 CVD events, and 458 CHD events during follow-up. All-cause mortality risk was significantly greater in sarcopenic (HR = 1.41, 95% CI = 1.22-1.63) and obese (HR = 1.21, 95% CI = 1.03-1.42) men than in the optimal reference group, with the highest risk in sarcopenic obese (HR = 1.72, 95% CI = 1.35-2.18), after adjustment for lifestyle characteristics. Risk of CVD mortality was significantly greater in sarcopenic and obese but not sarcopenic obese men. No association was seen between sarcopenic obesity groups and CHD or CVD events.\ud \ud CONCLUSION: Sarcopenia and central adiposity were associated with greater cardiovascular mortality and all-cause mortality. Sarcopenic obese men had the highest risk of all-cause mortality but not CVD mortality. Efforts to promote healthy aging should focus on preventing obesity and maintaining muscle mass.

Background and Purpose— Older adults have the highest risks of stroke and the lowest physical activity levels. It is important to quantify how walking (the predominant form of physical activity in older age) is associated with stroke. Methods— A total of 4252 men from a UK population-based cohort reported usual physical activity (regular walking, cycling, recreational activity, and sport) in 1998 to 2000. Nurses took fasting blood samples and made anthropometric measurements. Results— Among 3435 ambulatory men free from cardiovascular disease and heart failure in 1998 to 2000, 195 first strokes occurred during 11-year follow-up. Men walked a median of 7 (interquartile range, 3–12) hours/wk; walking more hours was associated with lower heart rate, D-dimer, and higher forced expiratory volume in 1 second. Compared with men walking 0 to 3 hours/wk, men walking 4 to 7, 8 to 14, 15 to 21, and >22 hours had age- and region-adjusted hazard ratios (95% confidence intervals) for stroke of 0.89 (0.60–1.31), 0.63 (0.40–1.00), 0.68 (0.35–1.32), and 0.36 (0.14–0.91), respectively, P (trend)=0.006. Hazard ratios were somewhat attenuated by adjustment for established and novel risk markers (inflammatory and hemostatic markers and cardiac function [N-terminal pro-brain natriuretic peptide]) and walking pace, but linear trends remained. There was little evidence for a dose–response relationship between walking pace and stroke; comparing average pace or faster to a baseline of slow pace, the hazard ratio for stroke was 0.65 (95% confidence interval, 0.44–0.97), which was fully mediated by time spent walking. Conclusions— Time spent walking was associated with reduced risk of onset of stroke in dose–response fashion, independent of walking pace. Walking could form an important part of stroke-prevention strategies in older people.

ObjectiveTo examine the dose-response associations between accelerometer assessed total physical activity, different intensities of physical activity, and sedentary time and all cause mortality.DesignSystematic review and harmonised meta-analysis.Data sourcesPubMed, PsycINFO, Embase, Web of Science, Sport Discus from inception to 31 July 2018.Eligibility criteriaProspective cohort studies assessing physical activity and sedentary time by accelerometry and associations with all cause mortality and reported effect estimates as hazard ratios, odds ratios, or relative risks with 95% confidence intervals.Data extraction and analysisGuidelines for meta-analyses and systematic reviews for observational studies and PRISMA guidelines were followed. Two authors independently screened the titles and abstracts. One author performed a full text review and another extracted the data. Two authors independently assessed the risk of bias. Individual level participant data were harmonised and analysed at study level. Data on physical activity were categorised by quarters at study level, and study specific associations with all cause mortality were analysed using Cox proportional hazards regression analyses. Study specific results were summarised using random effects meta-analysis.Main outcome measureAll cause mortality.Results39 studies were retrieved for full text review; 10 were eligible for inclusion, three were excluded owing to harmonisation challenges (eg, wrist placement of the accelerometer), and one study did not participate. Two additional studies with unpublished mortality data were also included. Thus, individual level data from eight studies (n=36 383; mean age 62.6 years; 72.8% women), with median follow-up of 5.8 years (range 3.0-14.5 years) and 2149 (5.9%) deaths were analysed. Any physical activity, regardless of intensity, was associated with lower risk of mortality, with a non-linear dose-response. Hazards ratios for mortality were 1.00 (referent) in the first quarter (least active), 0.48 (95% confidence interval 0.43 to 0.54) in the second quarter, 0.34 (0.26 to 0.45) in the third quarter, and 0.27 (0.23 to 0.32) in the fourth quarter (most active). Corresponding hazards ratios for light physical activity were 1.00, 0.60 (0.54 to 0.68), 0.44 (0.38 to 0.51), and 0.38 (0.28 to 0.51), and for moderate-to-vigorous physical activity were 1.00, 0.64 (0.55 to 0.74), 0.55 (0.40 to 0.74), and 0.52 (0.43 to 0.61). For sedentary time, hazards ratios were 1.00 (referent; least sedentary), 1.28 (1.09 to 1.51), 1.71 (1.36 to 2.15), and 2.63 (1.94 to 3.56).ConclusionHigher levels of total physical activity, at any intensity, and less time spent sedentary, are associated with substantially reduced risk for premature mortality, with evidence of a non-linear dose-response pattern in middle aged and older adults.Systematic review registrationPROSPERO CRD42018091808.

Diet and nutrition are strongly implicated in the aetiology of type 2 diabetes; low dietary fibre intake could be an important factor. Evidence from prospective observational studies has suggested that it may be low cereal fibre intake, rather than low fruit and vegetable fibre intake, which is particularly important. In this issue of Diabetologia (DOI 10.1007/s00125-015-3585-9 ) Kuijsten et al report on the prospective associations between different dietary fibre sources and type 2 diabetes risk in the European Prospective Investigation of Cancer and Nutrition (EPIC)-Interact study and set their findings in context with a meta-analysis of relevant published prospective studies. The results presented strengthen the evidence implicating cereal fibre as an important determinant of type 2 diabetes risk and suggest that randomised controlled trials examining the effect of cereal fibre supplementation on type 2 diabetes risk are now needed.

OBJECTIVE Energy intake, energy density, and nutrient intakes are implicated in type 2 diabetes risk in adults, but little is known about their influence on emerging type 2 diabetes risk in childhood. We examined these associations in a multiethnic population of children. RESEARCH DESIGN AND METHODS This was a cross-sectional study of 2,017 children predominantly of white European, South Asian, and black African-Caribbean origin aged 9–10 years who had a detailed 24-h dietary recall and measurements of body composition and provided a fasting blood sample for measurements of plasma glucose, HbA1c, and serum insulin; homeostasis model assessment of insulin resistance was also derived. RESULTS Energy intake was positively associated with insulin resistance. After the removal of 176 participants with implausible energy intakes (unlikely to be representative of habitual intake), energy intake was more strongly associated with insulin resistance and was also associated with glucose and fat mass index. Energy density was also positively associated with insulin resistance and fat mass index. However, in mutually adjusted analyses, the associations for energy intake remained while those for energy density became nonsignificant. Individual nutrient intakes showed no associations with type 2 diabetes risk markers. CONCLUSIONS Higher total energy intake was strongly associated with high levels of insulin resistance and may help to explain emerging type 2 diabetes risk in childhood. Studies are needed to establish whether reducing energy intake produces sustained favorable changes in insulin resistance and circulating glucose levels.

Low birth weight has been shown to be associated with later renal function, but it is unclear to what extent this is explained by other established kidney disease risk factors. Here we investigate the roles of diabetes, hypertension, and obesity using data from the Medical Research Council National Survey of Health and Development, a socially stratified sample of 5362 children born in March 1946 in England, Scotland, and Wales, and followed since. The birth weight of 2192 study members with complete data was related to three markers of renal function at age 60-64 (estimated glomerular filtration rate (eGFR) calculated using cystatin C (eGFRcys), eGFR calculated using creatinine and cystatin C (eGFRcr-cys), and the urine albumin-creatinine ratio) using linear regression. Each 1 kg lower birth weight was associated with a 2.25 ml/min per 1.73 m(2) (95% confidence interval 0.80-3.71) lower eGFRcys and a 2.13 ml/min per 1.73 m(2) (0.69-3.58) lower eGFRcr-cys. There was no evidence of an association with urine albumin-creatinine ratio. These associations with eGFR were not confounded by socioeconomic position and were not explained by diabetes or hypertension, but there was some evidence that they were stronger in study members who were overweight in adulthood. Thus, our findings highlight the role of lower birth weight in renal disease and suggest that in those born with lower birth weight particular emphasis should be placed on avoiding becoming overweight.

OBJECTIVE: Little is known about whether levels of physical fitness, which is related to adiposity and physical activity (PA), have changed in children, particularly the progressive increase in childhood obesity levels. We aimed to examine the time trends in resting pulse rate (a marker of physical fitness) among UK children, in order to better understand the trends in levels of physical fitness in recent decades. DESIGN AND SETTING: We used a cross-sectional study design and included data on over 22 000 children aged 9-11 years (mean 10.3 years) from five population-based studies conducted in the UK between 1980 and 2008. MAIN OUTCOME MEASURES: Resting pulse rate (bpm). RESULTS: Observed mean resting pulse rate was higher for girls than boys (82.2 bpm vs 78.7 bpm). During the study period mean pulse rate increased by 0.07 bpm/year (95% CI 0.04 to 0.09) among boys and to a lesser extent among girls, by 0.04 bpm/year (0.01 to 0.06) (p

Aims Socioeconomic position has been linked to incident heart failure (HF), but the underlying mechanisms are unclear. We examined the association of socioeconomic measures with incident HF in older adults and examined possible underlying pathways. Methods and results A socially representative cohort of men aged 60–79 years in 1998–2000 from 24 British towns was followed-up for 10 years for incident HF. Adult socioeconomic position was based on a cumulative score, including occupation, education, housing tenure, pension, and amenities. Childhood socioeconomic measures included father's occupational social class and household amenities. Prevalent myocardial infarction and HF cases were excluded. Among 3836 men, 229 incident cases of HF occurred over 10 years. Heart failure risk increased with an increasing score of adverse adult socioeconomic measures ( P for trend =