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BackgroundThis review aims to synthesise available evidence on the prevalence of chronic obstructive pulmonary disease (COPD), associated risk factors, hospitalisations and COPD readmissions in Africa.MethodUsing the Met-Analyses and Systematic Reviews of Observational Studies guideline, electronic databases were searched from inception to 1 October 2021. The quality of studies was assessed using the Newcastle-Ottawa Scale. Evidence from retrieved articles was synthesised, and a random-effect model meta-analysis was conducted. The protocol was registered on PROSPERO.ResultsThirty-nine studies met the inclusion criteria, with 13 included in the meta-analysis. The prevalence of COPD varied between the Global Initiative for Chronic Obstructive Lung Disease (2%–24%), American Thoracic Society/European Respiratory Society (1%–17%) and Medical Research Council chronic bronchitis (2%–11%) criteria, respectively. Increasing age, wheezing and asthma were consistent risk factors for COPD from studies included in the narrative synthesis. Our meta-analysis indicated that prior tuberculosis ((OR 5.98, 95% CI 4.18 to 8.56), smoking (OR 2.80, 95% CI: 2.19 to 3.59) and use of biomass fuel (OR 1.52, 95% CI: 1.39 to 1.67)) were significant risk factors for COPD. Long-term oxygen therapy (HR 4.97, 95% CI (1.04 to 23.74)) and frequent hospitalisation (≥3 per year) (HR 11.48, 95% CI (1.31 to 100.79)) were risk factors associated with 30-day COPD readmission.ConclusionThis study not only highlights specific risk factors for COPD risk in Africa but also demonstrates the paucity and absence of research in several countries in a continent with substantial COPD-related mortality. Our findings contribute towards the development of evidence-based clinical guidelines for COPD in Africa.PROSPERO registration numberCRD42020210581.

Background: Sarcopenia is an age-associated skeletal muscle condition characterized by low muscle mass, strength, and physical performance. There is no international consensus on a sarcopenia definition and no contemporaneous clinical and research guidelines specific to Australia and New Zealand. The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force aimed to develop consensus guidelines for sarcopenia prevention, assessment, management and research, informed by evidence, consumer opinion, and expert consensus, for use by health professionals and researchers in Australia and New Zealand. Methods: A four-phase modified Delphi process involving topic experts and informed by consumers, was undertaken between July 2020 and August 2021. Phase 1 involved a structured meeting of 29 Task Force members and a systematic literature search from which the Phase 2 online survey was developed (Qualtrics). Topic experts responded to 18 statements, using 11-point Likert scales with agreement threshold set a priori at >80%, and five multiple-choice questions. Statements with moderate agreement (70%–80%) were revised and re-introduced in Phase 3, and statements with low agreement (80%) were confirmed by the Task Force in Phase 4. Conclusions: The ANZSSFR Task Force present 17 sarcopenia management and research recommendations for use by health professionals and researchers which includes the recommendation to adopt the EWGSOP2 sarcopenia definition in Australia and New Zealand. This rigorous Delphi process that combined evidence, consumer expert opinion and topic expert consensus can inform similar initiatives in countries/regions lacking consensus on sarcopenia.

Background Mortality statistics using a single underlying cause of death (UC) are key health indicators. Rising multimorbidity and chronic disease mean that deaths increasingly involve multiple conditions. However, additional causes reported on death certificates are rarely integrated into mortality indicators, partly due to complexities in data and methods. This study aimed to assess trends and patterns in cause-related mortality in Australia, integrating multiple causes (MC) of death. Methods Deaths (n = 1 773 399) in Australia (2006–17) were mapped to 136 ICD-10-based groups and MC indicators applied. Age-standardized cause-related rates (deaths/100 000) based on the UC (ASRUC) were compared with rates based on any mention of the cause (ASRAM) using rate ratios (RR = ASRAM/ASRUC) and to rates based on weighting multiple contributing causes (ASRW). Results Deaths involved on average 3.4 causes in 2017; the percentage with >4 causes increased from 20.9 (2006) to 24.4 (2017). Ischaemic heart disease (ASRUC = 73.3, ASRAM = 135.8, ASRW = 63.5), dementia (ASRUC = 51.1, ASRAM = 98.1, ASRW = 52.1) and cerebrovascular diseases (ASRUC = 39.9, ASRAM = 76.7, ASRW = 33.5) ranked as leading causes by all methods. Causes with high RR included hypertension (ASRUC = 2.2, RR = 35.5), atrial fibrillation (ASRUC = 8.0, RR = 6.5) and diabetes (ASRUC = 18.5, RR = 3.5); the corresponding ASRW were 12.5, 12.6 and 24.0, respectively. Renal failure, atrial fibrillation and hypertension ranked among the 10 leading causes by ASRAM and ASRW but not by ASRUC. Practical considerations in working with MC data are discussed. Conclusions Despite the similarities in leading causes under the three methods, with integration of MC several preventable diseases emerged as leading causes. MC analyses offer a richer additional perspective for population health monitoring and policy development.

Using a qualitative design this study aimed to (1) explore the experience of people living with osteoarthritis (OA), (2) gain an understanding of their navigation of the health system and, (3) explore their opinions on the role of exercise and joint replacement surgery for the management of OA.Purposive sampling was used to recruit 26 participants with knee OA, aged 45 years and over, from Tasmania, Australia. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document participant understanding and experience of OA and their opinions on the role of exercise and surgery in managing OA.Of the 26 participants, 80% (n = 21) were female with a mean age of 66 years. The main theme identified was that individuals with knee OA were navigating a maze of OA treatments. Three related subthemes were that participants: (i) perceived their general practitioner did not have an ongoing role in their OA care, (ii) self-directed their management and, (iii) sampled from a 'smorgasbord' of treatment options, including low-value care options. Two other major themes were: the role of exercise for OA management, and surgery as a last resort.Our findings suggest that OA patients may not be choosing consistent, high-value care for their OA. This highlights the importance of an evidence-based multi-disciplinary approach to guide patients to self-manage their OA and support their navigation of the health system. Reducing emphasis on the pathway to surgery and streamlining access to conservative management strategies may assist people to receive high-value care.

BackgroundResearch and reporting of mortality indicators typically focus on a single underlying cause of death selected from multiple causes recorded on a death certificate. The need to incorporate the multiple causes in mortality statistics - reflecting increasing multimorbidity and complex causation patterns - is recognised internationally. This review aims to identify and appraise relevant multiple cause analytical methods and practices.MethodsWe searched Medline, PubMed, Scopus and Web of Science from inception to December 2020 without language restrictions, supplemented by consultation with international experts. Eligible articles included those analysing multiple causes of death from death certificates. The process identified 4,080 articles; after screening, 434 full texts were reviewed.ResultsMost reviewed articles (77%, n=332) were published since 2001. The majority examined mortality by “any-mention” of a cause of death (87%, n=377) and assessed pairwise combinations of causes (56%, n=245). Recently emerging (since 2001) were applications of methods to group deaths based on common cause patterns using, for example, cluster analysis (2%, n=9), and the application of multiple cause weights to re-evaluate mortality burden (1%, n=5). Multiple cause methods applied to specific research objectives are described for recently emerging approaches.ConclusionThis review confirms rapidly increasing international interest in the analysis of multiple causes of death and provides the most comprehensive overview of methods and practices to date. Available multiple cause methods are diverse but suit a range of research objectives, that with greater data availability and technology could be further developed and applied across a range of settings.

Context Vitamin D deficiency is a common, modifiable determinant of musculoskeletal health. Objective There are limited data that examine the longitudinal change in population 25-hydroxyvitamin D (25[OH]D) and none that evaluate the long-term skeletal outcomes of longitudinal vitamin D status. Methods A prospective cohort analysis was conducted of community-dwelling adults aged 50 to 80 years who had 25(OH)D assessed by radioimmunoassay and bone mineral density (BMD) by dual-energy x-ray absorptiometry at baseline (n = 1096), 2.5 (n = 870), and 10 (n = 565) years. Sun exposure was quantified by questionnaire and supplement use at clinic review. 25(OH)D less than 50 nmol/L was considered deficient. Participants were provided with their 25(OH)D results. Results Over 10 years 25(OH)D increased (52.2 ± 17.0 to 63.5 ± 23.6 nmol/L, P Conclusions Population 25(OH)D concentration increased because of a combination of increased sun exposure and supplement use. Maintaining or achieving vitamin D sufficiency was associated with less BMD loss over 10 years.

Background This study aims to describe the relationships between physical activity (PA), body composition, and multimorbidity over 10 years. Method Participants (N = 373; 49% women; average age 61.3 ± 6.7 years) were followed for 10 years. Multimorbidity was defined by self-report as the presence of 2 or more of 12 listed chronic conditions. PA (steps per day) at baseline was assessed by pedometer, handgrip strength (HGS) by dynamometer, and appendicular lean mass (ALM) and total body fat mass by dual-energy x-ray absorptiometry. Relative HGS and ALM were calculated by dividing each body mass index (BMI). Regression cubic splines were used to assess evidence for a nonlinear relationship. Results After 10 years, 45% participants had multimorbidity. There was a nonlinear relationship between PA and multimorbidity—PA was associated with lower multimorbidity risk among individuals who engaged in Discussion These findings highlight the potential clinical importance of maintaining adequate levels of PA and of reducing adiposity and maintaining muscle function for minimizing the risk of multimorbidity in older adults.

OBJECTIVE This study aimed to develop and test the feasibility of using an electronic tool to ascertain falls and their circumstances (TASeFALL) in people aged over 60 years. METHODS Forty participants (mean age: 69.3 ± 5.4 years, 55% women) were randomised to receive a monthly paper-based questionnaire (control group n = 19), compared with the same questionnaire sent via email with LimeSurvey software (TASeFALL n = 21). Falls and their circumstances were recorded prospectively over 12 months in all participants. The main outcomes were feasibility of enrolment, number of falls, adherence to completion of questionnaires and cost. RESULTS The incidence, number of falls and adherence to the completion of the questionnaire over the 12-month follow-up were similar in both the TASeFALL and control groups. However, the monthly paper-based questionnaire approach was 45% more expensive. CONCLUSIONS The TASeFALL is a feasible and cost-effective method of falls ascertainment for older people with email access that could have a wide research uptake.

Whether skin photosensitivity modulates sun exposure behaviours, consequent vitamin D status and skeletal health outcomes independently of constitutive pigmentation have not been systematically investigated. 1072 community-dwelling adults aged 50-80 years had skin photosensitivity quantified by questionnaire and melanin density by spectrophotometry. Bone mineral density (BMD), falls risk and 25-hydroxyvitamin D (25OHD) were measured using DXA, short form physiological profile assessment and radioimmunoassay, respectively. Sun exposure and symptomatic fractures were assessed by questionnaire. Participants were followed up at 2.5 (n = 879), 5 (n = 767) and 10 (n = 571) years. Higher resistance to sunburn and greater ability to tan were associated with reduced sun protection behaviours (RR 0.87, p < 0.001 & RR 0.88, p < 0.001), higher lifetime discretionary sun exposure in summer (RR 1.05, p = 0.001 & RR 1.07, p = 0.001) and winter (RR 1.07, p = 0.001 & RR 1.08, p = 0.02) and fewer lifetime sunburns (RR 0.86, p < 0.001 & RR 0.91, p = 0.001). Higher resistance to sunburn was associated with lower total body (β = - 0.006, p = 0.047) and femoral neck (β = - 0.006, p = 0.038) BMD, but paradoxically, fewer prevalent fractures (RR 0.94, p = 0.042). Greater ability to tan was associated with higher 25OHD (β = 1.43, p = 0.04), lumbar spine (β = 0.014, p = 0.046) and total body (β = 0.013, p = 0.006) BMD, but not fracture or falls risk. These associations were independent of constitutive melanin density. Cutaneous photosensitivity was associated with sun exposure behaviours, cutaneous sequelae and, consequently, 25OHD and BMD in older Caucasian adults independent of constitutive melanin density. There was no consistent association with fracture outcomes, suggesting environmental factors are at least as important.

Higher cutaneous melanin reduces vitamin D3 production. This may increase fracture risk. We found that cutaneous melanin density was associated with prevalent and short-term, but not long-term, incident fracture risk in older Caucasian adults. Melanin density either acts as a surrogate marker or its relationship with fracture changes with time. Higher cutaneous melanin reduces vitamin D3 production. This may impact lifetime vitamin D status and increase fracture risk. This study aimed to describe the relationship between spectrophotometrically determined constitutive melanin density, prevalent and incident fractures in a cohort of exclusively older Caucasian adults. 1072 community-dwelling adults aged 50–80 years had constitutive melanin density quantified using spectrophotometry. Participants were followed up at 2.5 (n = 879), 5 (n = 767), and 10 (n = 571) years after the baseline assessment. Prevalence and number of symptomatic fractures were assessed by questionnaire. Higher melanin density was independently associated with greater prevalence of any fracture (RR 1.08, p = 0.03), vertebral fracture (RR 1.41, p = 0.04) and major fracture (RR 1.12, p = 0.04) and the number of fractures (RR 1.09, p = 0.04) and vertebral fractures (RR 1.47, p = 0.04) in cross-sectional analysis. At the 2.5-year follow-up, higher melanin density was associated with incident fractures (RR 1.42, p = 0.01) and major fractures (RR 1.81, p = 0.01) and the number of incident fractures (RR 1.39, p = 0.02) and major fractures (RR 2.14, p = 0.01). The relationship between melanin density and incident fracture attenuated as the duration of follow-up increased and was not significant at the 5- or 10-year follow-up. Constitutive melanin density was associated with prevalent and short-term, but not long-term, incident fracture risk in older Caucasian adults. This suggests melanin density either acts as a surrogate marker for an unmeasured fracture risk factor or the relationship between melanin density and fracture changes with time.

Summary Background & aims Aging is characterized by progressive decline in physiologic reserves and functions as well as prolonged inflammation, increasing susceptibility to disease. Diet plays an important role in maintaining health, and reducing morbidity and mortality, especially in older populations. This study was designed to determine prospective associations between dietary inflammatory index (DII®) scores and bone health, sarcopenia-related outcomes, falls risk and incident fractures in community-dwelling Australian older adults. Methods A total of 1098 [51% male; age (mean ± SD) 63.0 ± 7.5 years] non-institutionalized older adults who participated in the Tasmanian Older Adult Cohort Study (TASOAC) at baseline, 768 at 5 years, and 566 at 10 years follow-up were included in this analysis. Baseline energy-adjusted DII (E-DII) scores were calculated using a validated Food Frequency Questionnaire. Changes in bone mineral density (BMD) and appendicular lean mass (ALM) were measured over ten years using dual-energy x-ray absorptiometry. Ten-year changes in hand grip, knee extensor and whole lower-limb muscle strength and quality were assessed by dynamometers and change in falls risk score using the Physical Profile Assessment (PPA). Incident fractures at any site and non-vertebral fractures over 10 years were self-reported. Results The E-DII range was −3.48 to +3.23 in men and −3.80 to +2.74 in women. Higher E-DII score (indicating a more pro-inflammatory diet) was associated with lower total hip (B: −0.009; 95% CI: −0.017, 0.000) and lumbar spine BMD (B: −0.013; 95% CI: −0.024, −0.002), and higher falls risk score (B: 0.040; 95% CI: 0.002, 0.078) over 10 years in men. Women with higher E-DII scores had higher whole lower-limb muscle quality over 10 years (B: 0.109; 95% CI: 0.002, 0.215). For every unit increase in E-DII score, incident fracture rates increased by 9.0% in men (IRR: 1.090; 95% CI: 1.011, 1.175) and decreased by 12.2% in women (IRR: 0.878; 95% CI: 0.800, 0.964) in a fully adjusted model. Conclusion Higher E-DII scores were associated with lower bone density, higher falls risk, and increased incidence of fractures in community-dwelling older men, but decreased fracture incidence in women, over 10 years. This suggests pro-inflammatory diets may be more detrimental to musculoskeletal health in older men than in women. Additional studies are warranted to elucidate these sex differences.

Objectives: To develop guidelines, informed by health-care consumer values and preferences, for sarcopenia prevention, assessment and management for use by clinicians and researchers in Australia and New Zealand. Methods: A three-phase Consumer Expert Delphi process was undertaken between July 2020 and August 2021. Consumer experts included adults with lived experience of sarcopenia or health-care utilisation. Phase 1 involved a structured meeting of the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force and consumer representatives from which the Phase 2 survey was developed. In Phase 2, consumers from Australia and New Zealand were surveyed online with opinions sought on sarcopenia outcome priorities, consultation preferences and interventions. Findings were confirmed and disseminated in Phase 3. Descriptive statistical analyses were performed. Results: Twenty-four consumers (mean ± standard deviation age 67.5 ± 12.8 years, 18 women) participated in Phase 2. Ten (42%) identified as being interested in sarcopenia, 7 (29%) were health-care consumers and 6 (25%) self-reported having/believing they have sarcopenia. Consumers identified physical performance, living circumstances, morale, quality of life and social connectedness as the most important outcomes related to sarcopenia. Consumers either had no preference (46%) or preferred their doctor (40%) to diagnose sarcopenia and preferred to undergo assessments at least yearly (54%). For prevention and treatment, 46% of consumers preferred resistance exercise, 2–3 times per week (54%). Conclusions: Consumer preferences reported in this study can inform the implementation of sarcopenia guidelines into clinical practice at local, state and national levels across Australia and New Zealand.

Background Mortality statistics are typically based on a single underlying cause of death (UCoD). Although UCoD provides a useful construct, the relevance of assuming that a single disease caused the death is diminishing, especially with increased life expectancy and high proportions of deaths in older ages from chronic/degenerative diseases. Focussing on common underlying causes of death in Australia, we quantified mortality incorporating weighting strategies for multiple causes of death (MCoD). Methods All deaths registered in Australia from 2015-2017 (478,396 deaths) and coded using International Classification of Diseases Version 10 were classified using an extended cause list (n = 136 causes) based on a World Health Organization short list. Age-standardised rates (ASR) were estimated using three weighting methods: (1) traditional approach using UCoD alone; (2) UCoD and associated causes of death (ACoDs) equally weighted and (3) UCoD weighted 0.5 arbitrarily and remaining 0.5 apportioned to the remaining ACoDs. Results Common UCoD were ischaemic heart diseases, cerebrovascular diseases, dementia; 57671, 31515 and 27377 deaths respectively. There were substantial changes in ASR depending on the weighting method used. Variation in mortality patterns estimated using the three weighting methods and challenges to further refinement of the weighting strategy will be discussed. Conclusions Mortality indicators incorporating MCoD enhance traditional measures of mortality and provide a means to reassess the role of diseases in causing death. Further disease specific methods are required to refine current weighting strategies. Key messages Weighting strategies for are useful for quantifying mortality incorporating MCoD, but methodological challenges exist.

Key contact person Dr Grace Joshy, Fellow, Research School of Population Health, Australian National University. Focus and outcomes for participants Mortality statistics are typically based on a single underlying cause of death (UCoD), derived from multiple conditions on the death certificate, and have provided critical evidence for policy and practice for over a century. There have been radical shifts in patterns of death in the past couple of decades; deaths in older ages are increasingly from chronic and degenerative diseases. The relevance of assuming that a single disease is causing the death is diminishing, especially with an aging population structure and increasing life expectancy. This symposium will enable participants to understand the complexities associated with mortality reporting/coding, strengths and limitations of available statistical methods for using multiple causes of death (MCoD) and the importance of quantifying mortality incorporating MCoD. Rationale for the symposium, including for its inclusion in the Congress The use of a single UCoD rather than MCoD means that vast amounts of potentially useful data are largely ignored, which is likely to bias mortality estimates (including under- and over-reporting of the importance of certain causes of death). Despite global recognition of the urgent need to better integrate data on MCoD into mortality statistics, use of these data are challenging and limited. Complexities arise from the way mortality information is reported on death certificates and coded to form mortality collections; limited understanding of available statistical methods also adds to the complexity. International Classification of Diseases 10th Revision (ICD-10) has been translated into 43 languages and it is being used by over 100 countries to report mortality data, a primary indicator of health status. The 2018 release of the 11th revision of the International Classification of Diseases, enriching data on multiple parameters including comorbidity, confers further urgency and a unique opportunity to optimise the use of MCoD in mortality reporting. The World Congress of Epidemiology 2020 will provide a unique platform for wider discussions on the challenges and opportunities for using MCoD data. The symposium will provide a deeper understanding and enhanced the use of MCoD data. The speakers are engaged in cutting-edge NHMRC-funded research on mortality incorporating MCoD and development of novel statistical methods. Presentation program The symposium will feature presentations from six speakers. Names of presenters James Eynstone-Hinkins, Lauren Moran, Saliu Balogun, Karen Bishop, Margarita Moreno-Betancur, Grace Joshy

Background Mortality reporting and research are typically focused on a single underlying cause of death (UCoD) selected from multiple reported causes. The need to incorporate multiple causes of death (MCoD) in mortality statistics is now recognised internationally, but there is scant methodological work to guide analytical approaches. This review aims to identify and appraise current methods and practices used to analyse MCoD data. Methods The Web of Science, Medline, Pubmed and Scopus (from inception to December 2019) were queried. Studies reporting MCoD alone or in comparison with single UCoD were included. The review is supplemented by qualitative interview with international experts. Results 3491 studies were identified; 141 full texts were included in the review. The measures usually estimated when analysing MCoD can be broadly categorised into descriptive measures (n = 93 studies), measures of associations between diseases (n = 46 studies) and advanced statistical methods (n = 11 studies). Descriptive statistics commonly used include standardized ratio of multiple to underlying cause (SRMU) and mortality rates based on any mention of a disease. Approaches used to assess measures of associations between diseases include the Cause-of-Death Association Indicator (CDAI) and social network analysis. The advanced statistical methods include weighting MCoD and lethal defect-wear model of mortality. Audit results will be discussed. Conclusions This review provides a comprehensive and updated summary of methodological approaches used to analyse MCoD data. The merit of each analytical framework is discussed. Key messages More work is needed to develop methodological frameworks that could be used to support routine consideration of MCoD in practice.

Background Four fifths of deaths in Australia involve multiple causes, but statistics typically use a single underlying cause of death (UC). The UC approach alone is insufficient for understanding the impact of non-underlying causes and identifying comorbid disease associations at death. Analysis of multiple causes of death (MC) is needed to measure the impact of all causes. We described MC patterns, considering cause-of-death coding and certification practices in Australia. Methods Using deaths registered in Australia from 2006 to 2017 (n = 1773525) coded to the International Classification of Diseases (ICD) and an extended classification (n = 136 causes) based on a World Health Organization short list, we described MCoD data by cause. Age-standardised rates based on UC and MC were compared using the standardised ratio of multiple to underlying causes (SRMU) to estimate the contribution of the cause to mortality compared to using the UC approach. Comorbidity was explored using the cause of death association indicator (CDAI) to compare the observed joint frequency of a contributory-underlying cause combined with expected frequency of the contributory cause (with any UC). Results On average 3.4 conditions caused each death and 24.4% of deaths had 5 plus causes. Largest SRMUs were for genitourinary diseases (8.0), blood diseases (7.8) and musculoskeletal conditions (6.7). CDAIs showed high associations between, for example, accidental alcohol and opioid poisoning, septicaemia and skin infections, and traumatic brain injury and falls. Conclusions MC indicators enhance measures of mortality and reassess the role of causes of death for descriptive and analytical epidemiology. Key messages This research demonstrates the value of MC analysis for Australian mortality data.

Objective Using a qualitative design this study aimed to 1) explore the attitudes towards and understanding of osteoarthritis (OA) held by Tasmanian general practitioners (GPs) and orthopaedic surgeons, 2) gain a deeper understanding of conservative and surgical management and 3) identify key barriers and challenges. Design Purposive sampling was used to recruit 17 ​GPs and 10 surgeons from Tasmania, Australia. Semi-structured interviews were audio-recorded, transcribed, coded, and thematically analysed to document understanding of OA, management and treatment decision making. Results GPs and surgeons had a shared understanding of the cause and management of OA which aligned well with evidence-based best practice. Most GPs acknowledged that severity of disease on an X-Ray does not correlate well with symptoms, although some GPs reported always using imaging to support their diagnosis. Conservative management was highly supported by all interviewees, focussing on exercise and/or physiotherapy. Key treatment barriers included managing poor patient understanding of OA, unrealistic expectations for treatment, lack of patient motivation and scepticism towards exercise, and cost and accessibility of conservative treatment options. Surgery was considered a suitable option when conservative management options had been exhausted. Conclusion This study uniquely interviewed GPs and surgeons from the same population, capturing two crucial areas of OA management. Some key barriers to treatment were identified and options for improving treatment include creating opportunities for increased patient education about OA, enhanced accessibility to OA conservative management programs along with improved reimbursement models supporting conservative management as first-line OA treatment.

Aims: This study aims to describe the associations of low muscle mass, handgrip (HGS) and lower-limb muscle strength (LMS) with health-related quality of life (HRQoL) over 10 years in community-dwelling older adults. Methods: Participants (N = 1002; 51% women; mean age 63 ± 7.4 years) were prospectively followed for 10 years. HRQoL was measured using the validated assessment of quality of life (AQoL) instrument. Appendicular lean mass (ALM) was assessed using dual energy X-ray absorptiometry and normalized to body mass index (BMI). HGS and LMS were assessed using dynamometers. Low ALM/BMI (ALM/BMI LOW ), LMS (LMS LOW ) and HGS (HGS LOW ) at baseline were defined as the lowest 20% of the sex-specific distribution for each measure. Linear mixed effect regression models, adjusting for confounders, were used to estimate the association between ALM/BMI LOW , LMS LOW , and HGS LOW at baseline and HRQoL over 10 years. Results: Participants with LMS LOW (β = -0.061, 95% CI: -0.089, -0.033) and women (β = -0.089, 95% CI: -0.129, -0.049) but not men (β = -0.023, 95% CI: -0.064, 0.019) with HGS LOW had clinically meaningful reductions in HRQoL over 10 years compared to those with normal strength. There was a weaker but statistically significant association between ALM/BMI LOW and 10-year HRQoL (β = -0.038, 95% CI: -0.068, -0.008). Conclusions: Lower-limb muscle strength and handgrip strength (in women only), which can be easily measured in clinical practice, appear more important than muscle mass for HRQoL.

Objectives: To examine associations of education and occupation with handgrip strength (HGS), lower limb strength (LLS) and appendicular lean mass (ALM). Methods: Measures of HGS, LLS and ALM (dual-energy X-ray absorptiometry) were ascertained at baseline in 1090 adults (50-80 years, 51% women), ~3 and 5 years. Education and occupation were self-reported, the latter categorised as high-skilled white collar (HSWC), low-skilled white collar (LSWC) or blue collar. Separate general estimating equations were performed. Results: The highest education group had greater HGS than the middle (0.33 psi) and lowest (0.48 psi) education groups, and 0.34 kg greater ALM than the lowest education group. HGS was 0.46 psi greater for HSWC than LSWC groups. Compared to LSWC groups, LLS was 5.38 and 7.08 kg greater in HSWC and blue-collar groups. Blue-collar and HSWC groups each had ~ 0.60-0.80kg greater ALM than LSWC. Conclusion: Progressive muscle loss can be prevented by targeted intervention; thus, we suggest clinical attention be directed towards specific social groups.

This study aims to assess whether older adults with low muscle mass or strength, in the presence of obesity, have an increased risk of knee (TKR) and hip replacement (THR) over 13 years. 1082 community-dwelling older adults (51% women; mean age 62.9 ± 7.5 years) were studied at baseline and multiple time points over 13 years. The incidence of TKR and THR was determined by data linkage to National Joint Replacement Registry. Appendicular lean and fat mass were measured using DXA. Lower-limb muscle strength (LMS) was assessed by dynamometer. Low muscle mass and strength were defined as the lowest sex-specific tertiles for appendicular lean mass (adjusted for height and total body fat mass) and lower-limb strength, respectively. Obesity was defined as the highest sex-specific tertile for total body fat mass. Competing risk regression models were used to estimate the sub-distribution hazard ratio (SHR) for TKR and THR. Over 13 years of follow-up, 6.8% (n = 74/1082) of the participants had a TKR and 4.7% (n = 50/1066) had THR. Participants with the combination of obesity and low muscle strength (SHR 3.36, 95% CI 1.50, 7.53) but low muscle mass (SHR 1.11, 95% CI 0.52, 2.40) had a significantly increased risk of TKR, compared to individuals with neither obesity nor low muscle mass/strength. However, obesity with low muscle strength did not lead to a significantly greater risk of TKR compared to having low muscle strength or obesity alone. There was no evidence for an association between obesity with low muscle mass or strength and THR (all p 0.05). This finding suggests that combining muscle and fat assessments to predict the future risk of TKR is no better than each condition on its own.

Aims To describe the associations between interindividual (between-person) and intraindividual (within-person) variability in physical activity (PA) and knee pain and functional limitation among older adults. We also investigated the potential bidirectional association of between-person and within-person variability in knee pain and functional limitation with PA. Method Participants (N = 1064; 51% women; mean age 63 ± 7.4 years) were measured at baseline, 2.5, and 5 years. PA was measured using pedometers. Knee pain and functional limitation were assessed using the WOMAC scale. A two-part hurdle model, with adjustment for confounders, estimated the association of between-person and within-person variability in PA with knee pain/functional limitation (as the outcome). Linear mixed effect regression models described the association of between-person and within-person variability in knee pain and functional limitation with PA (as the outcome). Results Between-person effects showed that participants with a higher 5-year average PA had lower average WOMAC scores (β= –1.17, 95% CI: –1.82, –0.51). Within-person effects showed that at time-points when participants had a higher PA level than average, they also had lower WOMAC scores (β= –0.85, 95% CI: –1.36, –0.35). Conversely, both between-person (β= –15.6, 95% CI: –22.5, –8.8) and within-person increase (β= –7.4, 95% CI: –13.5, –1.4) in WOMAC scores were associated with lower PA. Conclusion These findings suggest that PA and knee pain/dysfunctional contribute to the development of one another. Pain can lead to changes in inter- and intraindividual PA levels, but the reverse is also possible – changes in PA results in changes in inter- and intraindividual pain/dysfunctional levels.

This study aims to present the pattern and management of atypical facial clefts from a Nigerian population.This is a retrospective study of patients seen during series of surgical outreach programs in North Central Nigeria, between 2011 and 2017. All cases of atypical facial clefts encountered were evaluated for the pattern of presentation using Tessier classification system. All of them were surgically repaired and outcome was determined using a Likert scale. Data were presented using descriptive statistics.Outreach programs in North Central Nigeria by CleftFacial Deformity Foundation.Thirty-six patients, 19 (52.8%) males and 17 (47.2%) females, were studied. The age range was 1 week to 34 years, with mean (standard deviation) of 11.2 (11.8) years. Fifty-eight cleft cases were recorded, with Tessier 1 being the commonest (n = 14; 24.1%) cleft type. There were 35 (60.3%) cases of middle cleft, 14 (24.2%) cases of oblique cleft, and 9 (15.5%) cases of lateral cleft. Typical cleft lip and palate coexisted with atypical facial cleft in 2 (5.6%) patients. Cleft was found to be median in 12 (33.3%) patients and right sided in 9 (25%) patients. Majority (n = 24, 66.7%) of the cases were repaired by simple excision plus direct closure with successful outcome.Numerical classification by Paul Tessier has reduced the inconsistencies of nomenclature among practitioners. Majority of atypical facial clefts could be treated by simple techniques with satisfactory outcomes. However, the more complex cases will require multistaged surgical approach.

Background/AimThe clinical relevance of MRI knee abnormalities in athletes is unclear. This study aimed to determine the prevalence of MRI knee abnormalities in Australian Rules Football (ARF) players and describe their associations with pain, function, past and incident injury and surgery history.Methods75 male players (mean age 21, range 16–30) from the Tasmanian State Football League were examined early in the playing season (baseline). History of knee injury/surgery and knee pain and function were assessed. Players underwent MRI scans of both knees at baseline. Clinical measurements and MRI scans were repeated at the end of the season, and incident knee injuries during the season were recorded.ResultsMRI knee abnormalities were common at baseline (67% bone marrow lesions, 16% meniscal tear/extrusion, 43% cartilage defects, 67% effusion synovitis). Meniscal tears/extrusion and synovial fluid volume were positively associated with knee symptoms, but these associations were small in magnitude and did not persist after further accounting for injury history. Players with a history of injury were at a greater risk of having meniscal tears/extrusion, effusion synovitis and greater synovial fluid volume. In contrast, players with a history of surgery were at a greater risk of having cartilage defects and meniscal tears/extrusion. Incident injuries were significantly associated with worsening symptoms, BML development and incident meniscal damage.ConclusionsMRI abnormalities are common in ARF players, are linked to a previous knee injury and surgery history, as well as incident injury but do not dictate clinical symptomatology.

Recent emerging data indicate that obesity is an important risk factor for multiple sclerosis (MS) susceptibility and may be associated with MS disability progression. Marked interactions between obesity and human leukocyte antigen (HLA) genotype with regard to the risk of MS have been reported. Evidence from Mendelian randomization studies also point to a causal relationship between obesity and MS risk. In this report, we aimed to analyze the current evidence of the relationship between obesity and risk of MS and disability progression, examine data on the interaction between obesity and HLA risk genes of MS and Mendelian randomization studies and to explore the plausible biological mechanisms that may underlie this relationship.

Background The contribution of cerebral small vessel disease (cSVD) to the pathogenesis of frailty remains uncertain. We aimed to examine the associations between cSVD with progression of frailty in a population-based study of older people. Methods People aged between 60 and 85 years were randomly selected form the electoral roll to participate in the Tasmanian Study of Cognition and Gait. Participants underwent self-reported questionnaires, objective gait, cognitive and sensorimotor testing over three phases ranging between 2005 and 2012. These data were used to calculate a 41-item frailty index (FI) at three time points. Baseline brain magnetic resonance imaging was performed on all participants to measure cSVD. Generalized mixed models were used to examine associations between baseline cSVD and progression of frailty, adjusted for confounders of age, sex, level of education, and total intracranial volume. Results At baseline (n = 388) mean age was 72 years (SD = 7.0), 44% were female, and the median FI score was 0.20 (interquartile range [IQR] 0.12, 0.27). In fully adjusted models higher burden of baseline white matter hyperintensity (WMH) was associated with frailty progression over 4.4 years (β = 0.03, 95% CI: 0.01, 0.05; p = .004) independent of other SVD markers. Neither baseline infarcts (p = .23), nor microbleeds at baseline (p = .65) were associated with progression of frailty. Conclusions We provide evidence for an association between baseline WMHs and progression of frailty. Our findings add to a growing body of literature suggesting WMH is a marker for frailty.

Background:There is increasing use of complementary and alternative medicines (CAMs) alone or as an adjuvant therapy to conventional palliative medicines.1 However, there remains clinical uncertainty about the benefit of CAMs in the management of osteoarthritis in older population.Objectives:To describe the association between CAM use (alone or in combination with conventional analgesics) with knee symptoms and structural changes amongst a representative sample of Tasmanian older adults.Methods:A total of 1,099 participants were selected from the Tasmania Older Adult Cohort Study (TASOAC), an ongoing prospective population-based study. Exposure to CAM and conventional medications was classified into four categories according to the national drug code directory: 2 CAM only, conventional analgesics only, both CAM and conventional analgesics, and neither CAMs nor conventional analgesics. Knee pain was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a 1.5-T MRI of the right knee was performed at baseline and follow-up (around 2.6 years). Longitudinal associations were assessed using mixed effect linear models.Results:At baseline, participants‘ mean age was 63, 86.5% (n=951) reported any medication use. The prevalence of CAM use was 35.0% and of conventional analgesics was 58.6%. Over follow-up, the analgesic only group had a significant increase in WOMAC pain, function, and stiffness scores compared to those who took neither CAMs nor conventional analgesics. There was a statistically significant femoral cartilage volume loss across all four groups, and no statistical difference was found between participants who takes both CAMs and analgesics group and the reference group, but participant in the CAM only or the analgesics only groups loss statistically significant more femoral cartilage volume than the reference group (Table 1).Table 1.Association of change in clinical knee symptoms and knee structural changes over 2.6 years with different medications groups.Mean change for reference group*Change for each category, coefficient (95% confident intervals)CAMsBothAnalgesicsReference group*No. of participants327128257387327WOMAC pain (5-50)-0.95 (-1.42, -0.48)0.04 (-0.85, 0.93)0.32 (-0.4, 1.04)0.78 (0.13, 1.43)RefWOMAC function (17-170)-3.09 (-4.52, -1.67)1.02 (-1.7, 3.73)1.39 (-0.81, 3.59)2.32 (0.33, 4.31)RefWOMAC stiffness (2-20)-0.39 (-0.62, -0.17)0.15 (-0.28, 0.58)0.35 (0, 0.7)0.40 (0.09, 0.72)RefFemoral cartilage volume (mL)-187.98 (-228.79, -147.18)-113.81 (-192.60, -35.03)-1.92 (-65.00, 61.17)-127.19 (-186.31, -68.06)Ref*Reference group=participants taken neither CAMs nor conventional analgesicsConclusion:CAM use alone or in combination with conventional analgesics may associate with slower progression of knee pain. Conclusive evidence on the longitudinal benefits of CAM in the management of osteoarthritis among older adults warrants more studies.References:[1]Steel A, McIntyre E, Harnett J, et al. Complementary medicine use in the Australian population: Results of a nationally-representative cross-sectional survey. Sci Rep 2018;8:17325.[2]National Center for Health Statistics. Long-term Care Drug Database System: Drugs by NDC Class Code, Drug Code and Name 2007 Available from: https://www.cdc.gov/nchs/data/nnhsd/DrugsbyNDCClass3.pdf [accessed date: 2020 23 December].The data were fitted using mixed effect linear models, which were constructed by entering baseline medication group, phase, the interaction between medication group and phase, covariates (baseline age, sex, body mass index [BMI], baseline value of outcome), the interaction between the covariates and phase, random intercept, and random slope on phase (time).Disclosure of Interests:None declared

Purpose: To compare the performance of low muscle mass and function with falls risk, incident fracture and mortality over 10 years.1041 participants (50% women; mean age 63±7.5 years) were prospectively followed for 10 years. Falls risk was measured using the Physiological Profile Assessment, fractures were self-reported and mortality was ascertained from the death registry. Appendicular lean mass (ALM) was assessed using dual energy X-ray absorptiometry. Four anthropometric: (ALM/height2, ALM/body mass index, ALM/weight×100, a residuals method of ALM on height and total body fat) and four performance-based measures: (handgrip strength, lower-limb muscle strength, upper and lower-limb muscle quality) were examined. Participants in the lowest 20% of the sex-specific distribution for each anthropometric and performance-based measure were classified has having low muscle mass or function. Regression analyses were used to estimate associations between each anthropometric and performance-based measure at baseline and 10-year falls risk, incident fractures and mortality.Mean falls risk z-score at 10 years was 0.64 (SD 1.12), incident fractures and mortality over 10 years were 16% and 14% respectively. All baseline performance-based measures were significantly associated with higher falls risk score at 10 years. Low handgrip (RR 1.55, 95% CI: 1.09, 2.20) and ALM/body mass index (RR 1.54, 95% CI: 1.14, 2.08) were the only significant predictors of fracture and mortality respectively.Low handgrip strength, a simple and inexpensive test could be considered in clinical settings for identifying future falls and fractures. ALM/ body mass index could be most suitable in estimating 10-year mortality risk, but requires specialised equipment.

Background: Work-related musculoskeletal disorders (WMSDs) have been documented among various occupational groups in Nigeria. However, there is limited data on the prevalence of WMSDs among call center operators (CCOs). Objective: To determine the prevalence of WMSDs among CCOs in Nigeria and to explore the extent to which these discomforts impact the daily work activities of the respondents. Methods: 374 respondents who were randomly selected from 4 telecommunication companies in Lagos State, Nigeria, participated in this study. They were asked to complete a pre-tested questionnaire designed to capture the prevalence, impact and associated risk factors of WMSDs among CCOs. Results: 42% and 65.2% of respondents experienced at least one WMSDs in the past 7 days, and 12 months, respectively. Women and CCOs who received calls with hand-held phones rather than headsets reported more discomforts during both 7 days and 12 months periods. Neck, shoulder, upper back, and lower back were the most affected areas during past 7 days and 12 months. Discomforts in the neck, low back, and knees prevented most of the respondents from performing their daily work. Conclusion: WMSDs have a serious impact on the daily job activities of the CCOs in Nigeria.

Purpose The aim of this study was to determine and compare risk factors associated with incident fractures in older adults with and without obesity, defined by both body mass index (BMI) and body fat percentage. Methods 1,099 older adults (mean ± standard deviation age = 63.0 ± 7.5) years, participated in this prospective cohort study. Obesity status at baseline was defined by BMI (≥30 kg/m2) obtained by anthropometry and body fat percentage (≥30% for men and ≥40% for women) assessed by dual-energy X-ray absorptiometry (DXA). Total hip and lumbar spine areal bone mineral density (aBMD) were assessed by DXA up to five years. Incident fractures were self-reported up to 10 years. Results Prevalence of obesity was 28% according to BMI and 43% according to body fat percentage. Obese older adults by BMI, but not body fat percentage, had significantly higher aBMD at the total hip and spine compared with non-obese (both p-value 0.05). Mediation analysis confirmed that aBMD meditated the effects of BMI, but not body fat percentage, on all incident fractures. Higher baseline falls risk score was the only consistent predictor of increased likelihood of incident fracture in obese individuals only, according to both BMI and body fat percentage (both p-value

To determine whether older adults with low muscle mass (sarcopenia) and strength (dynapenia), in the presence of osteoporosis/osteopenia, have an increased risk of fracture and mortality over 10 years, compared to those with low muscle or low bone mass alone or with neither condition.1032 participants (52% women; mean age 62.9 ± 7.4 years) were prospectively followed for 10 years. Mortality was ascertained from the death registry and fractures were self-reported. Baseline appendicular lean mass (ALM) was assessed using dual-energy X-ray absorptiometry and normalised to body mass index (BMI). Hand grip strength (HGS) was assessed by dynamometer. Osteosarcopenia and osteodynapenia were defined as having T-scores of the total hip and/or lumbar spine bone mineral density (BMD)-1 combined with being in the lowest 20% of the sex-specific distribution for ALM/BMI or HGS respectively.Incident fracture risk was significantly higher in participants who were osteodynapenic (RR = 2.07, 95% CI: 1.26-3.39), dynapenic alone (RR = 1.74, 95% CI: 1.05-2.87), and osteopenic alone (RR = 1.63, 95% CI: 1.15-2.31), compared to those without dynapenia or osteopenia. Mortality risk was significantly higher only in participants with osteosarcopenia (RR = 1.49, 95% CI: 1.01-2.21) compared to those without sarcopenia or osteopenia. However, osteosarcopenia and osteodynapenia did not lead to a significantly greater fracture or mortality risk compared to having these conditions on their own.These findings suggest that the combined effect of osteopenia and sarcopenia or dynapenia on fracture and mortality risk, respectively, may not be greater than that of each individual condition.

Background The relationship between physical activity (PA) and osteoarthritis (OA) has been controversial, with some studies showing a detrimental effect and others showing either no effect or a beneficial effect. Traditionally, analysis has focused on examining the effect PA and/or strength have on OA between individuals (between-person comparison). Yet, how the variability in PA and strength over time within the same individual (within-person comparison) is associated with OA is not well recognised. Statistical methods, such as multilevel models that properly capture the within-person processes can be used to tell us whether changes within an individual over time relate to changes in OA outcomes in that same individual. Objectives This study aimed to investigate the associations of between-person and within-person variability in PA and leg strength with knee cartilage volume loss over 10.7 years in older adults. Methods 479 community-dwelling older-adults (50% female, mean age 61±6 years, range 50–80 years) were studied at baseline, 2.7, 5.1, and 10.7 years. PA (measured objectively as steps/day) and leg strength (measured objectively in kg) were assessed at all four time-points. Knee cartilage volume was measured using MRI at baseline and 10.7 years. Linear mixed-effect regression models were used to estimate the association of between-person and within-person variability in PA and leg strength with cartilage volume loss over 10.7 years. Models were adjusted for age, sex, body mass index and history of knee injury or surgery. Results Mean cartilage volume loss over 10.7 years was 465±231 mm3. No between-person associations existed between PA and cartilage volume loss (Beta: 18.8 per 1000 steps/day, 95% CI −6.1, 43.7). However, within-person variability in PA was protectively associated with changes in cartilage volume, such that having higher PA compared to an individual’s average level of PA minimised their cartilage volume loss over time (Beta: 32.8 per 1000 steps/day, 95% CI 20.8, 44.6). Between-person effects showed that participants with greater leg strength lost less cartilage volume over time (Beta: 5.4 per 1 kg, 95% CI 3.1, 7.8). Within-person variability in leg strength was also protectively associated with changes in cartilage volume, such that having higher leg strength compared to an individual’s average strength minimised their cartilage volume loss over time (Beta: 3.3 per 1 kg, 95% CI 2.1, 4.5). Conclusions Our unique analysis method adds a new perspective to the PA and OA debate. The implication of these findings demonstrate that individuals can minimise cartilage volume loss by increasing their own PA and strength, which supports the clinical recommendations of promoting PA and strength to prevent and treat OA. Disclosure of Interest None declared

Introduction the use of bed nets is a well-recognized and cost-effective preventive measure against malaria. However, little is known about factors associated with the use of bed nets among older people in Nigeria. Therefore, this study aimed to examine the determinants of bed net use among older Nigerian adults. Methods data from the first wave of the Nigeria General Household Survey-Panel were used, which included 3,439 participants aged 50 years and above. Log-binomial models were used to model the association between participants' sociodemographic characteristics and the use of bed nets. Results the frequency of bed net use was 26%. The adjusted prevalence ratio (PR) of bed net use was lower in women (PR = 0.83, 95% CI: 0.73-0.96), older age groups (60-69 years: PR=0.85, 95% CI:0.75-0.97; 70 years and above: PR = 0.80, 95% CI: 0.69-0.94), female-headed households (PR = 0.69, 95% CI: 0.53-0.89) and among those in the highest tertiles of per-capita household expenditure (PR=0.77, 95% CI: 0.66-0.90). However, the frequency of bed net use was higher among older adults residing in the rural areas (PR = 1.84, 95% CI: 1.55-2.18) and those who reported never having attended school (PR=1.15, 95% CI: 1.01-1.30). Conclusion the prevalence of bed net use among older adults is lower compared to previously reported data for younger adults, suggesting an increased risk of the older adults of exposure to malaria. Female sex, age ≥ 60 years, level of education, economic status, and rural vs urban residence were important determinants of bed net use among older adults.

Introduction : Orofacial cleft has a worldwide distribution but it is peculiar in the developing countries due to poor healthcare facility with resultant high incidence of unoperated adult cleft. Various model of surgical mission by foreign experts had existed to combat this menace. The indigenous rotatory model by Cleft & facial deformity foundation is hereby presented. Methods : Carrying out an outreach programme in a rural area begins with the identification of a hospital with optimum facility, followed by effective awareness campaign, then a pre- surgical meeting with the hospital management. Personnel, equipment and materials were mobilised to the site while surgery usually lasted one week. Results : Seventeen outreach programmes were carried out in 10 different hospitals from March 2011 to June 2017. There were 546 orofacial cleft patients, 280 (51.3%) males and 266 (48.7%) females. The age ranged between 1 week to 70years with a mean age ± (SD) of 9.3±11.5. Four hundred and forty eight (82.1%) of the cleft patients were operated. Three hundred and twenty two (59.0%) patients were treated under general anaesthesia while 126 (23.1%) were treated under local anaesthesia. Eight surgeons and 4 anaesthetics were trained during the study period with several local practitioners benefitting from exposure to standard practice. Standard techniques were employed for cheiloplasty and palatoplasty. Minor complications were recorded with one mortality. Conclusion : This model is an effective and efficient way of reaching out to the poor patients with orofacial cleft. Effective mobilization, large volume of safe and quality surgery, easy knowledge transfer and possibility of patient review are some of its advantages. With regular training and funding, it could be an effective way of minimising ignorance and eradicating adult cleft in Nigeria and other developing societies.

Background: Older adults are the most sedentary segment of society, often spending in excess of 8.5 hours a day sitting. Large amounts of time spent sedentary, defined as time spend sitting or in a reclining posture without spending energy, has been linked to an increased risk of chronic diseases, frailty, loss of function, disablement, social isolation, and premature death. Objectives: To evaluate the effectiveness of interventions aimed at reducing sedentary behaviour amongst older adults living independently in the community compared to control conditions involving either no intervention or interventions that do not target sedentary behaviour. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, EPPI-Centre databases (Trials Register of Promoting Health Interventions (TRoPHI) and the Obesity and Sedentary behaviour Database), WHO ICTRP, and ClinicalTrials.gov up to 18 January 2021. We also screened the reference lists of included articles and contacted authors to identify additional studies. Selection criteria: We included randomised controlled trials (RCTs) and cluster-RCTs. We included interventions purposefully designed to reduce sedentary time in older adults (aged 60 or over) living independently in the community. We included studies if some of the participants had multiple comorbidities, but excluded interventions that recruited clinical populations specifically (e.g. stroke survivors). Data collection and analysis: Two review authors independently screened titles and abstracts and full-text articles to determine study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted authors for additional data where required. Any disagreements in study screening or data extraction were settled by a third review author. Main results: We included seven studies in the review, six RCTs and one cluster-RCT, with a total of 397 participants. The majority of participants were female (n = 284), white, and highly educated. All trials were conducted in high-income countries. All studies evaluated individually based behaviour change interventions using a combination of behaviour change techniques such as goal setting, education, and behaviour monitoring or feedback. Four of the seven studies also measured secondary outcomes. The main sources of bias were related to selection bias (N = 2), performance bias (N = 6), blinding of outcome assessment (N = 2), and incomplete outcome data (N = 2) and selective reporting (N=1). The overall risk of bias was judged as unclear. Primary outcomes. The evidence suggests that interventions to change sedentary behaviour in community-dwelling older adults may reduce sedentary time (mean difference (MD) −44.91 min/day, 95% confidence interval (CI) −93.13 to 3.32; 397 participants; 7 studies; I = 73%; low-certainty evidence). We could not pool evidence on the effect of interventions on breaks in sedentary behaviour or time spent in specific domains such as TV time, as data from only one study were available for these outcomes. Secondary outcomes. We are uncertain whether interventions to reduce sedentary behaviour have any impact on the physical or mental health outcomes of community-dwelling older adults. We were able to pool change data for the following outcomes. • Physical function (MD 0.14 Short Physical Performance Battery (SPPB) score, 95% CI −0.38 to 0.66; higher score is favourable; 98 participants; 2 studies; I = 26%; low-certainty evidence). • Waist circumference (MD 1.14 cm, 95% CI −1.64 to 3.93; 100 participants; 2 studies; I = 0%; low-certainty evidence). • Fitness (MD -5.16 m in the 6-minute walk test, 95% CI −36.49 to 26.17; higher score is favourable; 80 participants; 2 studies; I = 29%; low-certainty evidence). • Blood pressure: systolic (MD −3.91 mmHg, 95% CI -10.95 to 3.13; 138 participants; 3 studies; I = 73%; very low-certainty evidence) and diastolic (MD −0.06 mmHg, 95% CI −5.72 to 5.60; 138 participants; 3 studies; I = 97%; very low-certainty evidence). • Glucose blood levels (MD 2.20 mg/dL, 95% CI −6.46 to 10.86; 100 participants; 2 studies; I = 0%; low-certainty evidence). No data were available on cognitive function, cost-effectiveness or adverse effects. Authors' conclusions: It is not clear whether interventions to reduce sedentary behaviour are effective at reducing sedentary time in community-dwelling older adults. We are uncertain if these interventions have any impact on the physical or mental health of community-dwelling older adults. There were few studies, and the certainty of the evidence is very low to low, mainly due to inconsistency in findings and imprecision. Future studies should consider interventions aimed at modifying the environment, policy, and social and cultural norms. Future studies should also use device-based measures of sedentary time, recruit larger samples, and gather information about quality of life, cost-effectiveness, and adverse event data.

Aims: To describe the associations between falls risk, and between-person and within-person variability in 25-hydroxyvitamin D (25OHD), physical activity (PA), knee pain and dysfunction in community-dwelling older people.

Aim To describe the associations of between-person and within-person variability in serum 25-hydroxyvitamin D (25(OH)D), physical activity (PA), and knee pain and dysfunction with muscle mass, strength, and muscle quality over 10 years in community-dwelling older adults. Method Participants (N = 1033; 51% women; mean age 63 ± 7.4 years) were measured at baseline, 2.5, 5, and 10 years. Lower limb lean mass (LLM) was assessed using dual energy X-ray absorptiometry, lower limb muscle strength (LMS) using a dynamometer, and lower limb muscle quality (LMQ) calculated as LMS/LLM. Knee pain and dysfunction were assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. PA was measured using pedometers. Linear-mixed effect regression models, with adjustment for confounders, were used to estimate the association of within-person and between-person variability in PA, 25(OH)D, and WOMAC scores with muscle mass, strength, and muscle quality. Results Both between-person and within-person increases in PA were associated with LLM, LMS, and LMQ (all P < 0.05). Within-person and between-person increases in knee pain and dysfunction were associated with LLS and LMQ, but not with LLM (all P < 0.05). Between-person effects showed that higher average 25(OH)D was associated with a higher 10-year average LLM, LMS, and LMQ (all P < 0.05), whereas within-person increases in average 25(OH)D were associated with a higher LMS and LMQ, but not with LLM. Conclusions Variability in 25(OH)D, pain, and dysfunction within an individual over time is related to muscle changes in that individual. Increasing one's own PA level further increases muscle mass, strength, and quality supporting the clinical recommendation of promoting PA to reduce age-related muscle loss.

Aims To describe the longitudinal associations between physiological falls risk, and between-person and within-person effects of 25-hydroxyvitamin D (25OHD), physical activity (PA), knee pain and dysfunction in community-dwelling older people. Methods Data for 1053 participants (51% women; mean age 63 ± 7.4 years) studied at baseline, 2.5, 5, and 10 years were analysed. Falls risk (Z-score) was measured using the Physiological Profile Assessment. Knee pain and dysfunction were assessed using the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC). Moderate-to-vigorous PA (MVPA) was measured using accelerometer. Linear mixed-effect regression models, with adjustment for confounders, were used to estimate the association between physiological falls risk and between-person and within-person effects of PA, 25OHD and WOMAC score. Results Between-person effects showed that 10-year average physiological falls risk was lower in participants who had a higher 10-year average 25OHD (β = −0.005 per nmol/l, 95% CI: −0.008, −0.002), log-MVPA (β = −0.16 per minute, 95% CI: −0.22, −0.10) and lower mean WOMAC score (β = 0.005 per-unit score, 95% CI: 0.003, 0.01). Within-person effects showed that a higher physiological falls risk at any time-point was associated with higher than average WOMAC score (β = 0.002 per-unit score, 95% CI: 0.0003, 0.004) and lower than average log-MVPA (β = −0.15 per minute, 95% CI: −0.24, −0.06), but not 25OHD, at the same time-point. Conclusion Having higher WOMAC global score above an individual's average increases the risk of falling, whereas, increasing one's own MVPA level further reduces their risk of falling. The presence of between-person but not within-person associations for 25OHD suggests the former may be confounded by other factors.

Introduction Previous studies in Nigeria have documented significant association between maternal education and child immunization. However, little is known about the pathway through which maternal education improves immunization uptake. This study aims to examine whether maternal literacy and socioeconomic status mediates the relationship between maternal education and complete immunization coverage in children. Methods Nationally representative data from the first wave of the Nigeria General Household Survey-Panel were used, which includes 661 children aged one year and below. Regression analyses were used to model the association between maternal education and child's immunization uptake; we then examined whether maternal literacy and household economic status mediates this association. Results Of the 661 children, 40% had complete immunization. The prevalence ratio (PR) of complete immunization in children whose mothers were educated versus those whose mothers were not educated was 1.44 (95% CI: 1.16-1.77). Maternal literacy substantially reduced the estimated association between maternal education and complete immunization by 90%, whereas household economic status reduced the estimates by 27%. Conclusion These findings suggest that complete immunization was higher in children whose mothers were educated, partly because maternal education leads to acquisition of literacy skills and better health-seeking behavior which then improves immunization uptake for their children. Socioeconomic status is an alternative pathway but with less substantial indirect effect.