Publications by authors named "Andreas Holtermann"

260 Publications

Occupational lifting and risk of hypertension, stratified by use of anti-hypertensives and age - a cross-sectional and prospective cohort study.

BMC Public Health 2021 Apr 14;21(1):721. Epub 2021 Apr 14.

National Research Centre for the Working Environment, Lersø Parkallé 105, 2100, Copenhagen, Denmark.

Background: Heavy occupational lifting is prevalent in the general working population and is sparsely reported to associate with hypertension, especially among older and hypertensive workers. We investigated if heavy occupational lifting is associated with hypertension and blood pressure (BP) in both cross-sectional and prospective study designs in the Copenhagen General Population Study, stratified by age, and use of anti-hypertensives.

Methods: Participation was conducted following the declaration of Helsinki and approved by the ethical committee (H-KF-01-144/01). By multivariable logistic and linear regression models, we investigated the association between heavy occupational lifting and hypertension, in a cross-sectional design (n = 67,363), using anti-hypertensives or BP ≥140/≥90 mmHg as outcome, and in a prospective design (n = 7020) with an above-median change in systolic BP (SBP) from baseline to follow-up and/or a shift from no use to use of anti-hypertensives as outcome, with and without stratification by age and use of anti-hypertensives.

Results: The odds ratio for hypertension was estimated at 0.97 (99% CI: 0.93-1.00) in the cross-sectional analysis, and at 1.08 (99% CI: 0.98-1.19) in the prospective analysis. The difference in SBP among workers with versus without heavy occupational lifting was estimated at - 0.29 mmHg (99% CI -0.82 - 0.25) in the cross-sectional and at 1.02 mmHg (99% CI -0.41 - 2.45) in the prospective analysis. No significant interaction between heavy occupational lifting and age, nor use of anti-hypertensives were shown.

Conclusions: Only the prospective analysis indicated heavy occupational lifting to increase the risk of hypertension. Further research on the association between occupational lifting and hypertension are needed.
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http://dx.doi.org/10.1186/s12889-021-10651-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045338PMC
April 2021

The physical activity paradox in cardiovascular disease and all-cause mortality: the contemporary Copenhagen General Population Study with 104 046 adults.

Eur Heart J 2021 Apr;42(15):1499-1511

The Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Nordre Fasanvej 57, Hovedvejen, Indgang 5, Frederiksberg 2000, Denmark.

Aims : Leisure time physical activity associates with reduced risk of cardiovascular disease and all-cause mortality, while these relationships for occupational physical activity are unclear. We tested the hypothesis that leisure time physical activity associates with reduced major adverse cardiovascular events (MACE) and all-cause mortality risk, while occupational physical activity associates with increased risks.

Methods And Results : We studied 104 046 women and men aged 20-100 years in the Copenhagen General Population Study with baseline measurements in 2003-2014 and median 10-year follow-up. Both leisure and occupational physical activity were based on self-report with four response categories. We observed 7913 (7.6%) MACE and 9846 (9.5%) deaths from all causes. Compared to low leisure time physical activity, multivariable adjusted (for lifestyle, health, living conditions, and socioeconomic factors) hazard ratios for MACE were 0.86 (0.78-0.96) for moderate, 0.77 (0.69-0.86) for high, and 0.85 (0.73-0.98) for very high activity; corresponding values for higher occupational physical activity were 1.04 (0.95-1.14), 1.15 (1.04-1.28), and 1.35 (1.14-1.59), respectively. For all-cause mortality, corresponding hazard ratios for higher leisure time physical activity were 0.74 (0.68-0.81), 0.59 (0.54-0.64), and 0.60 (0.52-0.69), and for higher occupational physical activity 1.06 (0.96-1.16), 1.13 (1.01-1.27), and 1.27 (1.05-1.54), respectively. Similar results were found within strata on lifestyle, health, living conditions, and socioeconomic factors, and when excluding individuals dying within the first 5 years of follow-up. Levels of the two domains of physical activity did not interact on risk of MACE (P = 0.40) or all-cause mortality (P = 0.31).

Conclusion : Higher leisure time physical activity associates with reduced MACE and all-cause mortality risk, while higher occupational physical activity associates with increased risks, independent of each other.
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http://dx.doi.org/10.1093/eurheartj/ehab087DOI Listing
April 2021

Validity of a Non-Proprietary Algorithm for Identifying Lying Down Using Raw Data from Thigh-Worn Triaxial Accelerometers.

Sensors (Basel) 2021 Jan 29;21(3). Epub 2021 Jan 29.

Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University, 751 85 Uppsala, Sweden.

Body postural allocation during daily life is important for health, and can be assessed with thigh-worn accelerometers. An algorithm based on sedentary bouts from the proprietary ActivePAL software can detect lying down from a single thigh-worn accelerometer using rotations of the thigh. However, it is not usable across brands of accelerometers. This algorithm has the potential to be refined. : To refine and assess the validity of an algorithm to detect lying down from raw data of thigh-worn accelerometers. Axivity-AX3 accelerometers were placed on the thigh and upper back (reference) on adults in a development dataset (n = 50) and a validation dataset (n = 47) for 7 days. Sedentary time from the open Acti4-algorithm was used as input to the algorithm. In addition to the thigh-rotation criterion in the existing algorithm, two criteria based on standard deviation of acceleration and a time duration criterion of sedentary bouts were added. The mean difference (95% agreement-limits) between the total identified lying time/day, between the refined algorithm and the reference was +2.9 (-135,141) min in the development dataset and +6.5 (-145,159) min in the validation dataset. The refined algorithm can be used to estimate lying time in studies using different accelerometer brands.
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http://dx.doi.org/10.3390/s21030904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866264PMC
January 2021

Work-Time Compositions of Physical Behaviors and Trajectories of Sick Leave Due to Musculoskeletal Pain.

Int J Environ Res Public Health 2021 Feb 5;18(4). Epub 2021 Feb 5.

National Research Centre for the Working Environment, 2100 Copenhagen, Denmark.

We aimed to investigate the association between work-time compositions of physical behavior and sick leave trajectories due to musculoskeletal pain over one year. We conducted a secondary analysis using the data of 981 workers in a Danish prospective cohort (DPHACTO 2012-2014). At baseline, we assessed physical behaviors (sitting, standing, light physical activity (LIPA), and moderate-to-vigorous physical activity (MVPA)) at work and during leisure, using accelerometers. Over 1 year follow-up, workers reported sick-leave days due to musculoskeletal pain at 4-week intervals. Four distinct trajectories of sick leave were previously identified in this cohort ("no sick leave", "few days-increasing trajectory", "some days-decreasing trajectory", "some days-increasing trajectory"), and used as an outcome in multinomial regression models with work-time compositions as predictors, adjusted for compositions of behavior during leisure, age, sex, body mass index, and smoking habits. More time spent sitting relative to the other behaviors was negatively associated with the trajectory of few days-increasing sick leave ( = 0.004), while time in LIPA was positively associated with the trajectory of some days-increasing sick leave ( = 0.009). Standing and MVPA were not significantly associated with sick leave trajectories. In conclusion, work-time compositions with more sitting relative to the other behaviors had lower risk for an increasing trajectory of sick leave due to pain, while compositions with more LIPA had higher risk. This may have implications for prevention of pain-related sick leave in blue-collar workers.
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http://dx.doi.org/10.3390/ijerph18041508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915038PMC
February 2021

Should leisure-time sedentary behavior be replaced with sleep or physical activity for prevention of diabetes?

Scand J Med Sci Sports 2021 Jan 19. Epub 2021 Jan 19.

Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark.

The aim was to examine the effects of replacing self-reported leisure-time sedentary behavior with sleep, light-to-moderate physical activity, or vigorous physical activity on incident diabetes among Danish adults using isotemporal substitution modeling. Participants ≥25 years from the Danish Capital Region Health Survey 2007 (N = 69 800, response rate 52.3%), 2010 (N = 95 150, response rate 52.3%), and 2013 (N = 95 150, response rate 43.5%) were included. Information on daily sleep duration, leisure-time sedentary behavior, and movement behaviors was collected by questionnaire. Information on incident diabetes was obtained from National registers. Analyses included Cox proportional hazards regression models and isotemporal substitution analyses, with time (in years) from baseline to incident diabetes or censoring December 31, 2017. Potential confounders, sex, age, BMI, ethnicity, education, smoking, inflammatory joint disease, perceived stress, physical and mental component scale and work status, were included. Out of N = 87 339 in the final study sample, n = 3007 had incident diabetes during a mean follow-up time of 7.4 years. Adults with incident diabetes included more men, higher mean age, and higher BMI, compared to respondents without incident diabetes. Theoretically substituting 30 minutes of leisure-time sedentary behavior with light-to-moderate PA (HR: 0.96; 95% CI: 0.94; 0.98) or with vigorous PA (HR: 0.82; 95% CI: 0.72; 0.94) decreased the risk of incident diabetes. We found no change in incident diabetes risk of substituting sedentary time with sleep (HR: 1.00; 95% CI: 0.97; 1.02). Substituting 30 minutes per day of leisure-time sedentary behavior with light-to-moderate or vigorous PA may significantly reduce the risk of incident diabetes among adults.
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http://dx.doi.org/10.1111/sms.13924DOI Listing
January 2021

Thigh-worn accelerometry for measuring movement and posture across the 24-hour cycle: a scoping review and expert statement.

BMJ Open Sport Exerc Med 2020 24;6(1):e000874. Epub 2020 Dec 24.

School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia.

Introduction: The Prospective Physical Activity Sitting and Sleep consortium (ProPASS) is an international collaboration platform committed to harmonise thigh-worn accelerometry data. The aim of this paper is to (1) outline observational thigh-worn accelerometry studies and (2) summarise key strategic directions arising from the inaugural ProPASS meeting.

Methods: (1) We performed a systematic scoping review for observational studies of thigh-worn triaxial accelerometers in free-living adults (n≥100, 24 hours monitoring protocols). (2)Attendees of the inaugural ProPASS meeting were sent a survey focused on areas related to developing ProPASS: important terminology (Q1); accelerometry constructs (Q2); advantages and distinct contribution of the consortium (Q3); data pooling and harmonisation (Q4); data access and sharing (Q5 and Q6).

Results: (1) Eighty eligible articles were identified (22 primary studies; n~17 685). The accelerometers used most often were the ActivPAL3 and ActiGraph GT3X. The most commonly collected health outcomes were cardiometabolic and musculoskeletal. (2) None of the survey questions elicited the predefined 60% agreement. Survey responses recommended that ProPASS: use the term physical behaviour or movement behaviour rather than 'physical activity' for the data we are collecting (Q1); make only minor changes to ProPASS's accelerometry construct (Q2); prioritise developing standardised protocols/tools (Q4); facilitate flexible methods of data sharing and access (Q5 and Q6).

Conclusions: Thigh-worn accelerometry is an emerging method of capturing movement and posture across the 24 hours cycle. In 2020, the literature is limited to 22 primary studies from high-income western countries. This work identified ProPASS's strategic directions-indicating areas where ProPASS can most benefit the field of research: use of clear terminology, refinement of the measured construct, standardised protocols/tools and flexible data sharing.
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http://dx.doi.org/10.1136/bmjsem-2020-000874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768971PMC
December 2020

Workplace physical activity promotion: why so many failures and few successes? The need for new thinking.

Br J Sports Med 2020 Dec 1. Epub 2020 Dec 1.

Department of Public and Occupational Health, Amsterdam UMC - VUMC Campus, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1136/bjsports-2020-103067DOI Listing
December 2020

How does occupational physical activity influence health? An umbrella review of 23 health outcomes across 158 observational studies.

Br J Sports Med 2020 Dec;54(24):1474-1481

Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands

Objective: Physical activity (PA) has substantial benefits across a range of health outcomes. There is uncertainty about the PA-specific health effects, and in particular, the occupational domain. In this umbrella review, we synthesised available evidence on the associations between occupational PA (OPA) and health-related outcomes (including cancer, all-cause mortality and cardiovascular disease). This work informed the development of WHO's guidelines on PA and sedentary behaviour (2020).

Design: Umbrella review of systematic reviews.

Data Source: We performed a literature search in PubMed, Web of Science, Embase, CINAHL and Sportdiscuss from database inception to 2 December 2019.

Eligibility Criteria For Selecting Studies: We included systematic reviews if they contained a quantitative assessment of OPA and its relationship with at least one health-related outcome.

Results: We summarised the evidence of 17 reviews covering 23 unique health-related outcomes. We graded most evidence as low or very low, or moderate quality. We found health benefits for those engaging in high versus low OPA for multiple cancer outcomes (including colon and prostate), ischaemic stroke, coronary heart disease and mental health (ie, mental well-being and life satisfaction). High OPA was associated with unfavourable health outcomes for all-cause mortality in men, mental ill health (ie, depression and anxiety), osteoarthritis, and sleep quality and duration.

Conclusions: We found favourable associations for most health-related outcomes with high OPA levels, but we also found some evidence for unfavourable associations due to high OPA levels. At this point, there is a need for better quality evidence to provide a unequivocal statement on the health effects of OPA.
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http://dx.doi.org/10.1136/bjsports-2020-102587DOI Listing
December 2020

Cardiorespiratory fitness, occupational aerobic workload and age: workplace measurements among blue-collar workers.

Int Arch Occup Environ Health 2021 Apr 8;94(3):503-513. Epub 2020 Nov 8.

The National Research Centre for the Work Environment, Copenhagen, Denmark.

Background: The knowledge, from laboratory studies dating back to the 1950s on the importance of the association between cardiorespiratory fitness and aerobic workload for workers health, is fundamental for promoting sustainable healthy employability among ageing blue-collar workers today. However, the association between cardiorespiratory fitness and aerobic workload has not yet been documented during daily work, and we do not know if it applies to the normal work of blue-collar workers in different age groups. We aim to investigate the association between cardiorespiratory fitness and aerobic workload among blue-collar workers using measurements of 24-h heart rate collected over consecutive working days.

Methods: We analyzed baseline cardiorespiratory fitness, assessed using a sub-maximal cycle ergometer test, and 1-4 days of 24-h heart rate measurement from 497 blue-collar workers participating in the DPHACTO study. We investigated the association between cardiorespiratory fitness and aerobic workload defined as the average percentage of heart rate reserve (%HRR), maximum %HRR and the duration time spent at a high HRR (> 30%) during working hours. The association was assessed using multivariate linear regression models adjusted for age, sex, self-rated health, shift-work, prescription medication and occupation, as well as for different age strata.

Results: Higher cardiorespiratory fitness was significantly associated with decreased mean %HRR -0.32 [95% CI -0.39 to -0.25], maximum %HRR -0.35 [95% CI -0.45 to -0.25] and time spent at  ≥ 30% HRR; -1.8% [95% CI -2.2 to -1.5%]. These associations were evident across age groups, with slightly stronger associations for workers aged 46-51 (total range 18-68).

Conclusions: Higher cardiorespiratory fitness was associated with the decreased aerobic workload during normal work across all age groups and levels of work intensity. Our findings highlight the importance of cardiorespiratory fitness when considering the workload and its relevance in the promotion of healthy sustainable employment.
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http://dx.doi.org/10.1007/s00420-020-01596-5DOI Listing
April 2021

The Relation between Domain-Specific Physical Behaviour and Cardiorespiratory Fitness: A Cross-Sectional Compositional Data Analysis on the Physical Activity Health Paradox Using Accelerometer-Assessed Data.

Int J Environ Res Public Health 2020 10 29;17(21). Epub 2020 Oct 29.

Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium.

In contrast to leisure time physical activity (LTPA), occupational physical activity (OPA) does not have similar beneficial health effects. These differential health effects might be explained by dissimilar effects of LTPA and OPA on cardiorespiratory fitness (CRF). This study investigated cross-sectional associations between different physical behaviours during both work and leisure time and CRF by using a Compositional Data Analysis approach. Physical behaviours were assessed by two accelerometers among 309 workers with various manual jobs. During work time, more sedentary behaviour (SB) was associated with higher CRF when compared relatively to time spent on other work behaviours, while more SB during leisure time was associated with lower CRF when compared to other leisure time behaviours. Reallocating more time to moderate-to-vigorous physical activity (MVPA) from the other behaviours within leisure time was positively associated with CRF, which was not the case for MVPA during work. The results of our study are in line with the physical activity health paradox and we call for further study on the interaction between LTPA and OPA by implementing device-worn measures in a longitudinal design. Our results highlight the need for recommendations to take into account the different effects of OPA and LTPA on CRF.
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http://dx.doi.org/10.3390/ijerph17217929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662405PMC
October 2020

Untapping the Health Enhancing Potential of Vigorous Intermittent Lifestyle Physical Activity (VILPA): Rationale, Scoping Review, and a 4-Pillar Research Framework.

Sports Med 2021 Jan;51(1):1-10

Department of Kinesiology, McMaster University, Hamilton, ON, Canada.

Recently revised public health guidelines acknowledge the health benefits of regular intermittent bouts of vigorous intensity incidental physical activity done as part of daily living, such as carrying shopping bags, walking uphill, and stair climbing. Despite this recognition and the advantages such lifestyle physical activity has over continuous vigorous intensity structured exercise, a scoping review we conducted revealed that current research in this area is, at best, rudimentary. Key gaps include the absence of an empirically-derived dose specification (e.g., minimum duration of lifestyle physical activity required to achieve absolute or relative vigorous intensity), lack of acceptable measurement standards, limited understanding of acute and chronic (adaptive) effects of intermittent vigorous bouts on health, and paucity of essential information necessary to develop feasible and scalable interventions (e.g., acceptability of this kind of physical activity by the public). To encourage collaboration and research agenda alignment among groups interested in this field, we propose a research framework to further understanding of vigorous intermittent lifestyle physical activity (VILPA). This framework comprises four pillars aimed at the development of: (a) an empirical definition of VILPA, (b) methods to reliably and accurately measure VILPA, (c) approaches to examine the short and long-term dose-response effects of VILPA, and (d) scalable and acceptable behavioural VILPA-promoting interventions.
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http://dx.doi.org/10.1007/s40279-020-01368-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806564PMC
January 2021

Can Childcare Work Be Designed to Promote High Intensity Physical Activity for Improved Fitness and Health? A Proof of Concept Study of the Goldilocks Principle.

Int J Environ Res Public Health 2020 10 12;17(20). Epub 2020 Oct 12.

The National Research Centre for the Working Environment, 2100 Copenhagen, Denmark.

Childcare workers are reported to have high variation in physical activity during work hours, but also to sit for about half of the workday and have almost no high intensity physical activity (HIPA). No study has investigated if their work can be re-designed to introduce HIPA, thus promoting fitness and health according to the Goldilocks principle. This study investigated the feasibility of designing pedagogical games ('Goldilocks-games') intended to lead to more HIPA. Heart rate was measured in nineteen childcare workers during Goldilocks-games, and compared to measurements during a regular workday. Worker perceptions of feasibility, and researcher observations of contextual factors were also collected. The Goldilocks-games (33 min) elicited significantly more HIPA (18/33 min) compared to the most active period of equal length on a regular workday (0.5/33 min). Seventy-four-percent of the childcare workers reported that it was feasible to integrate the Goldilocks-games pedagogically, and seventy-two-percent could see themselves using them. Thus, we found it possible to re-design a work task in childcare according to the Goldilocks principle so that it leads to substantial time with HIPA. The sustainability of Goldilocks-games in childcare, and their effectiveness in improving fitness and health among childcare workers, needs to be tested in further studies.
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http://dx.doi.org/10.3390/ijerph17207419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600739PMC
October 2020

The effect of occupational physical activity on dementia: Results from the Copenhagen Male Study.

Scand J Med Sci Sports 2021 Feb 26;31(2):446-455. Epub 2020 Oct 26.

Department of Public Health, University of Copenhagen, Copenhagen, Denmark.

Leisure-time physical activity (LTPA) reduces the risk of dementia, while the effect of occupational physical activity (OPA) on dementia is uncertain. Therefore, the aim of this study was to investigate the effect of OPA on dementia. For comparison, also the association between LTPA and dementia was analyzed. In this longitudinal study, we used self-reported questionnaire data on OPA and LTPA collected in 1970-71 from 4721 male employees, who were 40-59 years old at baseline. Dementia was identified through national registers and participants were followed from they turned 60 years and until 2016. We estimated incidence rate ratios (IRR) and adjusted for age, socioeconomic status, marital status, and psychological stress. In additional analyses, we included health behaviors and blood pressure and mutually adjusted OPA and LTPA. We identified 697 dementia cases during 86 557 person-years. We found an IRR of 1.48 (95% CI: 1.05-2.10) among participants with high OPA compared with participants in sedentary jobs. Participants with high LTPA had a non-significantly lower IRR of dementia compared with participants with a sedentary leisure time. In conclusion, LTPA and OPA are differentially associated with dementia. Therefore, current recommendations regarding the beneficial effect of physical activity on dementia only concern LTPA, and more research on OPA and dementia is needed.
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http://dx.doi.org/10.1111/sms.13846DOI Listing
February 2021

Zero problems with compositional data of physical behaviors: a comparison of three zero replacement methods.

Int J Behav Nutr Phys Act 2020 10 6;17(1):126. Epub 2020 Oct 6.

National Research Centre for the Working Environment, Lersø parkalle 105, 2100, Copenhagen, Denmark.

Background: Researchers applying compositional data analysis to time-use data (e.g., time spent in physical behaviors) often face the problem of zeros, that is, recordings of zero time spent in any of the studied behaviors. Zeros hinder the application of compositional data analysis because the analysis is based on log-ratios. One way to overcome this challenge is to replace the zeros with sensible small values. The aim of this study was to compare the performance of three existing replacement methods used within physical behavior time-use epidemiology: simple replacement, multiplicative replacement, and log-ratio expectation-maximization (lrEM) algorithm. Moreover, we assessed the consequence of choosing replacement values higher than the lowest observed value for a given behavior.

Method: Using a complete dataset based on accelerometer data from 1310 Danish adults as reference, multiple datasets were simulated across six scenarios of zeros (5-30% zeros in 5% increments). Moreover, four examples were produced based on real data, in which, 10 and 20% zeros were imposed and replaced using a replacement value of 0.5 min, 65% of the observation threshold, or an estimated value below the observation threshold. For the simulation study and the examples, the zeros were replaced using the three replacement methods and the degree of distortion introduced was assessed by comparison with the complete dataset.

Results: The lrEM method outperformed the other replacement methods as it had the smallest influence on the structure of relative variation of the datasets. Both the simple and multiplicative replacements introduced higher distortion, particularly in scenarios with more than 10% zeros; although the latter, like the lrEM, does preserve the ratios between behaviors with no zeros. The examples revealed that replacing zeros with a value higher than the observation threshold severely affected the structure of relative variation.

Conclusions: Given our findings, we encourage the use of replacement methods that preserve the relative structure of physical behavior data, as achieved by the multiplicative and lrEM replacements, and to avoid simple replacement. Moreover, we do not recommend replacing zeros with values higher than the lowest observed value for a behavior.
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http://dx.doi.org/10.1186/s12966-020-01029-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542467PMC
October 2020

Combined Effects of Physical Behavior Compositions and Psychosocial Resources on Perceived Exertion Among Eldercare Workers.

Ann Work Expo Health 2020 11;64(9):923-935

Centre for Musculoskeletal Research, Department of Occupational Health Sciences and Psychology, University of Gävle, Gävle, Sweden.

Objectives: High perceived physical exertion is common in eldercare workers and a strong predictor for impaired health. However, little is known on how physical behaviors at work associate with physical exertion in this group. The aim of this study was to determine the extent to which the composition of physical behaviors at work is associated with perceived physical exertion in nursing home eldercare workers, and the extent to which these associations are modified by psychosocial resources.

Methods: Our population consisted of 399 female eldercare workers from 126 wards in 20 different nursing homes. We evaluated time spent in physical behaviors at work [sitting, standing still, light activities (LAs), and moderate to vigorous activities (MVAs)] using triaxial accelerometers worn, on average, for three working days. We accounted for inherent codependency between the behaviors using compositional data analysis. We used multilevel linear mixed regression models to determine associations between the behaviors and perceived exertion, measured on a numeric rating scale (0-10), and included interactions between each behavior and psychosocial resources (influence at work, social support, and quality of leadership) to determine a possible moderating effect of resources. Regression results were illustrated using isotemporal substitution.

Results: Sitting was negatively (β: -0.64; P < 0.01) while MVA was positively (β: 0.95; P = 0.02) associated with perceived exertion. According to isotemporal substitution, replacing 30 min of MVA by sitting would, for an average worker, be associated with a decrease in physical exertion by -0.14 on the 0-10 scale. Job resources marginally moderated the association between LA and exertion. Thus, among workers with low influence and low social support, we found a positive association between LA and exertion, while that was not found for workers with medium or high influence and support (interactions for influence and support: P = 0.08 and P = 0.10).

Conclusions: Our findings suggest that reallocating time from MVA to sitting can mitigate perceived physical exertion in eldercare workers. More time in LA increased physical exertion only for workers with low psychosocial resources, supporting a positive effect of a better psychosocial work environment in elderly care.
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http://dx.doi.org/10.1093/annweh/wxaa079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751016PMC
November 2020

The physical activity paradox revisited: a prospective study on compositional accelerometer data and long-term sickness absence.

Int J Behav Nutr Phys Act 2020 07 20;17(1):93. Epub 2020 Jul 20.

National Research Centre for the Working Environment, Lersø Parkalle 105, DK-2100, Copenhagen Ø, Denmark.

Background: The 'physical activity paradox' advocates that leisure physical activity (PA) promotes health while high occupational PA impairs health. However, this paradox can be explained by methodological limitations of the previous studies-self-reported PA measures, insufficient adjustment for socioeconomic confounding or not addressing the compositional nature of PA. Therefore, this study investigated if we still observe the PA paradox in relation to long-term sick absence (LTSA) after adjusting for the abovementioned limitations.

Methods: Time spent on moderate-to-vigorous physical activity (MVPA) and remaining physical behaviors (sedentary behavior, standing, light PA and time in bed) at work and in leisure was measured for 929 workers using thigh accelerometry and expressed as isometric log-ratios (ilrs). LTSA was register-based first event of ≥6 consecutive weeks of sickness absence during 4-year follow-up. The association between ilrs and LTSA was analyzed using a Cox proportional hazards model adjusted for remaining physical behaviors and potential confounders, then separately adjusting for and stratifying by education and type of work.

Results: During the follow-up, 21% of the workers experienced LTSA. In leisure, more relative MVPA time was negatively associated with LTSA (20% lower risk with 20 min more MVPA, p = 0.02). At work, more relative MVPA time was positively associated with LTSA (15% higher risk with 20 min more MVPA, p = 0.02). Results remained unchanged when further adjusted for or stratified by education and type of work.

Conclusion: These findings provide further support to the 'PA paradox'.
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http://dx.doi.org/10.1186/s12966-020-00988-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370435PMC
July 2020

Can we walk away from cardiovascular disease risk or do we have to 'huff and puff'? A cross-sectional compositional accelerometer data analysis among adults and older adults in the Copenhagen City Heart Study.

Int J Behav Nutr Phys Act 2020 07 6;17(1):84. Epub 2020 Jul 6.

Musculoskeletal Disorders and Physical Workload, National Research Centre for the Working Environment, Lersø Parkallé 105, 2100, Copenhagen Ø, Denmark.

Background: It is unclear whether walking can decrease cardiovascular disease (CVD) risk or if high intensity physical activity (HIPA) is needed, and whether the association is modified by age. We investigated how sedentary behaviour, walking, and HIPA, were associated with systolic blood pressure (SBP), waist circumference (WC), and low-density lipoprotein cholesterol (LDL-C) among adults and older adults in a general population sample using compositional data analysis. Specifically, the measure of association was quantified by reallocating time between sedentary behaviour and 1) walking, and 2) HIPA.

Methods: Cross-sectional data from the fifth examination of the Copenhagen City Heart Study was used. Using the software Acti4, we estimated daily time spent in physical behaviours from accelerometer data worn 24 h/day for 7 days (i.e., right frontal thigh and iliac crest; median wear time: 6 days, 23.8 h/day). SBP, WC, and LDL-C were measured during a physical examination. Inclusion criteria were ≥ 5 days with ≥16 h of accelerometer recordings per day, and no use of antihypertensives, diuretics or cholesterol lowering medicine. The 24-h physical behaviour composition consisted of sedentary behaviour, standing, moving, walking, HIPA (i.e., sum of climbing stairs, running, cycling, and rowing), and time in bed. We used fitted values from linear regression models to predict the difference in outcome given the investigated time reallocations relative to the group-specific mean composition.

Results: Among 1053 eligible participants, we found an interaction between the physical behaviour composition and age. Age-stratified analyses (i.e.,
Conclusions: Less sedentary behaviour and more walking seems to be associated with lower CVD risk among older adults, while HIPA types are associated with lower risk among adults. Therefore, to reduce CVD risk, the modifying effect of age should be considered in future physical activity-promoting initiatives.
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http://dx.doi.org/10.1186/s12966-020-00985-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336624PMC
July 2020

Time-Based Data in Occupational Studies: The Whys, the Hows, and Some Remaining Challenges in Compositional Data Analysis (CoDA).

Ann Work Expo Health 2020 10;64(8):778-785

Centre for Musculoskeletal Research, Department of Occupational Health Sciences and Psychology, University of Gävle, Gävle, Sweden.

Data on the use of time in different exposures, behaviors, and work tasks are common in occupational research. Such data are most often expressed in hours, minutes, or percentage of work time. Thus, they are constrained or 'compositional', in that they add up to a finite sum (e.g. 8 h of work or 100% work time). Due to their properties, compositional data need to be processed and analyzed using specifically adapted methods. Compositional data analysis (CoDA) has become a particularly established framework to handle such data in various scientific fields such as nutritional epidemiology, geology, and chemistry, but has only recently gained attention in public and occupational health sciences. In this paper, we introduce the reader to CoDA by explaining why CoDA should be used when dealing with compositional time-use data, showing how to perform CoDA, including a worked example, and pointing at some remaining challenges in CoDA. The paper concludes by emphasizing that CoDA in occupational research is still in its infancy, and stresses the need for further development and experience in the use of CoDA for time-based occupational exposures. We hope that the paper will encourage researchers to adopt and apply CoDA in studies of work exposures and health.
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http://dx.doi.org/10.1093/annweh/wxaa056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544002PMC
October 2020

Light-intensity physical activity derived from count or activity types is differently associated with adiposity markers.

Scand J Med Sci Sports 2020 Oct 5;30(10):1966-1975. Epub 2020 Jul 5.

National Research Center for the Working Environment, Copenhagen, Denmark.

Aim: The aim of this study was to compare the association between count- and activity type-based definitions of light-intensity physical activity (LIPA) and adiposity markers.

Methods: A total of 516 Danish workers participated in 1-4 days of hip- and thigh-based accelerometer measurements. Three definitions of average daily time spent in LIPA were derived: LIPA (1) time spent between 100 and 2029 CPM, LIPA (2) time spent moving and slow walking, and LIPA (3) time spent moving, walking slow, and standing. Adiposity markers were body mass index (BMI), body fat percentage, and waist circumference. The cross-sectional association between the three LIPA definitions and adiposity markers was analyzed and interpreted using compositional regression models followed by reallocation of time between LIPA, moderate-to-vigorous physical activity (MVPA), and sedentary behavior (SB), respectively.

Results: The geometric means of daily time (min/day) spent in LIPA 1, LIPA 2, and LIPA 3 were 326, 102, and 274, respectively. We found the direction and strength of the association between the relative importance of daily time spent in LIPA and the adiposity markers to depend on the LIPA definition. For example, reallocating 30 minutes from MVPA to LIPA 1, LIPA 2 and LIPA 3 were associated with a 2.97 (95% CI: 0.68; 5.27), -0.71 (95% CI: -1.43; 0.02), and -0.45 (95% CI: -1.01; 0.11) difference in BMI, respectively.

Conclusion: Our findings highlight the need for caution when comparing results from studies using different definitions of LIPA.
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http://dx.doi.org/10.1111/sms.13743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7540429PMC
October 2020

Physical Work Demands of Childcare Workers in Denmark: Device-Based Measurements and Workplace Observations Among 199 Childcare Workers from 16 Day Nurseries.

Ann Work Expo Health 2020 07;64(6):586-595

Department of Musculoskeletal Disorders and Physical Workload, National Research Centre for the Working Environment, Lersø Parkallé 105, Copenhagen Ø, Denmark.

Objectives: Childcare workers in Denmark have high prevalence of musculoskeletal pain (MSP) and sickness absence, but the existing knowledge of their physical work demands is limited, hampering preventive initiatives. This study aimed to assess the physical work demands with accelerometers and workplace observations of childcare workers handling children age 0-3.

Methods: Data collection consisted of an electronic survey, anthropometric measurements, accelerometer measurements providing information of physical activity types and postures with Acti4 software from five consecutive workdays, as well as 4-h visual workplace observation per childcare worker from 16 Danish nurseries.

Results: In total, 199 childcare workers were enrolled in the study. A total of 4181 working hours of accelerometer measurements and 722 h of workplace observations were carried out. Accelerometer measurements showed that they spent about half of the working day (44.8%) in sedentary postures, and the rest standing (22.8%), moving (13.0%), walking (14.6%), running (0.1%), and climbing stairs (0.7%), with 4.1% in knee straining postures (kneeling and squatting) and 4.3% forward trunk inclination >60°. Workplace observations showed that they carried children 1.8% of the working hours.

Conclusions: Physical work demands of Danish childcare workers are characterized by about half of the workday being sedentary, and the remaining of the workday being quite evenly distributed between standing and dynamic activities, with low exposures to carrying children. Their exposure to forward bending of the trunk and knee straining postures could impose a risk for MSP and sickness absence, and preventive initiatives should be considered.
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http://dx.doi.org/10.1093/annweh/wxaa041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328469PMC
July 2020

Long overdue remarriage for better physical activity advice for all: bringing together the public health and occupational health agendas.

Br J Sports Med 2020 Dec 6;54(23):1377-1378. Epub 2020 May 6.

Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1136/bjsports-2019-101719DOI Listing
December 2020

Do organisational and ward-level factors explain the variance in multi-site musculoskeletal pain in eldercare workers? A multi-level cross-sectional study.

Int Arch Occup Environ Health 2020 Oct 18;93(7):891-898. Epub 2020 Apr 18.

National Research Centre for the Working Environment, Copenhagen, Denmark.

Purpose: Multi-site musculoskeletal pain (MSP) is highly prevalent among eldercare workers, leading to increased incidence of sickness absence and early retirement. Most research on MSP in eldercare workers has focused on individual-level factors reported by the employees, with limited focus at the organisation and ward level. To address this gap, the aim of this study was to investigate whether organisation and ward-level factors explain the variance in MSP among Danish eldercare workers.

Methods: A multi-level cross-sectional study was conducted among 20 Danish nursing homes, containing 126 wards, and 418 workers who participated in measurements of organisational factors, working environment factors, and MSP (classified as reporting pain in 2 or more body regions). Data were collected at the level of the organisation, ward, and individual. The proportion of variance in MSP explained by each level was estimated using variance components analysis. The association between factors at each level of the organisation and MSP was investigated using generalised linear mixed-effects regression.

Results: Sixty seven percent of participants reported having MSP. The organisational and ward-level factors explained 0% of the variance in MSP, while the individual-level factors explained 100% of the variance in MSP. Moreover, no factors at the organisational and ward levels showed statistically significant associations with MSP. Individual-level perceived physical exertion and quantitative demands had a statistically significant association with a higher prevalence of MSP.

Conclusions: The organisation and ward levels did not contribute to explaining any of the variance in MSP. All variance in MSP was explained at the individual level.
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http://dx.doi.org/10.1007/s00420-020-01540-7DOI Listing
October 2020

Towards a better understanding of the 'physical activity paradox': the need for a research agenda.

Br J Sports Med 2020 Sep 7;54(17):1055-1057. Epub 2020 Apr 7.

Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam, Netherlands.

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http://dx.doi.org/10.1136/bjsports-2019-101343DOI Listing
September 2020

Inter-Rater Reliability of Ergonomic Work Demands for Childcare Workers Using the Observation Instrument TRACK.

Int J Environ Res Public Health 2020 03 2;17(5). Epub 2020 Mar 2.

Musculoskeletal Disorders and Physical Work Demands, National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark.

The aim of this study is to evaluate the inter-rater reliability of a newly developed instrument-TRACK (observaTion woRk demAnds Childcare worK) for observations of ergonomic work demands in childcare work. Two trained raters conducted thirty hours of concurrent observation of fifteen childcare workers in three different day nurseries. Inter-rater reliability of ergonomic work demands was evaluated using Gwet's Agreement Coefficient (AC) and interpreted by the Landis and Koch benchmark scale. Twenty ergonomic work demand items were evaluated. Inter-rater reliability was 'almost perfect' for nine items (AC 0.81-1.00), 'substantial' for four items (AC 0.61-0.80), 'moderate' for four items (AC 0.41-0.60), 'fair' for two items (AC 0.21-0.40), and 'slight' (AC 0.00-0.20) for one item. No items had 'poor' (AC < 0.00) agreement. The instrument is reliable for assessing ergonomic work demands in childcare in real-life settings.
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http://dx.doi.org/10.3390/ijerph17051607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7084378PMC
March 2020

Detection of kneeling and squatting during work using wireless triaxial accelerometers.

Ergonomics 2020 May 5;63(5):607-617. Epub 2020 Mar 5.

National Research Centre for the Working Environment, Copenhagen, Denmark.

Occupational kneeling and squatting are well-documented risk factors for knee disorders. A method using 3 wireless accelerometers to detect and discriminate kneeling and squatting during work were developed based on data from a semi-standardised laboratory protocol. The method was tested for validity under free-living working conditions. The developed method showed high sensitivity (88-99%) and specificity (98-99%) for detection of kneeling and squatting during the semi-standardised laboratory conditions. During free-living working conditions, kneeling showed very high sensitivity (94%) and specificity (99%), while squatting results were non-conclusive due to limited duration of squatting during the free-living working conditions. This method shows great promise for long-term technical measurement of kneeling and squatting during normal working conditions using wireless accelerometers. The method opens up possibilities for using technical measurements to provide valid exposure assessments and intervention evaluations of kneeling and squatting, as well as increased feasibility for technical measurements in large cohort studies. Quantification of kneeling and squatting during work is important for prevention, but limited by either imprecise or costly methods. This study developed and validated an inexpensive wireless accelerometer-based measurement method that can be used by practitioners and researchers for long-term measurements of kneeling and squatting during free-living working conditions.
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http://dx.doi.org/10.1080/00140139.2020.1734668DOI Listing
May 2020

Can childcare work be designed to promote moderate and vigorous physical activity, cardiorespiratory fitness and health? Study protocol for the Goldilocks-childcare randomised controlled trial.

BMC Public Health 2020 Feb 17;20(1):237. Epub 2020 Feb 17.

National Research Centre for the Working Environment, Copenhagen, Denmark.

Background: Despite extensive efforts, issues like obesity and poor physical capacity remain challenges for a healthy work life in several occupations. The Goldilocks work principle offers a new approach, encouraging design of productive work to promote physical capacity and health. This paper presents the protocol for the Goldilocks-childcare study, a randomised controlled intervention trial aiming to evaluate the effectiveness of implementing the Goldilocks work principle in childcare. The primary aim of the intervention is to increase time in moderate to vigorous physical activity (MVPA) by having the childcare workers act as active role models for children in daily playful physical activities, and thereby improve cardiorespiratory fitness and health of the workers.

Methods: The study is a cluster-randomised trial with a usual-practice wait-list control group. The 10-week intervention consists of two phases. In the first, the childcare workers will participate in two participatory workshops aiming to a) develop playful physical activities ('Goldilocks-games') for children in which childcare workers participate as active role models at MVPA intensity, and b) develop action plans for implementation of the Goldilocks-games in daily work routines. In the second phase, childcare institutions will implement the Goldilocks-games. The primary outcome is working time spent in MVPA, and secondary outcomes are cardiorespiratory fitness, sleeping heart rate, perceived need for recovery, and productivity. Primary outcome and process evaluation will be based on direct measurements of physical activity and heart rate, determination of cardiorespiratory fitness, and questionnaires.

Discussion: If proven effective, the Goldilocks work principle has a large potential for promoting sustainable health and working lives of childcare workers.

Trial Registration: ISRCTN, ISRCTN15644757, Registered 25th December 2019.
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http://dx.doi.org/10.1186/s12889-020-8291-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026977PMC
February 2020

Musculoskeletal pain as a predictor for depression in the general working population of Denmark.

Scand J Public Health 2020 Jan 23:1403494819875337. Epub 2020 Jan 23.

National Research Centre for the Working Environment, Denmark.

This study examines the association between musculoskeletal complaints and subsequent use of antidepressants and/or psychiatric hospital treatment for depressive mood disorders in the Danish labour force. The study is based on two cohorts. The first cohort is the total labour force in 21 Danish municipalities (=693,860), where the risk of depression (psychiatric diagnosis or antidepressant treatment) during 2010-2015 was compared between individuals on long-term sickness absence due to musculoskeletal disorders (MSD) and non-sick-listed gainfully employed individuals. The second cohort is a random sample of the Danish labour force (=9248) who were followed during 2011-2015 to estimate the association between self-rated musculoskeletal pain and depression. All analyses were controlled for age, sex, calendar period and socio-economic status. Compared to non-sick-listed gainfully employed individuals, there was an increased risk of depression in individuals sick-listed with MSD, with rate ratios of 2.39 (99% confidence interval (CI) 2.22-2.58) for individuals with less severe MSD and 4.27 (99% CI 3.98-4.59) for individuals with more severe MSD. There was also an increased risk of depression associated with self-rated pain (yes vs. no), with a rate ratio of 2.17 (99% CI 1.69-2.78). The population attributable fraction of depression from musculoskeletal pain was 0.35 (99% CI 0.24-0.45).
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http://dx.doi.org/10.1177/1403494819875337DOI Listing
January 2020

The effect of training for a participatory ergonomic intervention on physical exertion and musculoskeletal pain among childcare workers (the TOY project) - a wait-list cluster-randomized controlled trial.

Scand J Work Environ Health 2020 07 16;46(4):429-436. Epub 2020 Jan 16.

National Research Centre for the Working Environment, Lersø Parkallé 105, 2100 Copenhagen Ø, Denmark.

Objective Many employees have high physical exertion at work and suffer from musculoskeletal pain (MSP) leading to sickness absence with large costs. Participatory ergonomics is a potentially effective intervention for reducing physical exertion, MSP and sickness absence. The main aim of this study was to investigate the effectiveness of a 20-week workplace participatory ergonomic intervention among childcare workers on physical exertion and MSP. Methods In a two-arm cluster-randomized trial, 190 workers were recruited from 16 childcare institutions and randomly assigned to either a 20-week participatory ergonomics intervention consisting of three training workshops or a control group receiving usual care. Primary outcomes were physical exertion during work, maximal pain intensity, number of pain regions, and pain-related work interference. Secondary outcomes were MSP-related sickness absence, need for recovery (NFR), employee involvement, and self-efficacy. We followed the intention-to-treat principle and adhered to the registered study protocol (ISRCTN10928313). Results After 20 weeks, half the workers noticed some positive changes in their work. However, there were no statistically discernible effects in physical exertion, maximum pain intensity, pain-related work interference, or number of pain regions. We found a significant reduction of MSP-related sickness absence in the intervention compared to the control group [-0.48 days per month (95% confidence interval (CI), -0.8- -0.1]. We found no significant effects in NRF or involvement of employees, but self-efficacy was reduced in the intervention compared to the control group [-0.2 (95% CI, -0.3- -0.0)]. Conclusion This 20-week training for a participatory ergonomic intervention in childcare workers did not show effects on physical exertion and MSP, but was both feasible and effective in reducing MSP-related sickness absence.
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http://dx.doi.org/10.5271/sjweh.3884DOI Listing
July 2020

Accelerometer-Measured Physical Activity at Work and Need for Recovery: A Compositional Analysis of Cross-sectional Data.

Ann Work Expo Health 2020 02;64(2):138-151

Musculoskeletal Disorders and Physical Workload, The National Research Centre for the Working Environment, Copenhagen, Denmark.

Objectives: Previous research has shown strong associations between occupational physical activity (OPA) and need for recovery (NFR). However this research has only utilized self-reported measures of OPA which may be biased. Thus, there is a need for investigating if the previously documented association between self-reported OPA and NFR can be found when using technical measures of OPA. There is also the need to investigate whether older workers are particularly susceptible to increased NFR, since age-related declines in physical capacity mean that it is likely these workers will have a higher NFR for a given physical activity. The aim of this study was to investigate the association between technically measured OPA and NFR, and whether this relationship is modified by age.

Methods: This study utilized data from the Danish Physical Activity Cohort with Objective Measurements cohort-comprising Danish workers (n = 840) from the cleaning, manufacturing, and transportation sectors. OPA was measured by accelerometers attached to the thigh and upper back for at least one work day and classified into four physical behaviour categories (sedentary, standing, light, or moderate/vigorous). NFR was measured using a shortened version of the Danish NFR scale. Analysis was conducted using linear regression and isotemporal substitution analyses for compositional data.

Results: The overall association between OPA and NFR was statistically significant in the unadjusted model (P < 0.001), but not when adjusted for age, sex, occupation, and shift work (P = 0.166). Isotemporal substitution showed small but significant reductions in NFR when increasing sedentary time relative to other behaviours (adjusted: ΔNFR = -0.010 [-0.019; -0.001]). There were no significant interactions between age and OPA (P = 0.409).

Conclusions: This study found significant associations between OPA and NFR, but the effect sizes were small. Reallocating 30 min to sedentary behaviours from other behaviours was associated with a reduced NFR, but the effect size may not be practically relevant. Moreover, no clear modifying effects of age were identified.
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http://dx.doi.org/10.1093/annweh/wxz095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031076PMC
February 2020