Journal of Physical Activity and Health, 2015, 12, 102  -108 http://dx.doi.org/10.1123/jpah.2013-0143 © 2015 Human Kinetics, Inc.

Official Journal of ISPAH www.JPAH-Journal.com ORIGINAL RESEARCH

Effect on Physical Fitness of a 10-Year Physical Activity Intervention in Primary Health Care Settings Priscila M. Nakamura, Camila B. Papini, Inaian P. Teixeira, Alberto Chiyoda, Eliete Luciano, Kelly Lynn Cordeira, and Eduardo Kokubun Background: Interventions in primary health care settings have been effective in increasing physical fitness. In 2001, the Programa de Exercício Físico em Unidades de Saúde (Physical Exercise in Health Primary Care Program—PEHPCP) was launched in Rio Claro City, Brazil. The intervention consisted of biweekly, 60-minute group sessions in all primary health care settings in the city. This study evaluated the effect of PEHPCP on physical fitness and on the aging process after a decade of ongoing implementation. Methods: There were 409 women (50 ± 26 y old) and 31 men (64 ± 10 y old) who were eligible for this study. Every 4 months, participants completed the American Alliance for Health, Physical Education, Recreation and Dance standardized tests. Results: Program participation was associated with a reduced effect, compared with baseline, of the natural decline of physical fitness caused by aging, as represented by changes in the following measures: coordination test time, –0.44 seconds; agility and dynamic balance test time; –1.81 seconds; aerobic capacity test time, 3.57 seconds; and muscle strength exercises, +0.60 repetitions. No significant effect on flexibility was found. Conclusions: The PEHPCP showed potential in improving muscle strength, coordination, aerobic capacity, and agility and dynamic balance in participants and in maintaining flexibility in participants. Keywords: elderly exercise, physical exercise, aging process, Brazil, prevention There is a growing concern in research related to the prevalence of noncommunicable diseases (NCDs), including type 2 diabetes, hypertension, and obesity. It is well accepted that physical activity reduces the risk of NCDs.1 In addition, it is well known that the aging process, defined as the natural decrease of human function resulting from an increase in age, reduces physical fitness (strength, endurance, agility, and flexibility) and can cause difficulties in performing daily life activities (ie, taking a shower and walking) in the elderly.2 Physical fitness is a measure often used to assess the capacity to perform daily activities independently.3 Thus, to reduce the risk of NCDs and improve normal functioning in the elderly, physical activity interventions that promote physical activity and physical fitness have been developed. Institutions such as the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the American College of Sports Medicine have been working together with universities worldwide to determine physical activity intervention and counseling models that can be more effective and efficient in promoting healthy lifestyles and increasing daily physical activity.4 In Brazil, there are important partnerships at universities and interventions promoting physical activity and healthy lifestyles, for example Curitibativa, Agita São Paulo, Academia da Cidade de Aracaju, Academia da Cidade em Recife, and Programa Ação e Saúde Floripa.5–9

Since 2001, the Programa de Exercício Físico em Unidades de Saúde (Physical Exercise in Health Primary Care Program— PEHPCP) has been implemented in a primary health care setting in Rio Claro, Brazil, to reduce the risk of NCDs and to improve health parameters of individuals already presenting such diseases. This intervention was developed through partnerships between Rio Claro Health Care System and the Núcleo de Atividade Física, Esporte e Saúde (Physical Activity, Sports, and Health Center) at São Paulo State University in Rio Claro City, Brazil. The PEHPCP intervention occurs twice per week in 60-minute sessions and includes aerobic, muscle strengthening, flexibility, coordination, balance, and agility exercises. Every 4 months, the physical fitness of all participants is evaluated. The goals of the intervention are to increase physical activity levels and to either improve or maintain a good level of health and quality of life in Rio Claro citizens.10 This study examines the effect of PEHPCP over a decade. The longitudinal design used in this study allows for the identification of causal associations above and beyond physical activity and fitness levels. Previous evaluation studies on Brazilian physical activity programs have been cross-sectional,11–15 leading to an issue with prevalence biases and rendering studies incapable of identifying whether changes in variables are causal.16 The aims of this study were (1) to assess physical fitness levels, as measured by coordination, agility and balance, aerobic capacity, muscle strength, and flexibility at various ages, and (2) to identify the effect of PEHPCP on decline of physical fitness caused by the aging process.

Nakamura ([email protected]), Papini, Teixeira, Chiyoda, Luciano, and Kokubun are with the Dept of Physical Education, Bioscience Institute, Physical Activity, Health and Sport Laboratory (NAFES), São Paulo University State, Rio Claro, Brazil. Cordeira is with the Epidemiology of Physical Activity Research Group, Federal University of Pelotas, Pelotas-RS, Brazil.

Methods

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Subjects Participants were recruited from primary health care settings in Rio Claro, Brazil, in 2001. At the start of the intervention, all participants

PA Intervention in Primary Health Care Settings   103

had at least 1 NCD and were in good enough physical condition to practice physical activity monitored by a physician. All participants in the program were evaluated for physical fitness approximately every 4 months. From 2002 to 2010, 803 participants completed at least 1 assessment. Of these participants, 409 women (50 ± 26 y old) and 31 men (64 ± 10 y old) completed at least 33% of all assessments over each 2-year period or completed at least 6 assessments over the 10-year period and were included in this study. Data were stored in a Microsoft Excel document. This database contained information on gender, age, assessment data, date of birth, assessment sequence, and physical fitness status. The local Research Ethics Committee approved this study, and participants were informed about the procedures and risks before giving written consent.

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Intervention Over the 10-year period, the PEHPCP intervention was composed of biweekly 60-minute sessions of aerobic, muscle strengthening, flexibility, coordination, balance, and agility exercises. Each session was split into 3 parts: (1) a warm-up exercise (10 min), which included exercises for major muscle groups; (2) the main part of the session (40 min), which included exercises to improve aerobic capacity (30 min) and muscle strengthening, flexibility, coordination, balance, and agility exercises (10 min); and (3) the final part (10 min), which included stretching exercises. This provided 60 minutes of moderate-intensity physical activity each week, or 40% of the physical activity necessary for participants to meet the WHO’s recommendation of 150 minutes per week of physical activity for good health.17 These sessions occurred in 4-week cycles according to physical training periodization, which splits up cardiorespiratory exercises (eg, walking and play activity) and neuromotor exercise (eg, muscle strength, agility, balance, flexibility, and coordination). To improve sustainability of the program, specific exercises performed within each category were left to the discretion of each primary health care setting. During the first month cycle, neuromotor exercise load volume decreased gradually from the beginning to the end of the month (25 to 15 min per session), whereas the cardiorespiratory exercise load volume increased gradually (20 to 30 min per session). The following month, neuromotor and cardiorespiratory exercises began with the same load and followed the opposite pattern compared with the previous month, thereby completing a sequence of increasing and decreasing of load volume. This load volume distribution periodization was used to effectively separate neuromotor and cardiorespiratory exercises while keeping the quantity of exercises proportional and not prioritizing any specific type of exercise.18 Trained physical education teachers, who participated in a weekly meeting at the University to discuss the participants’ problems, assessments, duration, load, and intensity of exercise, coordinated and ran all sessions.

Physical Fitness Assessment Participants were asked to complete a series of tests 3 times a year. At the baseline assessment, all participants were asked to provide demographic information, including date of birth, age, gender, address, telephone number, and full name. At this time, participants were familiarized with the correct way to complete each test, and a baseline evaluation was performed. At baseline and at each 4-month interval, physical fitness was evaluated using flexibility, arm muscle strength resistance, coordination, aerobic resistance,

agility and dynamic balance tests that were based on the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) protocol. For the flexibility test, barefoot participants sat on the ground, placed their heels in the center of the tape with their feet 30 cm apart. With legs outstretched and with the help of an assistant who held the knees of participants, the participant was asked to reach forward as far as they could with fingers outstretched and on top of each other and hold it for 2 seconds. The best result of 2 attempts was recorded. In the muscle strength resistance test, the participants attempted to do as many arm curls with their dominant arm as possible in 30 seconds. Participants were informed of the proper way to perform this exercise: (1) sit in the chair, hold the weight in the dominant hand using a suitcase grip (palm facing toward the body), and extend the arm in a vertical position down by the chair. (2) Brace the upper arm against the body so that only the lower arm is moving and curl the arm up through a full range of motion, gradually turning the palm up (flexion with supination). (3) As the arm is lowered through the full range of motion, gradually return to the starting position. (4) The arm must be fully bent and then fully straightened at the elbow to count as 1 repetition. In the coordination test, each participant sat at the front of a desk, putting his/her dominant hand on a can, with the thumb up and elbow flexed at an angle of 100° to 120°. When the evaluator signaled, the participant reversed the base supporting the can so that it was placed in the next position demarcated, and so on until all the cans were placed in the initial position at the next demarcation. The circuit was completed when the participant placed the can in the inverted position at the last mark. Each participant was timed while completing the circuit twice, uninterrupted. Before the 2 timed attempts, each participant was given 2 practice rounds. The lowest time of the 2 attempts was recorded. In the aerobic resistance test, participants walked as quickly as possible for 880 yards. The agility and dynamic balance test was conducted on 31-foot course marked by traffic cones. The participants started from a seated position, rose from chair, walked around a cone to the right, returned to a fully seated position in the chair. Then, they rose and walked around another cone the same distance away, but to the left of the chair, and returned to a fully seated position in the chair. One trial consisted of 2 complete circuits of the agility and dynamic balance course. This course was completed as quickly and safely as possible. The baseline and 4-month evaluations were given a number; for example, the baseline test was denoted test 1, the test at month 4 was denoted test 2, the test at month 8 was denoted test 3, and so forth. Undergraduate students who participated in a 1-week AAHPERD training collected all data.

Statistical Analysis Average scores from all physical fitness tests at baseline were calculated according to age group (20–29, 30–39, 40–49, 50–59, 60–69, and ≥ 70 y). The results were reported as means and standard deviations. Significant differences between age groups were determined. Significance level was set at P < .05. Normality of the data were ensured by the Kolmogorov-Smirnov test. A linear mixed model was used to assess changes in the mean from baseline (test 1) through the assessment sequence to test 20 (60 assessments) for all participants. The assessment sequence variable was defined as covariate, whereas age group (20–29, 30–39, 40–49, 50–59, 60–69, and ≥ 70 y) and gender (female and male)

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were defined as fixed factors. This linear mixed model, an extension of the general linear model, was used because it does not require observations to be independent with constant variance; repeated measures can be analyzed; and it allows for a large number of covariate structures, the inclusion of cases with incomplete data, and for data to be collected over time.19 The effect of PEHPCP on the aging process as measured by the physical fitness variable was also determined through the linear mixed model. The baseline assessment was used as covariate, and age groups were considered fixed factors to determine the effect of the aging process on physical fitness variables. By comparing the effect of the aging process on physical fitness variables and changes in physical fitness of participants in the PEHPCP program, the effect of the PEHPCP program on physical fitness was determined. Significance level was set at P < .05. All data were analyzed using SPSS (version 17.0).

Results The final sample consisted of 440 participants who had more than 2 assessments during each 2-year period and who performed 4 ± 2.6 fitness evaluations. This resulted in a sample of 409 women (50 ± 26 y old; weight, 46.3 ± 1.54 kg; height, 1.54 ± 0.6 m) and 31 men (64 ± 10 y old; weight: 78.5 ± 15.7 kg; height: 1.67 ± 0.9 m). The participants spent 18 ± 8.6 months in the program. Figure 1 shows the timeline of assessment and the number of participants according to each year. All physical fitness variables showed that the oldest age group (≥ 70 y) had significantly poorer physical activity outcomes at baseline than the younger age groups, except in aerobic capacity and flexibility compared with 20- to 29-year-olds. Aerobic capacity and flexibility scores were not significantly different among

age groups below 60 years of age. However, the 3 youngest age groups had significantly higher levels of coordination, agility and dynamic balance, and muscle strength than groups of individuals ≥ 50 years of age (Table 1). The linear mixed model showed that the two genders were significantly different (P < .05) in aerobic capacity, flexibility, and agility. Better aerobic capacity and agility were found in men (474.5 ± 17.4 s and 17.6 ± 0.6 s, respectively) than in women (538.1 ± 8.6 s and, 20.72 ± 0.36 s, respectively), P = .00. However, women were more flexible than men (59.4 ± 0.8 cm and 52.1 ± 1.5 cm, respectively) P = .00. The PEHPCP helped reduce the deterioration in coordination time (by –0.44 s), agility and dynamic balance time (by –1.81 s), aerobic capacity [by –3.57 s; 95% confidence interval (CI): 1.5–8.7], and muscle coordination repetitions (by +0.60 repetitions). The aging process was responsible for significant decreases in coordination time (1.09 s; 95% CI: 0.29–1.89), agility and dynamic balance time (1.48 s/y; 95% CI: 1.05–1.92), aerobic capacity (26.35 s/y; 95% CI: 4.5–41.04), and muscle strength (1.20 repetitions per year; 95% CI: –1.80 to –0.61). For coordination, there was a significant average decline of only 0.20 seconds per assessment or 0.69 seconds per year (95% CI: –0.9 to –0.5; Figure 2A); and for agility and dynamic balance, there was a significant decline of only 0.11 seconds per assessment or 0.33 seconds per year (95% CI: –0.48 to –0.18; Figure 2B). For aerobic capacity, there was a decline of 22.78 seconds per year (95% CI: 4.5 to 41.04; Figure 2C); and for muscle strength, there was a decline of 0.60 repetitions per year (95% CI: 0.42—0.78; Figure 2D). There were no significant findings for flexibility. There was a 0.87 cm (95% CI: 0.39–1.35) improvement for each assessment, but significance was not maintained throughout the year for the 0.83 cm/year improvement (95% CI: –2.30 to 0.67).

Figure 1 — Timeline of assessment and number of participants in each assessment.

Table 1  Average Scores on Physical Activity Tests by Age Group and Significant Differences in Average Scores between Age Groups. Mean (SD) Age group (y) 20–29 30–39 40–49 50–59 60–69

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≥ 70

Aerobic capacity (s)

Flexibility (cm)

Coordination (s)

Agility and dynamic balance (s)

Muscle strength (repetitions)

458.0 (43.0) 489.5 (25.4)*a 473.4 (12.5)*ab 494.5 (10.3)*ab 527.8 (9.00)*a 567.6 (12.0)

52.7 (4.1) 61.2 (2.3)*abd 55.7 (1.1)*ae 56.9 (0.9)*a 55.6 (0.8)*ae 52.4 (1.0)

9.20 (1.6)*abe 13.4 (0.9)*cd 9.80 (0.4)*abc 11.5 (0.3)*ab 12.5 (0.3)*a 14.1 (0.4)

16.0 (1.3)*abc 17.0 (0.7)*abc 17.2 (0.3)*abc 19.2 (0.2)*ab 20.3 (0.2)*a 23.6 (0.3)

31.2 (1.6)*abc 28.7 (0.9)*ab 28.3 (0.4)*abc 27.0 (0.3)*ab 25.9 (0.3)*a 24.8 (0.4)

* Significantly different at P < .05. a Significantly different from the ≥ 70 years age group.· b Significantly different from the 60–69 years age group. c Significantly different from the 50–59 years age group. d Significantly different from the 40–49 years age group. e

Significantly different from the 30–39 years age group.

Figure 2 — Values and trends according to assessment sequences for (A) coordination, (B) agility and dynamic balance, (C) aerobic capacity, (D) muscle strength, and (E) flexibility. 105

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Discussion The aim of this study was evaluate 10-year follow up for PEHPCP on the physical fitness of participants. Participants in the program showed significantly better coordination, agility and dynamic balance, aerobic capacity, and muscle strength each year. The PEHPCP program was associated with a hindering effect on the natural decline in physical fitness as a result of aging as measured by coordination, agility and dynamic balance, aerobic capacity, and muscle strength. This study supplies over a decade of longitudinal data to the literature and provides substantial information for interventions in low- and middle-income countries for the elderly. Currently, of 5508 published physical activity intervention studies, only 25 worldwide20 and only 3 in Brazil21–23 have been implemented for more than 1 year and have evaluated all physical fitness variables for adults or elderly people. Thus, this study contributes knowledge on the effect of age-related decline on physical fitness levels and provides a potential long-term strategy to impede the effect of the aging process on physical fitness. The gender differences in aerobic capacity, flexibility, and agility and dynamic balance results may be related to testosterone and estrogen levels. Aerobic capacity and agility in men (468.73 ± 18.37 s and 16.98 ± 0.72 s, respectively) showed better results than in women (533.21 ± 10.29 s and 20.03 ± 0.43 s, respectively), although these results may be limited by the lower number of men participating in the study. Although not assessed in this study, the literature suggests that this may be related to the higher levels of testosterone and hemoglobin in men (14–18 g/100 mL of blood) compared with women (12–16 g/100 mL of blood),24 which have been associated with a higher muscle mass concentration and therefore better agility results.3 Regarding flexibility, women (60.85 ± 0.98 cm) were 13.5% more flexible than men (53.61 ± 1.66 cm). According to Araújo,25 the difference in flexibility between men and women can range from 10% in puberty to 40% in older age (60+ years). Furthermore, according to Weineck,26 women have a larger torso than men (38% and 36% of total body size, respectively), allowing women to achieve a greater range of motion. Future studies that examine the relationship of estrogen and testosterone levels on physical fitness are needed. The significantly poorer physical fitness outcomes among the older age groups compared with younger age groups may be related to the natural aging process. The oldest participants (≥ 70 y) scored significantly lower than younger age groups, with the exception of aerobic capacity and flexibility compared with 20- to 29-year-olds. For coordination, agility and dynamic balance, and muscle strength, most participants < 60 years old scored significantly higher than those ≥ 60 years old. In this study, the natural yearly loss of physical fitness was 1.09 seconds in coordination time, 1.48 seconds in agility and dynamic balance time, 22.78 seconds in aerobic capacity, 1.20 repetitions for arm muscle strength, and 0.83 cm for flexibility. Similar findings were reported in other studies for aerobic capacity,27–30 muscle strength,28–31 flexibility,3,28,32 coordination,29,33 and agility and dynamic balance.29,34,35 Participation in the PEHPCP has the potential to hinder the effect of aging on coordination, agility and dynamic balance, muscle strength, and aerobic capacity. This aligns with the Paterson et al36 physical activity program, which was effective in reducing the effect of the aging process on physical activity related to agility, muscle strength, aerobic capacity, and other physical fitness variables. For aerobic capacity, Pauli et al21 showed maintenance of increased aerobic capacity after 12 years of supervised physical training program on physical fitness in the elderly. Similar to Bird et al,37 who found

no association between the flexibility of 32 elderly adults (mean age, 66.9 y) and a 32-week training program, PEHPCP did not have a significant influence on the age-related decline in flexibility. Related to agility, dynamic balance, and strength, the reverse effect on the aging process may be specifically related to the effect of physical activity on mobility performance. As in the current study, Visser et al38 reported a longitudinal study in Amsterdam measuring mobility in older men and women using a similar protocol to that used this study. Although the results showed that 45.6% of the participants decreased mobility performance over the 3-year period, those who either engaged in at least 1.3 hours per day of physical activity or participated in sports showed smaller decreases in mobility than those who did not. Furthermore, other studies show that low- and moderate-intensity muscle strength training led to modest increases in strength.11,21 This aligns with the finding that agility, balance, and strength training can help the elderly to prevent agedependent impairments and specially the fall risks.39,40 According to these findings, programs developed for the elderly population should focus on physical activity exercises related to agility and dynamic balance and strength to improve physical fitness and prevent falls. The literature suggests that the hindrance of the negative effect of aging on coordination may be related to the known positive effect of physical activity on eye-hand coordination.41–43 A study by Pei et al39 showed that elderly participants who had been practicing Tai Chi Chuan regularly for more than 3 years (n = 42) had better eye-hand coordination than the control group (n = 20). The Tai Chi Chuan group showed significantly better results in decreasing displacement (P = .003), movement time (P = .002), pause time (P < .001) and number of submovements (P = .001) than the control group. Thus, programs that promote physical activity, specifically coordination exercises, may be able to delay the loss of eye-hand coordination caused by the aging process. This study has several strengths and limitations. The major strengths of the study were the duration of the study, including 60 assessments over a 10-year time period, and the reach of the intervention, in all Primary Health Care Settings in Rio Claro (Brazil). The results of the current study, however, did not assess adverse events among participants or daily physical activity done outside of the health care setting, which may present an underestimation of the physical fitness level of participants. Another major limitation of this study was the small sample size of men (n = 31; 7.04%). According to da Silva et al44 the demand for services in primary health care setting is lower among men (12%) than among women (17%). Because all participants of the PEHPCP were recruited through primary health care settings, this bias may have translated to participation in PEHPCP. Thus, this study may provide more significant information for improving physical fitness of elderly woman than elderly men. Future programming needs to focus on recruitment of men to primary health care settings and associated programming.

Conclusion The primary care-based PEHPCP program showed potential in improving muscle strength, coordination, aerobic capacity, and agility and dynamic balance in participants and in maintaining flexibility in participants over a decade. Acknowledgments We kindly thank the following funding organizations: Fundo de Desenvolvimento da UNESP (Fundunesp), Conselho Nacional de Desenvolvimento

PA Intervention in Primary Health Care Settings   107 Científico e Técnológico (CNPq), Fundo Nacional da Saúde através da Secretaria de Vigilância e Saúde e Fundação Municipal de Saúde de Rio Claro, Pro Reitoria de Extensão Universitária (Proex). Furthermore, we appreciate the support from Núcleo de Atividade Física Esporte e Saúde (UNESP-Rio Claro).

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Effect on physical fitness of a 10-year physical activity intervention in primary health care settings.

Interventions in primary health care settings have been effective in increasing physical fitness. In 2001, the Programa de Exercício Físico em Unidade...
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