Basics of qualitative research: Grounded theory procedures and techniques

The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

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Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise

OBJECTIVE
To identify factors in childhood which might influence the development of obesity in adulthood.


BACKGROUND
The prevalence of obesity is increasing in the UK and other developed countries, in adults and children. The adverse health consequences of adult obesity are well documented, but are less certain for childhood obesity. An association between fatness in adolescence and undesirable socio-economic consequences, such as lower educational attainment and income, has been observed, particularly for women. Childhood factors implicated in the development of adult obesity therefore have far-reaching implications for costs to the health-services and economy.


SEARCH STRATEGY
In order to identify relevant studies, electronic databases--Medline, Embase, CAB abstracts, Psyclit and Sport Discus-were searched from the start date of the database to Spring 1998. The general search structure for electronic databases was (childhood or synonyms) AND (fatness or synonyms) AND (longitudinal or synonyms). Further studies were identified by citations in retrieved papers and by consultation with experts.


INCLUSION CRITERIA
Longitudinal observational studies of healthy children which included measurement of a risk factor in childhood (<18 y), and outcome measure at least 1 y later. Any measure of fatness, leanness or change in fatness or leanness was accepted. Measures of fat distribution were not included. Only studies with participants from an industrialized country were considered, and those concerning minority or special groups, e.g. Pima Indians or children born preterm, were excluded.


FINDINGS
Risk factors for obesity included parental fatness, social factors, birth weight, timing or rate of maturation, physical activity, dietary factors and other behavioural or psychological factors. Offspring of obese parent(s) were consistently seen to be at increased risk of fatness, although few studies have looked at this relationship over longer periods of childhood and into adulthood. The relative contributions of genes and inherited lifestyle factors to the parent-child fatness association remain largely unknown. No clear relationship is reported between socio-economic status (SES) in early life and childhood fatness. However, a strong consistent relationship is observed between low SES in early life and increased fatness in adulthood. Studies investigating SES were generally large but very few considered confounding by parental fatness. Women who change social class (social mobility) show the prevalence of obesity of the class they join, an association which is not present in men. The influence of other social factors such as family size, number of parents at home and childcare have been little researched. There is good evidence from large and reasonably long-term studies for an apparently clear relationship for increased fatness with higher birth weight, but in studies which attempted to address potential confounding by gestational age, parental fatness, or social group, the relationship was less consistent. The relationship between earlier maturation and greater subsequent fatness was investigated in predominantly smaller, but also a few large studies. Again, this relationship appeared to be consistent, but in general, the studies had not investigated whether there was confounding by other factors, including parental fatness, SES, earlier fatness in childhood, or dietary or activity behaviours. Studies investigating the role of diet or activity were generally small, and included diverse methods of risk factor measurement. There was almost no evidence for an influence of activity in infancy on later fatness, and inconsistent but suggestive evidence for a protective effect of activity in childhood on later fatness. No clear evidence for an effect of infant feeding on later fatness emerged, but follow-up to adulthood was rare, with only one study measuring fatness after 7y. Studies investigating diet in childhood were limited and inconc

Childhood predictors of adult obesity: a systematic review.

BACKGROUND\nObesity in childhood is associated with increased cardiovascular risk. It is uncertain whether this risk is attenuated in persons who are overweight or obese as children but not obese as adults.\n\n\nMETHODS\nWe analyzed data from four prospective cohort studies that measured childhood and adult body-mass index (BMI, the weight in kilograms divided by the square of the height in meters). The mean length of follow-up was 23 years. To define high adiposity status, international age-specific and sex-specific BMI cutoff points for overweight and obesity were used for children, and a BMI cutoff point of 30 was used for adults.\n\n\nRESULTS\nData were available for 6328 subjects. Subjects with consistently high adiposity status from childhood to adulthood, as compared with persons who had a normal BMI as children and were nonobese as adults, had an increased risk of type 2 diabetes (relative risk, 5.4; 95% confidence interval [CI], 3.4 to 8.5), hypertension (relative risk, 2.7; 95% CI, 2.2 to 3.3), elevated low-density lipoprotein cholesterol levels (relative risk, 1.8; 95% CI, 1.4 to 2.3), reduced high-density lipoprotein cholesterol levels (relative risk, 2.1; 95% CI, 1.8 to 2.5), elevated triglyceride levels (relative risk, 3.0; 95% CI, 2.4 to 3.8), and carotid-artery atherosclerosis (increased intima-media thickness of the carotid artery) (relative risk, 1.7; 95% CI, 1.4 to 2.2) (P ≤ 0.002 for all comparisons). Persons who were overweight or obese during childhood but were nonobese as adults had risks of the outcomes that were similar to those of persons who had a normal BMI consistently from childhood to adulthood (P>0.20 for all comparisons).\n\n\nCONCLUSIONS\nOverweight or obese children who were obese as adults had increased risks of type 2 diabetes, hypertension, dyslipidemia, and carotid-artery atherosclerosis. The risks of these outcomes among overweight or obese children who became nonobese by adulthood were similar to those among persons who were never obese. (Funded by the Academy of Finland and others.).

Childhood Adiposity, Adult Adiposity, and Cardiovascular Risk Factors EDITORIAL COMMENT

The Economic Approach To Human Behavior

Proprioceptive neuromuscular facilitation (PNF) stretching techniques are commonly used in the athletic and clinical environments to enhance both active and passive range of motion (ROM) with a view to optimising motor performance and rehabilitation. PNF stretching is positioned in the literature as the most effective stretching technique when the aim is to increase ROM, particularly in respect to short-term changes in ROM. With due consideration of the heterogeneity across the applied PNF stretching research, a summary of the findings suggests that an 'active' PNF stretching technique achieves the greatest gains in ROM, e.g. utilising a shortening contraction of the opposing muscle to place the target muscle on stretch, followed by a static contraction of the target muscle. The inclusion of a shortening contraction of the opposing muscle appears to have the greatest impact on enhancing ROM. When including a static contraction of the target muscle, this needs to be held for approximately 3 seconds at no more than 20% of a maximum voluntary contraction. The greatest changes in ROM generally occur after the first repetition and in order to achieve more lasting changes in ROM, PNF stretching needs to be performed once or twice per week. The superior changes in ROM that PNF stretching often produces compared with other stretching techniques has traditionally been attributed to autogenic and/or reciprocal inhibition, although the literature does not support this hypothesis. Instead, and in the absence of a biomechanical explanation, the contemporary view proposes that PNF stretching influences the point at which stretch is perceived or tolerated. The mechanism(s) underpinning the change in stretch perception or tolerance are not known, although pain modulation has been suggested.

Proprioceptive neuromuscular facilitation stretching : mechanisms and clinical implications.

Objective

To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery.



Methods

Seven semi-structured focus groups were conducted. A broad interview schedule guided the discussions which were audio-recorded and transcribed verbatim. Data were analysed thematically.



Results

Twenty-six women and 15 men with a mean age of 54 years (range 24–72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post-surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery.



Conclusion

Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post-surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/hex.12423

What are the support experiences and needs of patients who have received bariatric surgery

Psychosocial health status is an important and dynamic outcome for bariatric/metabolic surgery patients, as acknowledged in recent international standardised outcomes reporting guidelines. Multi-attribute utility-instruments (MAUIs) capture and assess an individual’s health-related quality-of-life (HRQoL) within a single valuation, their utility. Neither MAUIs nor utilities were discussed in the guidelines. Many MAUIs (e.g. EQ-5D) target physical health. Not so the AQoL-8D. Our objective was to explore agreement between, and suitability of, the EQ-5D-5L and AQoL-8D for assessing health state utility, and to determine whether either MAUI could be preferentially recommended for metabolic/bariatric surgery patients. Utilities for post-surgical private-sector patients (n = 33) were assessed using both instruments and summary statistics expressed as mean [standard deviation (SD)] and median [interquartile range (IQR)]. Interchangeability of the MAUIs was assessed with Bland–Altman analysis. Discriminatory attributes were investigated through floor/ceiling effects and dimension-to-dimension comparisons. Spearman’s rank measured associations between the instruments’ utility values and with the body mass index (BMI). Mean (SD) EQ-5D-5L utility value was 0.84 (0.15) and median 0.84 (IQR 0.75–1.00). Mean (SD) AQoL-8D utility value was 0.76 (0.17) and median 0.81 (IQR 0.63–0.88). Spearman’s rank was r = 0.68; (p < 0.001); however, Bland–Altman analysis revealed fundamental differences. Neither instrument gave rise to floor effects. A ceiling effect was observed with the EQ-5D-5L, with 36 % of participants obtaining a utility value of 1.00 (perfect health). These same participants obtained a mean utility of 0.87 on the AQoL-8D, primarily driven by the mental-super-dimension score (0.52). The AQoL-8D preferentially captures psychosocial aspects of metabolic/bariatric surgery patients’ HRQoL. We recommend the AQoL-8D as a preferred MAUI for these patients given their complex physical/psychosocial needs.

A Head-to-Head Comparison of the EQ-5D-5L and AQoL-8D Multi-Attribute Utility Instruments in Patients Who Have Previously Undergone Bariatric Surgery

Purpose:“parkrun” is a free and increasingly popular weekly 5-km walk/run international community event, representing a novel setting for physical activity (PA) promotion. However, little is known about who participates or why. This study aimed to identify sociodemographic, health, behavioral, individual, social, and environmental factors associated with higher levels of participation.Design:Cross-sectional.Setting:Tasmania, Australia; June 2016.Participants:Three hundred seventy two adult parkrun participants.Measures:Online survey measuring sociodemographic, health, individual, social and environmental factors, parkrun participation, and PA.Analysis:Descriptive statistics, zero-truncated Poisson regression models.Results:Respondents (n = 371) were more commonly women (58%), aged 35 to 53 years (54%), and occasional or nonwalkers/runners (53%) at registration. A total of 44% had overweight/obesity. Half had non-adult children, most spoke English at home, and 7% reported PA-limiting illness/injury/disabil...

https://journals.sagepub.com/doi/pdf/10.1177/0890117118770106

Exploring the Health-Promoting Potential of the “parkrun” Phenomenon: What Factors are Associated With Higher Levels of Participation?:

Issue addressed:
parkrun is a free, weekly, timed, international mass community 5‐km walk/run event. Unlike other paid events, parkrun attracts populations harder to engage in physical activity (PA) (eg, women, those with overweight/obesity or illness/injury/disability). This exploratory qualitative study investigated the individual, social and environmental factors associated with parkrun's broad appeal in Australia. Methods:
Tasmanian parkrunners who completed a quantitative survey (2016) were purposively recruited for a 2017 interview study. Semistructured interviews focused on reasons for parkrun participation. Data saturation was achieved by the tenth interview. Data were analysed thematically. Results:
Four themes emerged: (a) participation facilitators and barriers; (b) PA gain and broader community benefit; (c) social connections/networks; and (d) organisational issues. Appealing characteristics of parkrun included strong social support, performance gain opportunities, socialising, inclusivity (eg, all ages/abilities), sense of community, positive atmosphere and accessibility (eg, no cost and convenience). Some participants reported that parkrun had stimulated gains in their total PA (not always limited to walking/running) and that parkrun may also result in other community benefits (eg, supporting local businesses, fee‐based running club/event participation and "parkrun tourism"). Most participants first attended parkrun because of encouragement from their social networks, and participants subsequently encouraged others to attend. Participants found parkrun events well organised, but identified some potential threats (eg, local politics). Conclusions:
Social factors appeared critical in driving initial and ongoing parkrun participation. parkrun may lead to wider community benefits beyond that gained through increased individual PA. These findings highlight the "success factors" driving parkrun participation and provide insights for other community‐based PA promotion activities.

Melanie J. Sharman

Papers

Proprioceptive neuromuscular facilitation stretching : mechanisms and clinical implications.

What are the support experiences and needs of patients who have received bariatric surgery

A Head-to-Head Comparison of the EQ-5D-5L and AQoL-8D Multi-Attribute Utility Instruments in Patients Who Have Previously Undergone Bariatric Surgery

Exploring the Health-Promoting Potential of the “parkrun” Phenomenon: What Factors are Associated With Higher Levels of Participation?:

Health and broader community benefit of parkrun-An exploratory qualitative study.