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Hanne Hoaas,1,2 Paolo Zanaboni,1 Audhild Hjalmarsen,3,4 Bente Morseth,5 Birthe Dinesen,6 Angela T Burge,7–9 Narelle S Cox,7,9 Anne E Holland7–91Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway; 2Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway; 3Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway; 4Department of Pulmonary Medicine, University Hospital of North Norway, Tromsø, Norway; 5School of Sport Sciences, UiT The Arctic University of Norway, Tromsø, Norway; 6Laboratory of Welfare Technologies – Telehealth & Telerehabilitation, SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark; 7Discipline of Physiotherapy, La Trobe University, Melbourne, Australia; 8Department of Physiotherapy, Alfred Health, Melbourne, Australia; 9Institute for Breathing and Sleep, Melbourne, AustraliaPurpose: Seasons and weather conditions might influence participation in physical activity and contribute to differences between countries. This study aimed at investigating whether there were differences in physical activity levels between Norwegian, Danish and Australian people with chronic obstructive pulmonary disease (COPD), and establishing if any variations in physical activity were attributable to seasons.Patients and methods: A cross-sectional study where study subjects were people with COPD who participated in two separate clinical trials: the iTrain study (Norway, Denmark, and Australia) and the HomeBase study (Australia). Physical activity was objectively assessed with an activity monitor; variables were total energy expenditure, number of daily steps, awake sedentary time, light, and moderate-to-vigorous intensity physical activity. Differences in physical activity between countries and seasons were compared, with adjustment for disease severity.Results: In total, 168 participants were included from Norway (N=38), Denmark (N=36) and Australia (N=94). After controlling for disease severity, time spent in awake sedentary time was greater in Danish participants compared to the other countries (median 784 minutes/day [660–952] vs 775 minutes/day [626–877] for Norwegians vs 703 minutes/day [613–802] for Australians, P=0.013), whilst time spent in moderate to vigorous physical activity was lower (median 21 minutes/day [4–73] vs 30 minutes/day [7–93] for Norwegians vs 48 minutes/day [19–98] for Australians, P=0.024). Participants walked more during summer (median 3502 [1253–5407] steps/day) than in spring (median 2698 [1613–5207] steps/day), winter (median 2373 [1145–4206] steps/day) and autumn (median 1603 [738–4040] steps/day), regardless of geography. The median difference between summer and other seasons exceeded the minimal clinically important difference of 600 steps/day. However, the differences were not statistically significant (P=0.101).Conclusion: After controlling for disease severity, Danish participants spent more time in an awake sedentary state and less time in moderate to vigorous physical activity than their counterparts in Norway and Australia. People with COPD increased their physical activity in summer compared to other seasons. Weather conditions and seasonal variations may influence outcomes in clinical trials and health registries measuring physical activity over time, irrespective of the interventions delivered, and should be taken into account when interpreting results.Keywords: chronic obstructive pulmonary disease, activity monitoring, population comparison, seasons, weather

Abstract Background Vertebral fractures, the most common type of osteoporotic fractures, are associated with increased risk of subsequent fracture, morbidity, and mortality. The aim of this study was to examine the contribution of important risk factors to the variability in vertebral fracture risk. Methods Vertebral fracture was ascertained by VFA method (DXA, GE Lunar Prodigy) in 2887 men and women, aged between 38 and 87 years, in the population-based Tromsø Study 2007/2008. Bone mineral density (BMD; g/cm2) at the hip was measured by DXA. Lifestyle information was collected by questionnaires. Multivariable logistic regression model, with anthropometric and lifestyle factors included, was used to assess the association between each or combined risk factors and vertebral fracture risk. Population attributable risk was estimated for combined risk factors in the final multivariable model. Results In both sexes, age (odds ratio [OR] per 5 year increase: 1.32; 95% CI 1.19-1.45 in women and 1.21; 95% CI 1.10-1.33 in men) and BMD (OR per SD decrease: 1.60; 95% CI 1.34-1.90 in women and1.40; 95% CI 1.18-1.67 in men) were independent risk factors for vertebral fracture. At BMD levels higher than 0.85 g/cm2, men had a greater risk of fracture than women (OR 1.52; 95% CI 1.14-2.04), after adjusting for age. In women and men, respectively, approximately 46% and 33% of vertebral fracture risk was attributable to advancing age (more than 70 years) and low BMD (less than 0.85 g/cm2), with the latter having a greater effect than the former. Conclusions These data confirm that age and BMD are major risk factors for vertebral fracture risk. However, in both sexes the two factors accounted for less than half of fracture risk. The identification of individuals with vertebral fracture is still a challenge.

Abstract Background Osteoporotic vertebral fractures are, as the hip fractures, associated with increased morbidity and mortality. Norway has one of the highest reported incidences of hip fractures in the world. Because of methodological challenges, vertebral fractures are not extensively studied. The aim of this population based study was to describe, for the first time, the age- and sex specific occurrence of osteoporotic vertebral fractures in Norway. Methods Data was collected in the Tromso Study, 2007/8 survey. By the use of dual x-ray absorptiometry (GE Lunar Prodigy) vertebral fracture assessments were performed in 2887 women and men aged from 38 to 87 years, in addition to measurements of bone mineral density at the femoral sites. Information on lifestyle was collected through questionnaires. Comparisons between fractures and non-fractures were done sex stratified, by univariate analyses, adjusting for age when relevant. Results The prevalence of vertebral fractures varied from about 3% in the age group below 60 to about 19% in the 70+ group in women, and from 7.5% to about 20% in men, with an overall prevalence of 11.8% in women and 13.8% in men (p = 0.07). Among those with fractures, only one fracture was the most common; two and more fractures were present in approximately 30% of the cases. Fractures were seen from the fourth lumbar to the fifth thoracic vertebrae, most common between first lumbar and sixth thoracic vertebrae. The most common type of fracture was the wedge type in both sexes. Bone mineral density at the hip differed significantly according to type of fracture, being highest in those with wedge fractures and lowest in those with compression fractures. Conclusions The prevalence of vertebral fractures increased by age in women and men, but the overall prevalence was lower than expected, considering the high prevalence of hip and forearm fractures in Norway. In both sexes, the wedge type was the fracture type most frequently observed and most common in the thoracic region.

Purpose: This study aimed to investigate the effect of the MC and endogenous sex hormone concentrations on performance-determining variables in three distinct MC phases in endurance-trained females., Methods: Twenty-one eumenorrheic trained/highly trained endurance athletes completed a standardized test battery during the early follicular phase (EFP), ovulatory phase (OP), and midluteal phase (MLP) for either one ( n = 7) or two test cycles ( n = 14). MC phases were determined using calendar-based counting, urinary ovulation testing, and verified with serum hormone analysis. MCs were retrospectively classified as eumenorrheic or disturbed. Disturbed MCs were excluded from analysis. The test battery consisted of 4-6 × 5-min submaximal stages with stepwise speed increases, a 30-s all-out double-poling ski ergometer test, and a maximal incremental treadmill running test., Results: At a group level, there was no effect of MC phase or the serum concentrations of estrogen and progesterone on peak oxygen uptake (V̇O 2peak ), oxygen uptake at 4 mmol·L -1 blood lactate concentration, time to exhaustion, running economy, or mean 30-s power output (MPO 30s ). Serum testosterone concentration was positively associated with MPO 30s ( P = 0.016). Changes in V̇O 2peak from EFP to MLP were inconsistent between individuals and across cycles., Conclusions: None of the measured performance-determining variables were influenced by MC phase or serum estrogen or progesterone concentrations. Although some individual patterns could be observed, there was no indication that any single MC phase is consistently associated with improved or impaired V̇O 2peak on a group level., (Copyright © 2024 by the American College of Sports Medicine.)

Abstract: Knowledge is needed regarding mechanisms acting between physical activity (PA) and chronic pain. We investigated whether cold pain tolerance mediates an effect of leisure-time physical activity on the risk of chronic pain 7 to 8 years later using consecutive surveys of the population-based Tromsø Study. We included participants with information on baseline leisure-time PA (LTPA) and the level of cold pressor-assessed cold pain tolerance, who reported chronic pain status at follow-up as any of the following: chronic pain for ≥3 months, widespread chronic pain, moderate-to-severe chronic pain, or widespread moderate-to-severe chronic pain. We included 6834 participants (52% women; mean age, 55 years) in counterfactual mediation analyses. Prevalence decreased with severity, for example, 60% for chronic pain vs 5% for widespread moderate-to-severe chronic pain. People with one level higher LTPA rating (light to moderate or moderate to vigorous) at baseline had lower relative risk (RR) of 4 chronic pain states 7 to 8 years later. Total RR effect of a 1-level LTPA increase was 0.95 (0.91-1.00), that is, -5% decreased risk. Total effect RR for widespread chronic pain was 0.84 (0.73-0.97). Indirect effect for moderate-to-severe chronic pain was statistically significant at RR 0.993 (0.988-0.999); total effect RR was 0.91 (0.83-0.98). Statistically significantly mediated RR for widespread moderate-to-severe chronic pain was 0.988 (0.977-0.999); total effect RR was 0.77 (0.64-0.94). This shows small mediation of the effect of LTPA through pain tolerance on 2 moderate-to-severe chronic pain types. This suggests pain tolerance to be one possible mechanism through which PA modifies the risk of moderate-to-severe chronic pain types with and without widespread pain., (Copyright © 2024 International Association for the Study of Pain.)

Purpose: The aim was to study if aerobic capacity varies during different phases of the menstrual cycle (MC) in endurance-trained female athletes. Methods: Ten endurance-trained eumenorrheic women performed a submaximal test followed by an incremental test until exhaustion three times during one MC, early follicular phase (EFP), late follicular phase (LFP), and midluteal phase (MLP). During the submaximal test, the respiratory exchange ratio (RER) and utilization of fat and carbohydrates were analyzed; and, during the incremental test, VO 2 peak , maximal heart rate, utilization of fat and carbohydrates, and RER were analyzed. Lactate levels were analyzed at rest, during the submaximal test, and after the incremental test. The anaerobic threshold was determined at RER = 1. Results: No significant differences ( p  < .05) between the MC phases were seen in a maximal heart rate or VO 2peak . Similarly, VO 2 , heart rate, RER, fatty acid oxidation, and carbohydrate oxidation at 70, 80, 90, and 100% of VO 2peak did not differ significantly between MC phases. There were no significant differences between these phases in resting lactate before the test or during the submaximal tests, though there was a significant difference in lactate concentration 3 minutes after the incremental test between the EFP and the LFP ( p  = .043). Conclusion: This study did not display variations in physiological parameters between EFP, LFP, and MLP, indicating similar aerobic capacity despite hormonal variations. This knowledge may be useful when planning for competition in aerobic events.

Abstract: Paradoxical associations have been observed for leisure-time physical activity (LTPA) and occupational physical activity (OPA) and several health-related outcomes. Typically, higher LTPA is associated with health benefits and high OPA with health hazards. Using data from the Tromsø Study (2015-2016), we assessed how questionnaire-based LTPA and OPA (n = 21,083) and accelerometer-measured physical activity (PA) (n = 6778) relate to pain outcomes. Leisure-time physical activity and OPA were categorized as inactive PA, low PA, and moderate-to-vigorous PA and then aggregated into 9 levels, eg, inactive LTPA/inactive OPA. Accelerometer-measured PA included counts/minute, steps/day, and WHO PA recommendations from 2010 to 2020. Three binary pain outcomes (any pain, any chronic pain, and moderate-to-severe chronic pain) were constructed based on pain location, intensity, duration, and impact on daily activities. By using Poisson regression to estimate absolute and relative associations, we found that high LTPA was associated with lower pain prevalence and vice versa for OPA. Compared to inactive LTPA, prevalence ratio (PR) with 95% confidence intervals was lowest for moderate-to-vigorous LTPA, 0.93 (0.89-0.96) for any pain, 0.88 (0.84-0.93) for any chronic pain, and 0.66 (0.59-0.75) for moderate-to-severe chronic pain. Compared to sedentary OPA, the ratio was highest for moderate-to-vigorous OPA, 1.04 (1.01-1.07) for any pain, 1.06 (1.02-1.10) for any chronic pain, and 1.33 (1.21-1.46) for moderate-to-severe chronic pain. Aggregated LTPA and OPA showed lower outcomes for moderate-to-vigorous LTPA combined with lower levels of OPA. Higher levels of accelerometer-measured PA were associated with less pain. To summarize, we found inverse associations for LTPA and OPA. Benefits from LTPA seem to depend on low levels of OPA., (Copyright © 2024 International Association for the Study of Pain.)

Examining fracture dynamics by socioeconomic status may inform healthcare and prevention. We found a higher risk of hip fracture in men and women with lower educational level in Norway. However, by age 90 + years, the cumulative incidence was higher in those with higher education, due to their higher life expectancy., Purpose: Socioeconomic gradients are seen for several health outcomes in high-income countries. We aimed to examine possible educational gradients in risk of hip fracture in Norway and to describe the cumulative incidence of hip fracture by educational level., Methods: In a population-wide cohort of Norwegians aged ≥ 50 years, information on attained education from Statistics Norway was linked to hospital-treated hip fractures and deaths during 2002-2019. We estimated relative fracture risk by educational level (primary, secondary or tertiary) in Cox proportional hazards regression. We also examined the cumulative incidence over attained age by gender and educational level in competing risk regression., Results: The population included N = 1,389,858 individuals with 135,938 incident hip fractures. Compared with men who had attained tertiary education, hazard ratios (95% confidence intervals) for hip fracture were 1.44 (1.40, 1.49) in men with primary education only and 1.26 (1.22, 1.29) in men with secondary education. In women, the corresponding estimates were 1.28 (1.25, 1.31) and 1.16 (1.13, 1.19). In the age range 50 to 90 years, the highest cumulative incidence of hip fracture was seen in those with primary education. The gradient gradually diminished with advancing age and was reversed in the oldest (> 90 years) in both genders., Conclusions: There was a clear educational gradient in hip fracture incidence in both men and women in Norway, with a higher risk in people with lower education. Despite this, the cumulative incidence of hip fracture in old age was highest among people with higher education, due to their higher life expectancy., (© 2024. The Author(s).)

Introduction: It is unclear whether moderate-to-vigorous physical activity (MVPA) is associated with a lower mortality risk, over and above its contribution to total physical activity volume., Methods: 46,682 adults (mean age: 64 years) were included in a meta-analysis of nine prospective cohort studies. Each cohort generated tertiles of accelerometry-measured physical activity volume and volume-adjusted MVPA. Hazard ratios (HR, with 95% confidence intervals) for mortality were estimated separately and in joint models combining volume and MVPA. Data was collected between 2001 and 2019 and analyzed in 2023., Results: During a mean follow-up of 9 years, 4,666 deaths were recorded. Higher physical activity volume, and a greater contribution from volume-adjusted MVPA, were each associated with lower mortality hazard in multivariable-adjusted models. Compared to the least active tertile, higher physical activity volume was associated with a lower mortality (HRs: 0.62; 0.58, 0.67 and 0.50; 0.42, 0.60 for ascending tertiles). Similarly, a greater contribution from MVPA was associated with a lower mortality (HRs: 0.94; 0.85, 1.04 and 0.88; 0.79, 0.98). In joint analysis, a lower mortality from higher volume-adjusted MVPA was only observed for the middle tertile of physical activity volume., Conclusions: The total volume of physical activity was associated with a lower risk of mortality to a greater extent than the contribution of MVPA to physical activity volume. Integrating any intensity of physical activity into daily life may lower mortality risk in middle-aged and older adults, with a small added benefit if the same amount of activity is performed with a higher intensity., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Positive associations between physical activity and bone health have been found in population-based studies, however, mostly based on self-reported physical activity. Therefore, we investigated the association between accelerometer-measured physical activity, measured in steps per day and minutes of moderate to vigorous physical activity (MVPA) per day, and total hip areal BMD (aBMD) measured by DXA in a general population, utilizing multiple regression models. The study participants, 1560 women and 1177 men aged 40-84 yr, were part of the seventh survey of the Tromsø Study (2015-2016). In both genders, we found a positive association between the number of daily steps and aBMD adjusted for age, BMI, and smoking status ( P  < .001). In women, an increase of 1000 steps per day was associated with 0.005 g/cm 2 higher aBMD. For men, a polynomial curve indicated a positive association with aBMD up to 5000 steps per day, plateauing between 5000 and 14 000 steps, and then increasing again. Additionally, MVPA duration was positively associated with aBMD in both women ( P  < .001) and men ( P  = .004) when adjusted for age, BMI, and smoking status. Specifically, each 60-min increase in daily MVPA was associated with 0.028 and 0.023 g/cm 2 higher aBMD in women and men, respectively. Despite positive associations, the clinical impact of physical activity on aBMD in this general population of adults and older adults was relatively small, and a large increase in daily MVPA might not be achievable for most individuals. Therefore, further longitudinal population-based studies incorporating device-based measures of physical activity could add more clarity to these relationships., Competing Interests: None declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Society for Bone and Mineral Research.)

Competing Interests: Conflict of interest: None declared.

Objective: To examine the dose-response association between estimated cardiorespiratory fitness (eCRF) and risk of myocardial infarction (MI)., Patients and Methods: Adults who attended Tromsø Study surveys 4-6 (Janurary 1,1994-December 20, 2008) with no previous cardiovascular disease were followed up through December 31, 2014 for incident MI. Associations were examined using restricted cubic splines Fine and Gray regressions, adjusted for education, smoking, alcohol, diet, sex, adiposity, physical activity, study survey, and age (timescale) in the total cohort and subsamples with hyperlipidemia (n=2956), hypertension (n=8290), obesity (n=5784), metabolic syndrome (n=1410), smokers (n=3823), and poor diet (n=3463) and in those who were physically inactive (n=6255)., Results: Of 14,285 participants (mean age ± SD, 53.7±11.4 years), 979 (6.9%) experienced MI during follow-up (median, 7.2 years; 25th-75th, 5.3-14.6 years). Females with median eCRF (32 mL/kg/min) had 43% lower MI risk (subdistributed hazard ratio [SHR], 0.57; 95% CI, 0.48-0.68) than those at the 10th percentile (25 mL/kg/min) as reference. The lowest MI risk was observed at 47 mL/kg/min (SHR, 0.02; 95% CI, 0.01-0.11). Males had 26% lower MI risk at median eCRF (40 mL/kg/min; SHR, 0.74; 95% CI, 0.63-0.86) than those at the 10th percentile (32 mL/kg/min), and the lowest risk was 69% (SHR, 0.31; 95% CI, 0.14-0.71) at 60 mL/kg/min. The associations were similar in subsamples with cardiovascular disease risk factors., Conclusion: Higher eCRF associated with lower MI risk in females and males, but associations were more pronounced among females than those in males. This suggest eCRF as a vital estimate to implement in medical care to identify individuals at high risk of future MI, especially for females., Competing Interests: M.L.L. has received lecture fees from 10.13039/100004326Bayer, 10.13039/100004339Sanofi, and 10.13039/100002491BMS/10.13039/100004319Pfizer not related to this study. The remaining authors declare no conflict of interest., (© 2023 The Authors.)

Objective: Associations between occupational physical activity (OPA) and mortality risks are inconclusive. We aimed to examine associations between (1) OPA separately and (2) jointly with leisure time physical activity (LTPA), and risk of all-cause, cardiovascular disease (CVD) and cancer mortality, over four decades with updated exposure and covariates every 6-8 years., Methods: Adults aged 20-65 years from the Tromsø Study surveys Tromsø3-Tromsø7 (1986-2016) were included. We categorised OPA as low (sedentary), moderate (walking work), high (walking+lifting work) or very high (heavy manual labour) and LTPA as inactive, moderate and vigorous. We used Cox/Fine and Gray regressions to examine associations, adjusted for age, body mass index, smoking, education, diet, alcohol and LTPA (aim 1 only)., Results: Of 29 605 participants with 44 140 total observations, 4131 (14.0%) died, 1057 (25.6%) from CVD and 1660 (40.4%) from cancer, during follow-up (median: 29.1 years, 25th-75th: 16.5.1-35.3). In men, compared with low OPA, high OPA was associated with lower all-cause (HR 0.83, 95% CI 0.74 to 0.92) and CVD (subdistributed HR (SHR) 0.68, 95% CI 0.54 to 0.84) but not cancer mortality (SHR 0.99, 95% CI 0.84 to 1.19), while no association was observed for moderate or very high OPA. In joint analyses using inactive LTPA and low OPA as reference, vigorous LTPA was associated with lower all-cause mortality combined with low (HR 0.75, 95% CI 0.64 to 0.89), high (HR 0.67, 95% CI 0.54 to 0.82) and very high OPA (HR 0.74, 95% CI 0.58 to 0.94), but not with moderate OPA. In women, there were no associations between OPA, or combined OPA and LTPA, with mortality., Conclusion: High OPA, but not moderate and very high OPA, was associated with lower all-cause and CVD mortality risk in men but not in women. Vigorous LTPA was associated with lower mortality risk in men with low, high and very high OPA, but not moderate OPA., Competing Interests: Competing interests: M-LL has received lecture fees from Bayer, Sanofi and BMS/Pfizer not related to this study. The remaining authors declare no conflict of interest., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To examine whether moderate-to-vigorous physical activity (MVPA) modifies the association between sedentary time and mortality and vice versa, and estimate the joint associations of MVPA and sedentary time on mortality risk., Methods: This study involved individual participant data analysis of four prospective cohort studies (Norway, Sweden, USA, baseline: 2003-2016, 11 989 participants ≥50 years, 50.5% women) with hip-accelerometry-measured physical activity and sedentary time. Associations were examined using restricted cubic splines and fractional polynomials in Cox regressions adjusted for sex, education, body mass index, smoking, alcohol, study cohort, cardiovascular disease, cancer, and/or diabetes, accelerometry wear time and age., Results: 6.7% (n=805) died during follow-up (median 5.2 years, IQR 4.2 years). More than 12 daily sedentary hours (reference 8 hours) was associated with mortality risk only among those accumulating <22 min of MVPA per day (HR 1.38, 95% CI 1.10 to 1.74). Higher MVPA levels were associated with lower mortality risk irrespective of sedentary time, for example, HR for 10 versus 0 daily min of MVPA was 0.85 (95% CI 0.74 to 0.96) in those accumulating <10.5 daily sedentary hours and 0.65 (95% CI 0.53 to 0.79) in those accumulating ≥10.5 daily sedentary hours. Joint association analyses confirmed that higher MVPA was superior to lower sedentary time in lowering mortality risk, for example, 10 versus 0 daily min of MVPA was associated with 28-55% lower mortality risk across the sedentary time spectrum (lowest risk, 10 daily sedentary hours: HR 0.45, 95% CI 0.31 to 0.65)., Conclusions: Sedentary time was associated with higher mortality risk but only in individuals accumulating less than 22 min of MVPA per day. Higher MVPA levels were associated with lower mortality risk irrespective of the amount of sedentary time., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To analyze factors predicting mandibular cortical width (MCW) and mandibular cortical index (MCI) in adult females and males., Material and Methods: Data on 427 females and 335 males aged 40-84 from The Tromsø study: Tromsø7 were used. T-score, age, menopausal status (for females), remaining teeth, and periodontal status were analyzed in linear and logistic regression analyses as predictors of MCW and MCI, respectively., Results: T-score, age, and the number of remaining teeth significantly predicted MCW in females but not males. Standardized β coefficients were 0.286, -0.231, and 0.131, respectively. The linear regression model explained 24% of MCW variation in females. MCI in females was significantly predicted by T-score, age, and remaining teeth with the Wald values of 9.65, 6.17, and 5.83, respectively. The logistic regression model explained 16.3-23% of the variation in MCI in females. In males, T-score was the only significant predictor of the eroded cortex, and the logistic model explained only 4.3-5.8% of the variation in MCI., Conclusions: The T-score demonstrated a stronger relationship with MCW and MCI than other factors in females, which supports the usefulness of those indices for osteoporosis screening. Conversely, the T-score exhibited no association with MCW and remained the only significant predictor of MCI in males, yet to a lesser extent than in females., Clinical Relevance: Understanding factors affecting mandibular cortical morphology is essential for further investigations of MCW and MCI usefulness for osteoporosis screening in females and males., (© 2023. The Author(s).)

Purpose: To describe and compare the annual physical training characteristics between Norwegian female cross-country (XC) skiers and biathletes across competition levels and age categories., Methods: Daily training sessions for 1 year were recorded for 45 XC skiers and 26 biathletes, comprising international/national team (inter[national]) and nonnational/regional team members (nonnational) of both junior and senior age. Endurance, strength, flexibility, speed, and power training sessions were recorded. Data included exercise modality, intensity, and duration. Data were analyzed using linear mixed-effects models., Results: The total annual physical training volume consisted of ∼90% endurance training for both groups, although XC skiers had significantly higher total volumes (∼10%; P = .003; d = 0.78) than biathletes. Senior XC skiers performed more training hours of skiing and/or roller skiing compared with biathletes over the season. However, biathletes compensated for this lower volume by more skating and a higher proportion of endurance training as skiing (81% [17%]) compared with XC skiers (68% [16%]; P < .001; d = 0.94). Overall, (inter)national-level athletes completed a higher annual training volume than non-national-level athletes (740 [90] h vs 649 [95] h; P = .004;d = 0.81). Although juniors reported less endurance volume than seniors, they maintained a relatively stable level of endurance training across the preparatory and competition period, unlike senior athletes., Conclusions: The higher annual physical training volume by XC skiers compared with biathletes is likely caused by the different demands of the 2 sports; XC skiing necessitates training for 2 skiing styles, while biathlon requires additional shooting practice. However, biathletes compensate with a higher proportion of ski training, particularly in the skating technique.

Background: Physical activity (PA) is associated with reduced mortality. However, whether there is an added benefit of long-term endurance training is unclear. Thus, we aimed to examine 10-year mortality in older male endurance athletes compared with an older male general population., Method: Male athletes (n = 503) participating in an annual long-distance ski race (median years of participation: 14, range: 1-53) from the Norwegian Birkebeiner Aging study (BiAS), and non-athletic men (n = 1867) attending the sixth Tromsø Study (Tromsø6) aged ≥65 years were included. Associations with endurance sport practice and joint exposures of endurance sport practice and self-reported leisure-time PA with all-cause mortality were examined. We analyzed the data with Cox proportional hazard models and regression standardization., Results: After 10 years (median: 10.4, range: 0.5-11.1) the mortality rate was lower in athletes (hazard ratio (HR) 0.34, 95% confidence interval (CI): 0.24-0.49) compared with non-athletes, corresponding to a 15% (95% CI: 12-19%) absolute risk reduction associated with endurance sport practice. In joint analyses categorized according to PA and endurance sport practice, we observed an inverse dose-response relationship with mortality (p < 0.001). Compared to inactive non-athletes, PA was associated with lower mortality in both active non-athletes and athletes. However, the observed benefit among participants reporting moderate-to-vigorous PA was larger in athletes (HR: 0.21, 95% CI: 0.14-0.32) than non-athletes (HR: 0.43, 95% CI: 0.31-0.59) (p < 0.01)., Conclusion: Endurance sport practice was associated with reduced 10-year mortality, beyond the effect of PA in older men. This study suggests that long-term endurance sport practice maintained into older adulthood promotes longevity., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Physical activity (PA) might influence the risk or progression of chronic pain through pain tolerance. Hence, we aimed to assess whether habitual leisure-time PA level and PA change affects pain tolerance longitudinally in the population. Our sample (n = 10,732; 51% women) was gathered from the sixth (Tromsø6, 2007-08) and seventh (Tromsø7, 2015-16) waves of the prospective population-based Tromsø Study, Norway. Level of leisure-time PA (sedentary, light, moderate, or vigorous) was derived from questionnaires; experimental pain tolerance was measured by the cold-pressor test (CPT). We used ordinary, and multiple-adjusted mixed, Tobit regression to assess 1) the effect of longitudinal PA change on CPT tolerance at follow-up, and 2) whether a change in pain tolerance over time varied with level of LTPA. We found that participants with high consistent PA levels over the two surveys (Tromsø6 and Tromsø7) had significantly higher tolerance than those staying sedentary (20.4 s. (95% CI: 13.7, 27.1)). Repeated measurements show that light (6.7 s. (CI 3.4, 10.0)), moderate (CI 14.1 s. (9.9, 18.3)), and vigorous (16.3 s. (CI 6.0, 26.5)) PA groups had higher pain tolerance than sedentary, with non-significant interaction showed slightly falling effects of PA over time. In conclusion, being physically active at either of two time points measured 7-8 years apart was associated with higher pain tolerance compared to being sedentary at both time-points. Pain tolerance increased with higher total activity levels, and more for those who increased their activity level during follow-up. This indicates that not only total PA amount matters but also the direction of change. PA did not significantly moderate pain tolerance change over time, though estimates suggested a slightly falling effect possibly due to ageing. These results support increased PA levels as a possible non-pharmacological pathway towards reducing or preventing chronic pain., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Årnes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Abstract: Epidemiological literature on the relationship between physical activity and chronic pain is scarce and inconsistent. Hence, our aim was to assess the relationship applying comprehensive methodology, including self-reported and accelerometer measures of physical activity and different severity levels of chronic pain. We used data from the Tromsø Study (2015-2016). All residents in the municipality, aged 40 years and older were invited to participate (n = 32,591, 51% women). A total of 21,083 (53%) women reported on questionnaires. Additionally, 6778 participants (54% women) were invited to wear accelerometers (6125 with complete measurements). Our exposure measures were self-reported leisure time physical activity, exercise frequency, duration, and intensity and 2 accelerometer measures (steps per day and minutes of moderate to vigorous physical activity per day). Outcome measurements were chronic pain and moderate-to-severe chronic pain. We used Poisson regression to estimate chronic pain prevalence and prevalence ratios for each physical activity measure, with adjustments for sex, age, education level, smoking history, and occupational physical activity. Our main analyses showed an inverse dose-response relationship between all physical activity measures and both severity measures of chronic pain, except that the dose-response relationship with exercise duration was only found for moderate-to-severe pain. All findings were stronger for the moderate-to-severe pain outcomes than for chronic pain. Robustness analyses gave similar results as the main analyses. We conclude that an inverse dose-response association between physical activity and chronic pain is consistent across measures. To summarize, higher levels of physical activity is associated with less chronic pain and moderate-to-severe chronic pain., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.)

Objective: The aim of this study was to investigate the diagnostic efficacy of the radiomorphometric indices of mandibular cortical width (MCW) and mandibular cortical index (MCI) of cortical erosion for osteoporosis screening in adults (≥40 years) and older adults (≥65 years) to determine whether adding a fracture risk assessment tool (FRAX) would improve efficacy., Study Design: One observer measured MCW and assessed MCI on dental panoramic radiographs acquired for patients in the Tromsø study. These indices, alone and with FRAX scores, were evaluated for efficacy in predicting osteoporosis, which was diagnosed by bone density measurement at the femoral necks with dual-energy X-ray absorptiometry., Results: MCW ≤3 mm and MCI indicating heavily eroded cortices (C3) had accuracies of 68.8% and 83.6%, respectively, in identifying osteoporosis. In females >65 years, MCW ≤3 mm and C3 produced higher sensitivities but lower specificities, with slightly lower accuracies (61.4% and 79.8%, respectively) compared with all females. The addition of FRAX scores >15% improved the accuracy of MCW ≤3 mm (81.7%) and C3 (87.9%), resulting in high specificity (86.6% and 95.4%). Combining MCW ≤3 mm or C3 with FRAX >15% increased the probabilities of detecting osteoporosis by increasing positive likelihood ratios., Conclusions: MCW ≤3 mm or MCI C3, when combined with FRAX >15%, showed superior diagnostic efficacy, with high specificity in detecting females without osteoporosis., (Copyright © 2022. Published by Elsevier Inc.)

Vertebral fractures have been associated with increased mortality, but findings are inconclusive, and many vertebral fractures avoid clinical attention. We investigated this association in a general population of 2,476 older adults aged ≥55 years from Tromsø, Norway, who were followed over 2007-2020, using dual-energy x-ray absorptiometry (DXA) at baseline to evaluate vertebral fractures (mild, moderate, or severe). We used multiple Cox regression models to estimate hazard ratios (HRs) for all-cause mortality, adjusted for age, sex, body mass index, education, smoking, alcohol intake, cardiovascular disease, and respiratory disease. Mean follow-up in the cohort was 11.2 (standard deviation, 2.7) years; 341 participants (13.8%) had ≥1 vertebral fracture at baseline, and 636 participants (25.7%) died between baseline and follow-up. Full-adjustment models showed a nonsignificant association between vertebral fracture status (yes/no) and mortality. Participants with ≥3 vertebral fractures (HR = 2.43, 95% confidence interval: 1.57, 3.78) or ≥1 severe vertebral fracture (HR = 1.65, 95% confidence interval: 1.26, 2.15) had increased mortality compared with those with no vertebral fractures. Dual-energy x-ray absorptiometry-based screening could be a potent and feasible tool in detecting vertebral fractures that are often clinically silent yet independently associated with premature death. Our data indicated that detailed vertebral assessment could be warranted for a more accurate survival estimation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.)

Aims: Endurance sport practice is associated with a high prevalence of atrial fibrillation (AF), which increases the risk of stroke in the general population. However, stroke risk in endurance athletes with AF is sparsely investigated. Most studies have been limited by design and are largely restricted to younger and middle-aged populations. Thus, we aimed to investigate AF and stroke risk in older athletes exposed to prolonged endurance training., Method: During a 10-year period, 505 male athletes aged ≥65 years frequently participating in a long-distance ski race were compared with 1867 men of the same age from the general population. The main exposure was endurance sport practice with self-reported AF and stroke as outcomes. Stroke risk was further examined by joint modelling of AF and endurance practice. Statistical analysis was conducted with a modified Poisson model., Results: Athletes (median age: 68, range: 65-90) participated in a long-distance ski race over a median of 14 years (range: 1-53). Prevalence (28.5% vs 17.8%) and adjusted risk of AF (risk ratio (RR): 1.88, 95% CI: 1.49 to 2.37) were higher in athletes compared with non-athletes, whereas the prevalence (5.4% vs 9.7%) and risk of stroke were lower (RR: 0.60, 95% CI: 0.37 to 0.95). Compared with athletes without AF, risk of stroke was twofold in athletes (RR: 2.38, 95% CI: 1.08 to 5.24) and nearly fourfold in non-athletes (RR: 3.87, 95% CI: 1.98 to 7.57) with AF., Conclusion: Although older male endurance athletes experienced an increased risk of AF, the long-term risk of stroke was substantially reduced compared with non-athletes., Competing Interests: Competing interests: M-LL has received lecture fees from Bayer, Sanofi and BMS/Pfizer not related to this study. MM has received lecture fees from Bayer, Boehringer-Ingelheim, Bristol Myers Squibb, mSD and Pfizer not related to this work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Physical inactivity is the fourth leading risk factor for global mortality, and inactive adults have a higher risk to develop lifestyle diseases. To date, there is preliminary evidence of the efficacy of fitness technologies and other digital interventions for physical activity (PA) promotion. Intervention studies are needed to test the effectiveness and implementation of innovative PA promotion strategies., Methods and Analysis: The ONWARDS study is a hybrid type I effectiveness-implementation randomized control trial aiming at an inactive and presumably high-risk population living in Northern Norway. One hundred and eighty participants will be assigned to 3 groups in a 1:1:1 ratio and participate for 18 months. Participants in group A will be provided an activity tracker with the personalized metric Personal Activity Intelligence (PAI). Participants in group B will be provided with both an activity tracker with the personalized metric PAI and access to online training videos (Les Mills+) to perform home-based training. Participants in group C will be provided an activity tracker with the personalized metric PAI, home-based online training and additional peer support via social media. The primary objective is to test which combination of interventions is more effective in increasing PA levels and sustaining long-term exercise adherence. Secondary objectives include: proportion of participants reaching PA recommendations; exercise adherence; physical fitness; cardiovascular risk; quality of life; perceived competence for exercise; self-efficacy; social support; usability; users' perspectives on implementation outcomes (adoption, acceptability, adherence, sustainability). The study design will allow testing the effectiveness of the interventions while gathering information on implementation in a real-world situation., Discussion: This study can contribute to reduce disparities in PA levels among inactive adults by promoting PA and long-term adherence. Increased PA might, in turn, result in better prevention of lifestyle diseases. Digital interventions delivered at home can become an alternative to training facilities, making PA accessible and feasible for inactive populations and overcoming known barriers to PA. If effective, such interventions could potentially be offered through national health portals to citizens who do not meet the minimum recommendations on PA or prescribed by general practitioners or specialists., Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04526444, Registered 23 April 2021, identifier: NCT04526444., Competing Interests: Author AEE was employed by Memento U. Author BH is Head of Research at Les Mills International. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Zanaboni, Manskow, Sagelv, Morseth, Edvardsen, Aamot, Nes, Hastings, Gagnon and Antypas.)

Background: The Saltin-Grimby Physical Activity Level Scale (SGPALS) is commonly used to measure physical activity (PA) in population studies, but its validity in adolescents is unknown. This study aimed to assess the criterion validity of the SGPALS against accelerometry in a large sample of adolescents. A secondary aim was to examine the validity across strata of sex, body mass index (BMI), parental educational level, study program and self-reported health., Methods: The study is based on data from 572 adolescents aged 15-17 years who participated in the Fit Futures Study 2010-11 in Northern Norway. The participants were invited to wear an accelerometer (GT3X) attached to their hip for seven consecutive days. We used Spearman's rho and linear regression models to assess the validity of the SGPALS against the following accelerometry estimates of PA; mean counts/minute (CPM), steps/day, and minutes/day of moderate-to-vigorous physical activity (MVPA)., Results: The SGPALS correlated with mean CPM (ρ = 0.40, p<0.01), steps/day (ρ = 0.35, p<0.01) and MVPA min/day (ρ = 0.35, p<0.01). We observed no differences between correlations within demographic strata (all p>0.001). Higher scores on SGPALS were associated with a higher CPM, higher number of steps per day and more minutes of MVPA per day, with the following mean differences in PA measurements between the SGPALS ranks: CPM increased by 53 counts (95% CI: 44 to 62), steps/day increased by 925 steps (95% CI: 731 to 1118), and MVPA by 8.4 min/day (95% CI: 6.7 to 10.0). Mean difference between the highest and lowest SGPALS category was 2947 steps/day (6509 vs. 9456 steps/day) and 26.4 min/day MVPA (35.2 minutes vs 61.6 minutes)., Conclusion: We found satisfactory ranking validity of SGPALS measured against accelerometry in adolescents, which was fairly stable across strata of sex, BMI, and education. However, the validity of SGPALS in providing information on absolute physical activity levels seem limited., Competing Interests: The authors have declared that no competing interests exist.

Purpose: The purpose of this study was to investigate associations between cardiovascular risk factors and the thickness of retinal nerve fiber layer (RNFL), ganglion cell-inner plexiform layer (GCIPL), and outer retina layers (ORL)., Methods: In this population-based study, we included participants from the Tromsø Study: Tromsø6 (2007 to 2008) and Tromsø7 (2015 to 2016). Persons with diabetes and/or diagnosed glaucoma were excluded from this study. Retinal thickness was measured on optical coherence tomography (Cirrus HD-OCT) macula-scans, segmented on RNFL, GCIPL, and ORL and associations were analyzed cross-sectionally (N = 8288) and longitudinally (N = 2595). We used directed acyclic graphs (DAGs) for model selection, and linear regression to adjust for confounders and mediators in models assessing direct effects. Factors examined were age, sex, blood pressure, daily smoking, serum lipids, glycated hemoglobin, body mass index (BMI), total body fat percentage (BFP), and the adjustment variables refraction and height., Results: The explained variance of cardiovascular risk factors was highest in GCIPL (0.126). GCIPL had a strong negative association with age. Women had thicker GCIPL than men at higher age and thinner ORL at all ages (P < 0.001). Systolic blood pressure was negatively associated with RNFL/GCIPL (P = 0.001/0.004), with indication of a U-shaped relationship with GCIPL in women. The negative association with BMI was strongest in men, with significant effect for RNFL/GCIPL/ORL (P = 0.001/<0.001/0.019) and in women for GCIPL/ORL (P = 0.030/0.037). BFP was negatively associated with GCIPL (P = 0.01). Higher baseline BMI was associated with a reduction in GCIPL over 8 years (P = 0.03)., Conclusions: Cardiovascular risk factors explained 12.6% of the variance in GCIPL, with weight and blood pressure the most important modifiable factors.

Background: Current knowledge about the relationship between physical activity (PA) and cardiac remodeling is mainly derived from cross-sectional studies of athletes, and there is a knowledge gap of this association in the general adult and elderly population. Therefore, we aimed to explore the longitudinal association between cumulative PA and change in cardiac structure and function in a general adult and elderly population., Methods: This longitudinal study includes 594 participants from the sixth (Tromsø6, 2007-08) and seventh (Tromsø7, 2015-16) survey of the Tromsø Study. Cardiac structure and function were assessed by echocardiography at two time points, and PA was self-reported by questionnaire at both time points. PA volume was expressed as cumulative PA (Low, Moderate, and Hard) and the association with left atrial (LA) and left ventricular (LV) structure and function was assessed using ANCOVA., Results: Overall, LA diameter index (LADi) increased significantly more in Hard compared to Moderate PA (+0.08 cm/m 2 , 95% CI 0.01-0.15, p = 0.020) from Tromsø6 to Tromsø7. When stratified by sex or age, higher levels of cumulative PA were associated with increased LADi in males and in participants <65 years only. Indexed LV mass (LVMi) increased significantly more in Moderate than in Low PA (+3.9 g/m 2.7 , 95% CI 0.23-7.57, p = 0.037). When stratified by sex or age, these changes in LVMi and indexed LV diameter (LVDi) were only significant in females. No significant associations were observed between cumulative PA and change in relative wall thickness, E/e' ratio, e' velocity, LV ejection fraction, and LADi/LVDi ratio., Conclusion: Higher levels of cumulative PA were associated with increased LADi in males and participants <65 years, and with increased LVMi and LVDi in females. Despite cardiac chamber enlargement, the pump function of the heart did not change with higher levels of PA, and the atrioventricular ratio was unchanged. Our results indicate that cardiac chamber enlargement is a physiological response to PA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Heitmann, Welde, Løchen, Stylidis, Schirmer and Morseth.)

Purpose: To investigate the prevalence of hormonal contraceptive (HC) use by female cross-country (XC) skiers and biathletes competing at a national and/or international level, their reasons for HC use, and to compare negative symptoms related to the HC-/menstrual cycle in HC users and non-HC users. Additionally, to characterize the self-perceived influence of HC use on training and performance., Methods: A total of 113 Norwegian competitive XC skiers and biathletes completed an online questionnaire including both closed and open-ended questions. The questions were designed to assess the type of HC, reasons for use, self-reported negative symptoms related to HC-/menstrual cycle, as well as athletes' experiences regarding how HC use affects training and performance., Results: In total, 68% of all the athletes used HC, with 64 and 36% of them using a progestin-only and combined type HC, respectively. Non-contraceptive reasons for HC use were reported by 51% of the progestin-only HC users vs. 75% of the combined HC users ( P = 0.039), with reduction of negative menstrual-related symptoms as the most common reason. Of the athletes reporting regular withdrawal bleedings in connection to HC use, 80% of the progestin-only and 86% of combined HC users experienced negative menstrual-related symptoms, which was comparable to the non-HC group (86%). The majority (81%) of HC users experienced solely positive, or no effect, of HC use on training and performance, with no differences between progestin-only and combined HC users ( P = 0.942)., Conclusions: In total, 68% of the XC skiers and biathletes used HC, with the highest proportion (64%) using a progestin-only HC. Many athletes used HC to manipulate their menstrual cycle due to perceived negative menstrual-related symptoms that interfered with their training sessions and/or competitions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Engseth, Andersson, Solli, Morseth, Thomassen, Noordhof, Sandbakk and Welde.)

Aims: To investigate European guideline treatment target achievement in cardiovascular risk factors, medication use, and lifestyle, after myocardial infarction (MI) or ischaemic stroke, in women and men living in Norway., Methods and Results: In the population-based Tromsø Study 2015-16 (attendance 65%), 904 participants had previous validated MI and/or stroke. Cross-sectionally, we investigated target achievement for blood pressure (<140/90 mmHg, <130/80 mmHg if diabetes), LDL cholesterol (<1.8 mmol/L), HbA1c (<7.0% if diabetes), overweight (body mass index (BMI) <25 kg/m2, waist circumference women <80 cm, men <94 cm), smoking (non-smoking), physical activity (self-reported >sedentary, accelerometer-measured moderate-to-vigorous ≥150 min/week), diet (intake of fruits ≥200 g/day, vegetables ≥200 g/day, fish ≥200 g/week, saturated fat <10E%, fibre ≥30 g/day, alcohol women ≤10 g/day, men ≤20 g/day), and medication use (antihypertensives, lipid-lowering drugs, antithrombotics, and antidiabetics), using regression models. Proportion of target achievement was for blood pressure 55.2%, LDL cholesterol 9.0%, HbA1c 42.5%, BMI 21.1%, waist circumference 15.7%, non-smoking 86.7%, self-reported physical activity 79%, objectively measured physical activity 11.8%, intake of fruit 64.4%, vegetables 40.7%, fish 96.7%, saturated fat 24.3%, fibre 29.9%, and alcohol 78.5%, use of antidiabetics 83.6%, lipid-lowering drugs 81.0%, antihypertensives 75.9%, and antithrombotics 74.6%. Only 0.7% achieved all cardiovascular risk factor targets combined. Largely, there was little difference between the sexes, and in characteristics, medication use, and lifestyle among target achievers compared to non-achievers., Conclusion: Secondary prevention of cardiovascular disease was suboptimal. A negligible proportion achieved the treatment target for all risk factors. Improvement in follow-up care and treatment after MI and stroke is needed., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: The aim was to investigate the long-term association between leisure time physical activity and hip areal bone mineral density (aBMD), in addition to change in hip aBMD over time, in 32-86 years old women and men., Methods: Data were retrieved from the 2001, 2007-2008, and 2015-2016 surveys of the Tromsø Study, a longitudinal population study in Norway. Leisure time physical activity was assessed by the four-level Saltin-Grimby Physical Activity Level Scale which refers to physical exertion in the past twelve months. Hip aBMD was assessed by Dual-Energy X-ray Absorptiometry. Linear Mixed Model analysis was used to examine long-term associations between physical activity and hip aBMD (n = 6324). In addition, the annual change in hip aBMD was analyzed in a subsample of 3199 participants., Results: Physical activity was significantly and positively associated with total hip aBMD in the overall cohort (p<0.005). Participants who reported vigorous activity had 28.20 mg/cm2 higher aBMD than those who were inactive (95% CI 14.71; 41.69, controlled for confounders), and even light physical activity was associated with higher aBMD than inactivity (8.32 mg/cm2, 95% CI 4.89; 11.76). Associations between physical activity and femoral neck aBMD yielded similar results. Hip aBMD decreased with age in both sexes, although more prominently in women. From 2001 to 2007-2008, aBMD changed by -5.76 mg/cm2 per year (95% CI -6.08; -5.44) in women, and -2.31 mg/cm2 (95% CI -2.69; -1.93), in men. From 2007-2008 to 2015-2016, the change was -4.45 mg/cm2 per year (95% CI -4.84; -4.06) in women, and -1.45 mg/cm2 (95% CI -1.92; -0.98) in men., Conclusions: In this cohort of adult men and women, physical activity levels were positively associated with hip aBMD in a dose-response relationship. Hip aBMD decreased with age, although more pronounced in women than men., Competing Interests: The authors have declared that no competing interests exist.

Aims: Left atrial (LA) enlargement is an independent risk factor for atrial fibrillation (AF). Interestingly, some athletes have increased risk of AF, which may be linked to LA enlargement; however, little is known about the relationship between LA enlargement and AF risk at moderate-level physical activity (PA). We aimed to explore the associations between PA, LA size and risk of incident AF, and if PA can attenuate the risk of AF with LA enlargement., Methods: This prospective study followed 2479 participants (52.4% female), free from known cardiac pathology, for median 20.2 years. Participants were followed up for hospital-diagnosed AF, confirmed by electrocardiography, from 1994-95 through 2016. At baseline, LA size was evaluated by anteroposterior LA diameter, and PA was self-reported by questionnaire., Results: We observed a U-shaped relationship between PA and AF, and moderately active had 32% lower AF risk than inactive (HR adjusted 0.68, 95% CI 0.50 to 0.93). Participants with LA enlargement had 38% higher AF risk compared with participants with normal LA size (HR adjusted 1.38, 95% CI 1.12 to 1.69). However, the increased AF risk with LA enlargement was attenuated by PA; compared with inactive participants with LA enlargement, the AF risk was 45% lower among active with LA enlargement (HR adjusted 0.55, 95% CI 0.39 to 0.79). AF risk in active participants with LA enlargement did not differ from active with normal LA size. These patterns were observed in both men and women, and in participants over/under 65 years., Conclusion: Moderate PA was associated with reduced AF risk, and PA attenuated the increased risk of AF with LA enlargement in both men and women and all age groups., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Physical inactivity and obesity are global public health challenges. Older adults are important to target for prevention and management of disease and chronic conditions. However, many individuals struggle with maintaining increased physical activity (PA) and improved diet. This feasibility study provides the foundation for the RESTART trial, a randomized controlled trial (RCT) to test a complex intervention to facilitate favourable lifestyle changes older adults can sustain. The primary objective of this study was to investigate study feasibility (recruitment, adherence, side-effects, and logistics) using an interdisciplinary approach., Methods: This 1-year prospective mixed-method single-arm feasibility study was conducted in Tromsø, Norway, from September 2017. We invited by mail randomly selected participants from the seventh survey of the Tromsø Study (2015-2016) aged 55-75 years with sedentary lifestyle, obesity, and elevated cardiovascular risk. Participants attended a 6-month complex lifestyle intervention program, comprising instructor-led high-intensive exercise and nutritionist- and psychologist-led counselling, followed by a 6-month follow-up. All participants used a Polar activity tracker for daily activity monitoring during the intervention. Participants were interviewed three times throughout the study. Primary outcome was study feasibility measures., Results: We invited potential participants (n=75) by mail of which 27 % (n=20) agreed to participate. Telephone screening excluded four participants, and altogether 16 participants completed baseline screening. The intervention and test procedures of primary and secondary outcomes were feasible and acceptable for the participants. There were no exercise-induced injuries, indicating that the intervention program is safe. Participants experienced that the dietary and psychological counselling were delivered too early in the intervention and in too close proximity to the start of the exercise program. Minor logistic improvements were implemented throughout the intervention period., Conclusion: This study indicates that it is feasible to conduct a full-scale RCT of a multi-component randomized intervention trial, based on the model of the present study. No dropouts due to exercise-induced injury indicates that the exercises were safe. While minor improvements in logistics were implemented during the intervention, we will improve recruitment and adherence strategies, rearrange schedule of intervention contents (exercise, diet, and psychology), as well as improve the content of the dietary and behavioural counselling to maximize outcome effects in the RESTART protocol., Trial Registration: ClinicalTrials.gov Identifier: NCT03807323 Registered 16 January 2019 - retrospectively registered., (© 2021. The Author(s).)

Background: Sarcopenia is an age-related muscle disease primarily characterized by reductions in muscle strength that increases the risk of falls, fractures, cognitive impairment, and mortality. Exercise is currently preferred in prevention and treatment, but it is unknown how different habitual physical activity and sedentary behaviour patterns associate with sarcopenia status. The purpose of the present study was to compare associations of these patterns with probable sarcopenia in older adults., Methods: In 3653 community-dwelling participants (51% women) aged 60-84 years from the seventh survey of the Tromsø Study, we assessed objective physical activity and sedentary behaviour collected over 8 days (ActiGraph wGT3X-BT Accelerometer), grip strength (Jamar+ Digital Dynamometer), five-repetition chair stands, and self-reported disease. We combined tertiles of sedentary (SED) time and moderate-to-vigorous physical activity (MVPA) to create nine different activity profiles (SED HIGH , SED MOD , and SED LOW combined with MVPA HIGH , MVPA MOD , or MVPA LOW ). Multiple logistic regression models were used to examine how these profiles associated with probable sarcopenia, defined by low handgrip strength and/or slow chair stands time according to the revised European Working Group on Sarcopenia in Older People criteria., Results: Probable sarcopenia was present in 227 (6.2%) participants. Men with probable sarcopenia had on average 35.3 min more SED time and 20 min less MVPA compared with participants without sarcopenia (P < 0.01 for all), while women with probable sarcopenia only had 18 min less MVPA (P < 0.001). Compared with the SED HIGH -MVPA LOW reference activity profile (714.2 min SED/day and 10.4 min MVPA/day), the SED HIGH -MVPA MOD profile (697.1 min SED/day and 31.5 min MVPA/day) had significantly lower odds ratio (OR) for probable sarcopenia (OR 0.17, 95% confidence interval [CI] 0.08-0.35), while the SED LOW -MVPA LOW profile (482.9 min SED/day and 11.0 min MVPA/day) did not (OR 0.72, 95% CI 0.47-1.11). These findings were not influenced by age, sex, smoking, or self-reported diseases, and higher levels of MVPA did not further decrease ORs for probable sarcopenia., Conclusions: Older adults who achieve moderate amounts of MVPA have reduced odds for probable sarcopenia, even when they have high sedentary time. Those with low sedentary time did not have reduced odds for probable sarcopenia when they also had low amounts of MVPA. These findings need confirmation in longitudinal studies but suggest that interventions for preventing sarcopenia should prioritize increasing MVPA over reducing sedentary behaviour., (© 2021 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of Society on Sarcopenia, Cachexia and Wasting Disorders.)

Objectives: To examine whether leisure time physical activity changes predict subsequent body mass index (BMI) changes, and conversely, whether BMI changes predict subsequent leisure time physical activity changes., Methods: This prospective cohort study included adults attending ≥3 consecutive Tromsø Study surveys (time: T1, T2, T3) during 1974-2016 (n = 10779). If participants attended >3 surveys, we used the three most recent surveys. We computed physical activity change (assessed by the Saltin-Grimby Physical Activity Level Scale) from T1 to T2, categorized as Persistently Inactive (n = 992), Persistently Active (n = 7314), Active to Inactive (n = 1167) and Inactive to Active (n = 1306). We computed BMI change from T2 to T3, which regressed on preceding physical activity changes using analyses of covariance. The reverse association (BMI change from T1 to T2 and physical activity change from T2 to T3; n = 4385) was assessed using multinomial regression., Results: Average BMI increase was 0.86 kg/m 2 (95% CI: 0.82-0.90) from T2 to T3. With adjustment for sex, birth year, education, smoking and BMI at T2, there was no association between physical activity change from T1 to T2 and BMI change from T2 to T3 (Persistently Inactive: 0.89 kg/m 2 (95% CI: 0.77-1.00), Persistently Active: 0.85 kg/m 2 (95% CI: 0.81-0.89), Active to Inactive: 0.90 kg/m 2 (95% CI: 0.79-1.00), Inactive to Active 0.85 kg/m 2 (95% CI: 0.75-0.95), p = 0.84). Conversely, increasing BMI was associated with Persistently Inactive (odds ratio (OR): 1.17, 95% CI: 1.08-1.27, p < 0.001) and changing from Active to Inactive (OR: 1.16, 95% CI: 1.07-1.25, p < 0.001) compared with being Persistently Active., Conclusions: We found no association between leisure time physical activity changes and subsequent BMI changes, whereas BMI change predicted subsequent physical activity change. These findings indicate that BMI change predicts subsequent physical activity change at population level and not vice versa., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: The main aim was to examine age-specific risk factor associations with incident atrial fibrillation (AF) and their attributable fraction in a large European cohort. Additionally, we aimed to examine risk of stroke and mortality in relation to new-onset AF across age., Methods: We used individual-level data (n=66 951, 49.1% men, age range 40-98 years at baseline) from five European cohorts of the MOnica Risk, Genetics, Archiving and Monograph Consortium. The participants were followed for incident AF for up to 10 years and the association with modifiable risk factors from the baseline examinations (body mass index (BMI), hypertension, diabetes, daily smoking, alcohol consumption and history of stroke and myocardial infarction (MI)) was examined. Additionally, the participants were followed up for incident stroke and all-cause mortality after new-onset AF., Results: AF incidence increased from 0.9 per 1000 person-years at baseline age 40-49 years, to 17.7 at baseline age ≥70 years. Multivariable-adjusted Cox models showed that higher BMI, hypertension, high alcohol consumption and a history of stroke or MI were associated with increased risk of AF across age groups (p<0.05). Between 30% and 40% of the AF risk could be attributed to BMI, hypertension and a history of stroke or MI. New-onset AF was associated with a twofold increase in risk of stroke and death at ages≥70 years (p≤0.001)., Conclusion: In this large European cohort aged 40 years and above, risk of AF was largely attributed to BMI, high alcohol consumption and a history MI or stroke from middle age. Thus, preventive measures for AF should target risk factors such as obesity and hypertension from early age and continue throughout life., Competing Interests: Competing interests: RBS has received lecture fees and advisory board fees from BMS/Pfizer outside this work., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)